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Postcombat Reentry

Chapter 12

POSTCOMBAT REENTRY

INTRODUCTION

HISTORICAL REVIEW

Major Wars

Limited Wars

Rapid Deployment Operations

REENTRY ISSUES

Acute Reactions to Combat

Reintegration to Peacetime Garrison and Family Life

Validation

THE ROLES OF MENTAL HEALTH PROFESSIONALS

Consultation on Command Action

Participation in Unit Recovery Processes

Psychiatric Treatment

SUMMARY AND CONCLUSIONS

FARIS R. KIRKLAND, Ph.D.*

*Lieutenant Colonel (ret), Field Artillery, U.S. Army; Senior Research Associate, University City Science Center, 3624 Market Street,

Philadephia, Pennsylvania 19104; Guest Scientist, Department of Military Psychiatry, Division of Neuropsychiatry, Walter Reed Army Institute

of Research, Washington, DC 20307-5100
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Leslie Anderson Troops Boarding Homebound Ship 1947

Captain Leslie Anderson, who joined the U.S. Army Combat Art Section toward the end of World War II,

depicts troops boarding a ship to head for home. The return home is a greatly anticipated event for all

soldiers, sailors, and airmen, especially after combat. With the increased range of air transports in the 1960s,

these trips were shifted from ships to planes, resulting in less time to decompress from battle and prepare

oneself mentally for return to civilian life.

Art: Courtesy of US Center of Military History, Washington, DC.
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Postcombat Reentry

INTRODUCTION

Major wars in the 20th century have usually

comprised indoctrination of populations with the

grievances against potential adversaries, a period

of mounting tension vis-à-vis a particular adversary, years of combat, and involvement of the populace in enduring hardships and contributing to the

war effort. Throughout this process individuals

who are members, or who are likely to become

members, of the armed services have time to get

used to the psychological roles they will be playing

as delegates of the population. They learn that they

will be called upon to take great risks as champions

of their people in a generally agreed-upon cause,1

(eg, David representing the Israelites against the

Philistine Goliath2). Civilians and military personnel alike have time to cultivate a set of perceptions

that the enemy is an evil pseudospecies whose

people may be killed and whose property may be

destroyed without inhibition.3,4 The development

of wartime mind-sets helps military personnel not

only to carry out their combat duties but also to

manage the attendant trauma and guilt so they can

reenter the peacetime world when the war ends.

The attitudinal adjustments necessary to define a

group as enemy are easy to learn, but they require

time, social support, and certain sociocultural prerequisites.5,6 Similarly, the transition back to peace—

relating to families, friends, and coworkers; dealing

with social and material situations from a civilian

rather than a military perspective; and perceiving

the former enemy as neutral or even friendly—

requires time and social support.7–9 Among the

strongest social supports that can help the individual soldier make the transition from war to peace

is a national consensus about the war that legitimates his behavior in combat and validates the

suffering, deprivation, guilt, and fear that he experienced. Not all service members have been able to

manage to put their wars behind them and get on

with their lives. In many cases lack of a positive

consensus has played a role in these failures10–12

Further discussion of this may be found in Chapter

16, Chronic Post-Traumatic Stress Disorder; Chapter 17, The Prisoner of War; and Chapter 18, Followup Studies of Veterans, in this volume.

Some campaigns required only fractional commitment of national resources and did not put national survival in jeopardy (Boer War 1899–1902,13

French Indo-China War 1945–1954,14 Korean conflict

1950–1953,15 French Algerian War 1954–1962,16 Vietnam conflict 1963–1973,17 Soviet intervention in

Afghanistan 1980–1990). These wars were conducted

in a different psycho-political climate from that obtaining in major wars, and produced different reentry

issues. Governmental assertions about the national

interests that were at stake were not particularly credible, and the longer the wars went on the more threadbare became public support. Civilian inconvenience

and involvement were modest, and because casualties were few and affected but few families, there

was little pressure in the society as a whole for

validation of the war effort to reduce dissonance

arising from public distress (Table 12-1).

Soldiers participating in these limited wars had

time prior to induction, during training, and during

deployment voyages to adjust to the prospect of

combat, but reentry presented a number of problems. The most serious of these was that the absence

of a national consensus in support of the war made

legitimation of the soldiers’ actions and validation

of their suffering problematic. Moreover, return

from the two limited wars waged by the United

States was on an individual basis. The returnees

were not able to process their experiences with the

comrades with whom they had trained and fought.

Various kinds of acting out by veterans resulted.

The effects of post-traumatic stress disorder on vetTABLE 12-1

CASUALTIES AMONG GREAT POWERS IN

LIMITED WARS

War Dates Deaths

Boer War 1899–1902 21,942 British

French Indo-China War 1945–1954 29,685 French

Korean Conflict 1950–1953 33,629 U. S.

French Algerian War 1954–1962 12,000 French

Vietnam Conflict 1963–1973 56,737 U. S.

Data sources: [Boer War] Amery LS, ed. The Times History of

the War in South Africa, Vol. 7. London: Sampson Low, Marston; 1909: 24–25. [French Indo-China War] O’Ballance E.

The Indo-China War: 1945-54, A Study in Guerrilla Warfare. London: Faber & Faber; 1964: 249. [Korean Conflict] Blair C. The

Forgotten War. New York: Times Books; 1987: ix. [French Algerian War] O’Ballance E. The Algerian Insurrection: 1954-1962.

Hamden, CT: Archon Books; 1967: 201. [Vietnam Conflict]

Westmoreland WC. A Soldier Reports. Garden City, NY:

Doubleday; 1976: 299.
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294

erans of the American troops who fought in Vietnam are discussed extensively in this volume (Chapter 3, Disorders of Frustration and Loneliness, and

Chapter 16, Chronic Post-Traumatic Stress Disorder). The lack of consensus in France about the wars

in Indo-China and Algeria led to military challenges to the regime in 1958 and 1961.18,19 The stress

imposed on the weakening fabric of the Soviet Union

by the intervention in Afghanistan was one of the

factors in the collapse of the communist union.

Regimental officers were sufficiently alienated from

the national leadership that they would not order

their troops to fire on demonstrators opposing a

military coup to restore the regime.

A third kind of conflict has emerged during the

Cold War era—rapid deployment, short duration

interventions such as the British reconquest of the

Falkland Islands (1982), the U.S. invasion of Grenada

(1983) and Panama (1989), and the Persian Gulf War

(1990–1991). The psychological sequelae of such

conflicts differ from those encountered in longer

wars, especially wars in which there was time to

prepare psychologically in advance. One might

expect that a soldier who is involved in a short

period of fighting would experience less psychic

distress than one who endured prolonged combat,

and that has proved to be the case, as discussed in

Chapter 1, Psychiatric Lessons of War.

Several other factors warrant consideration. The

most important of these is that when a state is

defended by a small, long-service professional

armed force, the same personnel are likely to be

involved in several armed interventions. The soldiers are not, as was the case with the majority of

soldiers in wars fought by mass conscript armies,

discharged to the civil sector for management of

their reentry problems; they stay in the service. It is

essential that reentry issues be understood so that

steps can be taken to capitalize on those aspects of

combat experience that strengthen a service

member’s competence and confidence, and to mitigate traumatic or depressing aspects.

A second factor that merits consideration is that

rapid deployment to combat can deprive service

members of opportunities to develop clearly defined attitudes about the virtues of the American

cause, the evil nature of the adversary, and the

importance of the campaign to values that are important to them. As a consequence, military personnel participating in rapid deployment operations may have but little psychological armor to

help them manage the experience of killing, the loss

of comrades, or the pain and shock of wounds to

themselves. A psychologically informed effort must

be made before combat to prepare personnel for

these experiences. Similarly, postbattle action is

necessary to facilitate recovery from these traumata

both to alleviate suffering and to preserve the combat potential of units.

The purpose of this chapter is, first, to review the

experiences of participants in rapid deployment

campaigns, and second, to describe the action by

command and by mental health professionals that

supported reentry processes and strengthened the

psychological integrity of individuals and units.

The first section will be a historical summary with a

view to identifying policies and behavior relevant

to reentry from rapid deployment campaigns. The

second section is a catalogue of issues that have

emerged from research on such campaigns. The

third section is a discussion of the roles of mental

health professionals, operating in support of, and in

collaboration with, command in managing the reentry process.

HISTORICAL REVIEW

Between 1775 and 1992 the armed forces of the

United States have waged seven major wars—six

against foreign powers and one nationwide civil

war. They have conducted more than 30 limited

wars or armed interventions that entailed the use of

substantial forces, and carried out hundreds of military operations that included combat or the threat

of combat. Following each campaign there have

been reentry processes. Of interest to the mental

health community are those that provide guidance

for policy and conduct in the future. This historical

review will focus on reentry processes that affected

the postwar active army. It has three parts: (1)

major wars, (2) limited wars, and (3) rapid deployment wars.

Major Wars

The American solution to reentry following its

seven major wars has been demobilization. After

the Revolutionary War the army was reduced to 718

men. Following the War of 1812, 71% of the army

was demobilized; after the Mexican War, 77%; the

Civil War, 94%; the Spanish-American War, 62%;

World War I, 94%; World War II, 93%.20 Demobilization made reentry a societal, not a military prob-
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Postcombat Reentry

lem. The former soldiers went home to the approbation and welcome of their friends and families;

the Regular Army went into hibernation. Many

potential problems were solved by units staying

together during long trips home by sea, foot, and

horse-drawn vehicle from Vera Cruz (1849), from

the Philippines (1902), and from France (1918–1919).

Soldiers and leaders could process their experiences together, reassure each other, agree on acceptable myths that validated their behavior and

feelings. World War I was the last—until the invasion of Panama (1989–1990) from which units made

the journey home as units.

World War II was totally different from the standpoint of reentry. Though units to a large extent

trained, deployed and fought with the same men—

less casualties and plus replacements, when it was

time to go home it was every man for himself. In

spite of the national consensus that World War II

was a “good” war,8 there were numerous manifestations of hostility and episodes of indiscipline in

connection with the processes of returning home,

demobilizing, and reentry into civilian life. A system was devised by which each soldier could earn

points for time in the service, time overseas, time in

combat, wounds, and decorations. Those with the

most points were to be sent home first. The design

of the point system was based on research among

military personnel.21

An unforeseen consequence of the point system

was that it transformed the serviceman from a

member of a social unit to an isolated individual.

He no longer had the support of the comrades and

leaders with whom he had trained and fought,

and who had given his deeds and discomforts

meaning. Because there was a finite number of

ships and aircraft with which to bring personnel

home, many of them were frustrated by having to

wait. In 1946 there were reports that the Pentagon

intended to slow the demobilization process.

Servicemen “took to the streets and demonstrated

in more than a dozen countries.”22 In some embarkation camps soldiers left without authorization,

did not report for guard duty, and misbehaved in

local civilian communities.23,24 In the camps, the

soldiers were a mob of angry individuals deprived

of the fabric of trusted comrades, leaders whom

they knew, and the networks of missions, trust, and

mutual obligations that had given psychological

substance to the authoritarian structure of the armed

services. That fabric was necessary to sustain, orient, and support soldiers’ self-control. Without it,

they acted out their feelings of helplessness and

frustration.

The effects of the predischarge period of alienation were to focus and solidify the feelings of

discontent that had accumulated during the soldier’s

service, attenuate the memories of effectiveness

and comradeship, and send many home from the

service with a bitter sense of denigration and impotence. The veterans of World War II, though they

participated in a much longer struggle and won a

more comprehensive victory than did their forbears

from World War I (1917–1918), were not the committed and cohesive advocates for the armed services that the older veterans were.

Another consequence of the bitterness engendered by the individualized return and demobilization process was a series of complaints about the

behavior of officers. The criticism provoked an

investigation by a commission chaired by Lieutenant General James Doolittle. The commission found

that many officers had behaved inappropriately,

and proposed sweeping reforms.25 The reforms,

oriented toward removing arbitrary distinctions in

dress and privileges between officers and enlisted

personnel, did not address the fundamental issue—

which was how to build mutual respect up and

down the hierarchy. The reforms proved to be a

source of confusion and alienation that complicated

relationships between officers and enlisted personnel for more than 30 years.

Postcombat alienation, acting out, and hostility

to the armed forces differed from symptoms of

combat stress disorders or nostalgia, but they were

still part of the psychological aftereffects of a midintensity traditional war. By comparing the reentry

policies employed after World War II and their

consequences with the policies and consequences

following other conflicts it is possible to identify

actions that are most adaptive.

Limited Wars

Between 1783 and 1940, the United States engaged in 14 limited war campaigns—an average of

one every 11 years, as shown in Table 12-2. The

guerrilla wars, like the major wars, were fought

mainly with volunteers. When the job was done,

the volunteer regiments went back to the United

States and were disbanded. Return from the combat zone was by ship or on foot, and provided

plenty of time for soldiers to talk through their

experiences with each other. The regular officers

and noncommissioned officers (NCOs) had to look

for places in regular units, usually several ranks

lower than those they had held in the regiments of

volunteers.26
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296

Quasi-war with 1798–1800 Naval

France

Barbary Coast wars 1801–1805 Naval

Seminole War 1817–1818 Guerrilla

Second Seminole War 1835–1842 Guerrilla

Philippine 1899–1903, Pacification

Insurrection 1910–1913

China Relief 1900–1901 Pacification

Expedition

Cuban Pacification 1906–1909 Pacification

Nicaraguan 1912, 1926–1933 Pacification

Pacification

Haitian Expedition 1915, 1919–1920 Pacification

Santo Domingo 1916 Pacification

Mexican Border 1911–1919 Pacification

Campaign

TABLE 12-2

LIMITED WARS 1783-1940

War Dates Type

Most of the pacification operations were carried

out by Regular Army or U.S. Marine Corps regiments that remained intact after the operation.

Though deployment and return were slowed by the

transportation technology available, combat was

often intense and brief. These operations were

small-scale forerunners of rapid deployment campaigns such as the U.S. invasions of Grenada and

Panama and the Persian Gulf War. Unfortunately

they took place before the era of interest in the

psychological dimensions of warfare, and little has

been written that is helpful in understanding the

dynamics of the reentry process.

Between 1945 and 1992 the United States intervened more than 15 times in other countries with

substantial forces: Korea (1950–1953), Lebanon

(1958), Quemoy and Matsu (1958–1963), Cuba (1962–

1963), the Congo (1964), the Dominican Republic

(1965–1966), Vietnam (1963–1973), twice in Cambodia (an evacuation in April 1975 and the Mayaguez

battle in May 1975), Vietnam evacuation (1975),

Lebanon again (1982–1983), Grenada (1983), Honduras (1988), Panama (1989), the Persian Gulf region (1990–1991), Somalia (1992), and Haiti (1994).

None of these operations involved the survival of

the United States, and the levels of popular support

varied from almost total approval (Persian Gulf,

Grenada) to high levels of disapproval (Vietnam

after 1968). The forces varied in size from less than

a division of ground troops to the bulk of American

combat strength. Most involved land, sea, and air

forces. Those before 1973 were supported by conscription. Those after 1980 resemble expected future operations most closely in being carried out by

professional forces, in the rapidity with which forces

were projected and the brief time deployed, and in

their frequency—an average of one major operation

every 2 years.

Reentry following the two largest limited conflicts—Korea and Vietnam—resembled that following World War II in that service members left the

combat zone as individuals. Because most of them

were discharged shortly after completing their obligated tours, reentry was a matter for the civil sector to

handle. But the conflicts in Korea and Vietnam were

not supported by a solid national consensus. The

country was apathetic about the Korean conflict,

especially after the first year when armistice negotiations began and progress at the bargaining table

attracted more attention than combat operations.

Casualty rates were high during the first year, but

total casualties were so low that too few families

were affected for them to become a matter of widespread concern. Three years of combat in Korea

killed only about one tenth as many Americans as 4

years of World War II. Returning soldiers were

ignored by the populace, but often received a hostile reception from their own service.27

Service members returning from the conflict in

Vietnam were for the most part met with indifference until 1968.28 From 1969 on they stood a good

chance of encountering savage abuse.11,28,29 The

widespread post-traumatic stress disorders (PTSD)

reported among veterans of the conflict in Vietnam

have been partially attributed to absence of validation and legitimation from the civilian population.

Another factor, one that is rarely cited, was the

absence of support and validation from comrades

and leaders—who either came home before or were

still in Vietnam. The veteran of Vietnam went from

the battle zone to the United States in 48 hours. He

did not have time to think and talk through what he

had seen and done, and in any event he went back

with strangers, not the men he had served with. He

had to confront reentry to the civilian world completely alone, and often it was a hostile world.

The record of reentry following World War I,

World War II, the Philippine Insurrection, the Korean conflict and the Vietnam conflict are of limited

relevance for the future. Either the units demobilized, or they stayed in the field and men rotated

through them. The units never reentered until the

war was over; the individuals left the service at the

end of their obligated service. The problem for the

future is reentry in which a unit deploys, fights, and
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Postcombat Reentry

returns—as a unit. The unit and its members will

continue to stay together, and must remain ready

for the next deployment. Only the most recent

history is directly relevant—the history of rapid

deployment wars with short periods of combat.

Rapid Deployment Operations

In 1982, 13,000 Argentinean troops seized and

garrisoned the British Falkland Islands. In 7 weeks

a British multi-service task force assembled and

moved 8,000 miles to put ashore a force of 10,000

men to recapture the islands. In 24 days of bitter

land, sea and air fighting 252 British soldiers were

killed, 6 ships were sunk, and approximately 1

dozen aircraft were destroyed.30 The reentry processes for the British units are useful for this study

because the British attack resembled the type the

United States has used since and probably will

continue to use, and because the British used regular units, not conscripts.

The British units stayed together after the battle,

preparing for the next one. Reentry problems rarely

emerged for two reasons. The more important

reason is the supportive nature of the British regimental system. It assures the soldier that he will

always be with the same unit, the same comrades

and leaders, and the same traditions. He partakes

of, contributes to, and derives significance as a

person from the regiment.31,32 The honor of the

regiment requires him to behave in certain ways.

He follows the traditions, feels proud of living up to

them, and is cloaked with their dignity. He never

experiences reentry alone.33,34

The second reason that reentry problems rarely

emerge is the British tradition of undemonstrativeness and reluctance to express emotions. These

cultural behavioral characteristics limit the range of

communications and can mask psychological distress. Ritualized manifestations of loyalty to the

regiment distract men from their fears and help

them through difficult moments, but they also make

it hard for leaders to detect incipient problems in

time to take action to alleviate them. Probably some

leaders are only too glad that discipline, honor, and

the stiff upper lip protect them from having to

become aware of, and deal with, psychological pain

in subordinates that they are working hard to deny

in themselves. Often the first hint of combat stress

reaction is serious acting out or decompensation.

The United States conducted rapid deployment

operations involving combat in Grenada in 1983,

Panama in 1989, Saudi Arabia in 1990, and Somalia

in 1992. Many units train continuously for the rapid

deployment mission. They know they could go into

combat any day on short notice. They know that the

mission is real, because their units have gone into

combat on 24-hours notice.

The classic rapid deployment operation was

Operation Just Cause (OJC)—the invasion of Panama

in December 1989. A force of about 4,000 combat

troops was on the ground in Panama. An additional

16,000 were air-dropped and airlanded over a 24-

hour period, and within 48 hours the entire Panamanian military structure was destroyed. Rules of

engagement were strict: U.S. soldiers could fire

only at enemy personnel who could be seen firing at

them. No suppressive fire was permitted, and no

indirect fire by artillery or mortars was used. Only

two aerial bombs were dropped, and they were in

remote locations. As a result, the action by U.S.

forces caused few civilian casualties and minimal

collateral damage. Unfortunately, a much larger

number of civilians were killed and one barrio destroyed by fire as a result of action by Noriega’s

Dignity Battalions and of personal vendettas carried out during the collapse of the Panamanian

government.

The Department of Military Psychiatry of the

Walter Reed Army Institute of Research (WRAIR)

conducted extensive research into the human dimensions of OJC. The WRAIR team interviewed

more than 800 soldiers of all ranks from ten infantry

battalions and two military police companies. The

research caught the units in the midst of the reentry

process just after they returned to their home stations in the United States, or in Panama in the case

of units permanently stationed there. The findings

from that study have provided much of the empirical data on which the analyses that follow are based.35

The data from the study done by WRAIR indicated that few soldiers suffered from traditional

combat stress reactions or disorders of loneliness or

frustration (nostalgia), but that rapid deployment,

short-duration campaigns provoked specific types

of stress reactions in some soldiers, and most units

reported some difficulties in coming down from

combat to the mundane routines of training. It is

these kinds of issues that commanders and mental

health professionals need to understand. Properly

managed, they can preserve the psychological readiness of units that have taken part in a rapid deployment combat mission. If they are treated with

benign neglect because no one knows how to handle

them, or because other matters appear to be more

important, morale and cohesion can languish and

the unit can lapse into a degraded state of psychological readiness.
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298

REENTRY ISSUES

The 10 infantry battalions studied by the team

from WRAIR were cohesive and competent. Three

had been in Panama for several months before Operation Just Cause was launched. Members of the

battalions lived and trained together 24-hours-aday, week in and week out. They patrolled constantly and provocatively, and had frequent hostile

encounters, with loaded weapons, with members of

General Noriega’s Panamanian Defense Force (PDF).

These battalions became cohesive in conditions that

were not far removed from combat. Two others

were elite Ranger battalions in which cohesion was

developed by continuous high-intensity training,

free from distractions not related to the mission.

Five battalions, including one of those already in

Panama, were COHORT (cohesion, operational

readiness, training) units. Their first-term soldiers

had gone through initial entry training together

and stayed together for 3-year tours in their battalions. The last battalion, though neither Ranger nor

COHORT, was a part of the division that has been

on the highest alert status in the army for decades.

Several of the battalions that were not in Panama

when OJC was initiated were on relaxed alert status. Two had sent most of their personnel on Christmas leave. Nonetheless they assembled, packed

their equipment and were airborne en route to combat in about 24 hours. Three parachuted into combat; four were airlanded. Official after-action reports and the findings from the WRAIR study

indicate that all of the battalions performed their

missions effectively. Most of the action was at

squad or platoon level, though some company commanders were able to control all of their platoons

some of the time.

Six of the battalions studied engaged in severe

combat. Between them they suffered 10 killed and

116 wounded in action. In addition there were 6

men killed in accidents. Only one of the 10 battalions studied had no fatalities. OJC is an appropriate

case study because it is a prototype of future military operations, and because it was an unqualified

success with minimal friendly casualties. As a

consequence, the reentry problems that emerged

were few in number and easy to recognize and

study. From the 10 battalions studied it is possible

to describe the range of problems that may arise and

the techniques used by commanders and mental

health professionals that were most effective in

dealing with them. The issues fell into three categories: (1) acute reactions to combat, (2) postcombat

validation, and (3) reintegration into the postwar

world.

Acute Reactions to Combat

Veterans of OJC reported three kinds of emotional reactions to combat: (1) distress over killing

PDF soldiers; (2) a complex mix of grief, guilt, and

rage over losing comrades; and (3) generalized patterns of anxiety, irritability, and nightmares.

Distress over Killing

Casualties that the soldier inflicted himself on

enemy soldiers were usually described as the most

stressful events. A first sergeant described the

reactions of soldiers who had killed PDF in close

combat: “They don’t feel good having a confirmed

kill.” A company commander said: “Shooting people

has been harder for most soldiers to come to grips

with than the death of a friend.” A squad leader

said of one of his men: “He killed two. That night he

was punching the wall and crying. He has a bad

feeling.” His comrades described a soldier who had

killed a PDF in a fire fight: “Joe was wound up,

talked a mile a minute. He kept asking us what we

thought. We told him he had done a good job. He

was a pain in the ass, wouldn’t shut up. Finally they

sent him to the rear to decompress. We never heard

from him again.” The platoon sergeant of a platoon

that had riddled a bus full of fleeing PDF officers

said: “There was blood running out the door. People

were screaming and bleeding to death. I’ll never

forget that sight.”

Evidence was more often indirect than direct;

many of those who had killed were reticent about it,

and their distress sometimes took the form of withdrawal or denial: “He was dazed after shooting a

PDF soldier three times in the neck—a perfect shot.

But he didn’t want to talk about it.” The squad

mates of a one soldier said: “After he killed two

guys hand-to-hand he got real quiet. He has since

gotten out. He should have gotten counseling.”

One squad leader described one of his men who had

killed two PDF at close range: “He was the most

upset guy. He got very quiet.” A company commander reported that he had hoped to make a

soldier who had two confirmed kills an institutional hero: “He kept to himself. He got out. He

said he never wanted to be in a situation where he

would have to do that again.”
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Postcombat Reentry

Confronting feelings proved to alleviate stress to

some extent. A platoon sergeant said: “Then there’s

the burden of killing people. I can’t reconcile it, I

just carry it.” A private reported: “I hit an adult and

a child. That bothered me.” A group of squad

leaders distressed by the fact that they and their

men had killed a number of PDF said: “We consoled

each other.” A sergeant major encountered a group

of soldiers who had been in a fire fight: “They had

killed some people and wanted to talk. It was an

impromptu session with 14 guys.”

Compassion for the PDF was an issue. One

soldier said: “When we saw how terrified they

were, we felt sorry for them.” Another noted when

describing dead PDF: “They were just soldiers,

doing their job.” A Spanish-speaking soldier told

his squad mates that their prisoner had said, “He

doesn’t like Noriega, but he has five kids and needed

a job.”

Some soldiers had no apparent negative reaction

to killing. After a car full of civilians had failed to

stop at a road block and one of the occupants was

killed a soldier said, “Better one of them than one of

us.” A private described the mood of himself and

his comrades: “We were very excited. We had been

in the country 2 days, killed people, and had no

casualties. We were hyped up, felt invincible.”

When a soldier was killed accidentally, his comrades said of their killing some PDF: “It was gratifying to get some kills. It made us feel better.” One

soldier who killed a PDF said: “It was like a video

game. He was shooting at me.” A squad leader who

had encountered a PDF ambush said: “It didn’t

mean anything to me. I shot one, the team leader

got the other.” A spokesman for a squad that had

killed two and wounded two PDF said: “It was a

relief. We didn’t know how we would react, and we

had done okay.”

There were three factors that made it difficult for

the soldiers who fought in OJC to manage the psychological aftereffects of killing PDF soldiers. The

first and most obvious is the aversion most mammals have to killing conspecifics (members of their

own species).36,37 This aversion does not preclude

killing in all cases, but it does constitute a threshold

the strength of which varies with species and among

individuals within a species.38–40 Pseudospeciation,

the ability of humans and some other primates to

classify certain members of their own species as

“other,” can neutralize the threshold of inhibition so they can kill conspecifics.41–43 While

pseudospeciation makes it possible to kill, it does

not include processes to neutralize the affect associated with an action against which there are phylogenetically strong inhibitions. The soldier who kills

is left with his psychological afterburn.

The second factor was ambivalence. The soldiers

who fought in OJC had had opportunities to adjust

their perceptions to classify the Panamanian dictator Noriega and his henchmen in the PDF as “bad,”

as inhuman enough to kill. But the pseudospeciation process was partially vitiated as a psychological support by the identification U.S. soldiers had

with PDF personnel as soldiers, and as frightened

human beings.

The third factor was isolation. The afterburn U.S.

soldiers experienced was exacerbated by the fact

that comparatively few U.S. soldiers killed anybody. Those who did were alone with the conflict

between having done something inherently

aversive, and having done a praiseworthy deed in

the context of their social group. Their ability to

communicate with and derive support from their

group was apparently inhibited to some extent by

this conflict. Because the combat phase was brief,

there was not enough time for killing to become

routine, for it to become an experience most of the

soldiers shared. Those who had killed were likely

to remain a breed apart.

Reactions to Casualties Among Comrades

Soldiers and leaders reacted to casualties among

their own comrades in patterns that were fairly

constant irrespective of whether the casualties were

caused by enemy fire, friendly fire, or accident. The

intensity of their reactions was a function primarily

of how well they knew the victims. There were six

emotional themes evident within these response

patterns: (1) anger, (2) grief, (3) horror, (4) guilt, (5)

bonding, and (6) dependency on the mission.

Soldiers expressed anger toward the PDF even if

they had nothing to do with causing the casualties.

The following are responses by soldiers whose comrades were killed by friendly fire support systems:

“We were more aggressive toward the enemy.” “It

helped to return fire.” “If we hadn’t been able to

shoot at the PDF we’d have fallen apart.” Their

reactions were about the same when the PDF killed

an American. When one soldier was killed, his

platoon sergeant said: “People got mad. They

wanted revenge.” A squad leader observed: “It was

hard to enforce the rules of engagement after Joe

was killed. The guys did what I told them, but I

sensed that they were close to getting out of control.” Another squad leader said: “They were eager

to kill someone. One guy was especially eager to

kill. I said, ‘Let’s get it under control, get Panama
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300

squared away.’” The essence of the emotional state

of the comrades of dead Americans is evident in a

description of a junior NCO whose best friend was

killed in action: “He was freaked out, angry and

frustrated.” Their complete helplessness in the

presence of the totality of death was extremely

difficult for these young soldiers. They were in the

early years of their manhood, they had chosen the

U.S. Army as a means to achieve a sense of potency,

of instant adulthood, and instead they were faced

with a loss about which they could do nothing.

The second theme, grief, took two forms: (1)

immediate shock, and (2) a deeper feeling that men

experienced later. The immediate response was a

compound of refusal to believe and a wish to undo

the death. A company commander who had just

lost a man said: “I wanted to be alone with him for

a while. I closed his eyes. Then the medics pushed

me away, and I lost it.” Another officer expressed

a similar feeling: “He’s yours and he’s lost and

there’s a family.” Describing a death that was

reported over the company command radio net, a

soldier said, “The platoon went batsh__ over the

radio.” A soldier who observed a platoon in which

two soldiers were killed and two others wounded

said: “The squad froze when the squad leader was

hit. The platoon leader got them going again with

words and by touching them. He said to the team

leader, ‘You’re one-one [the radio call sign of the

fallen squad leader] now,’ and the team leader took

charge.” Several soldiers expressed a sense of time

rushing by: “It all happened so fast. We couldn’t

stop.” “If you stop to mourn, you make mistakes.”

“There was so much going on. We really didn’t

have time to be sad then.” “It happened so fast. It

was deeply sad, but it went through so fast we

didn’t have time to grieve then.” One soldier recalled a succession of thoughts flashing through his

mind: “His wife is pregnant. Am I going to get

home? I was nervous. Oh my God.”

The longer-lasting grief responses were often

delayed. A private who had lost a comrade experienced his grief most acutely at a memorial service in

the continental United States (CONUS): “It hit me

when I saw his family and I realized how much he

had lost.” A platoon leader described his men’s grief:

“You could see in their eyes that they were missing

something.” A soldier who saw another killed beside

him reported, “I still see it in my mind and think

about it every day.” A squad leader described the

members of his squad after a man had been killed:

“They were sad. I was sad. His best friend was real

quiet.” A commander who met another who had

lost men said, “I’m sorry about your guys.” The

other replied, “Yeah, it’s rough.” Expression of grief

was sometimes possible, sometimes not. In some

companies soldiers reported that during memorial

services: “There wasn’t a dry eye in the place.” “The

company commander spoke, and he broke down.

That helped.” But in another unit a soldier said:

“I’m sure people were sad, but we all felt it would

be a sign of weakness to cry.” A company commander reported, “I was really sad, but I didn’t

think it would be right for the men to know it.”

Though OJC was limited in time and scope, some

soldiers experienced or witnessed a full measure of

horror. A soldier who looked into a comrade’s face

just after he had been mortally wounded in the head

said, “I’ll never forget his look of terror; he was still

alive.” The members of a mechanized infantry

squad told how their machine gunner had been hit:

“When daylight came we saw the track and the gun

were covered with his blood. It stank.” A platoon

sergeant said that casualties affected the least experienced soldiers most: “The newbies were overwhelmed.” A soldier described what happened

when a rocket hit a soldier from behind: “It set off an

explosion in his ruck. There were parts of him all

over Bill.” A soldier who witnessed the wounding

of his comrades said: “I couldn’t forget about the

wounds, how bad they were. It could have been me.

I felt weird, wanted to be alone.” The best friend of

a man who was accidentally killed by a gunshot in

the head was angry and tearful as he described

cleaning up the mess.

Guilt was a particular burden of leaders and

medical aidmen—those who saw keeping others

alive to be their responsibility. A company commander who lost a man in a well-planned and

executed operation said: “I was so stunned I couldn’t

believe it. Could anything have been done better?”

A squad leader who had lost men insisted, “I would

rather it had been me than them.” In another unit a

squad leader felt responsible for casualties, but his

platoon leader reported, “The squad helped the

squad leader to stop blaming himself.” A team

leader who had been near his squad leader when he

was mortally wounded kept saying, “He took my

bullet.” One medic who tried to treat a man whose

arms had been blown off was distressed to admit, “I

felt a moment’s hesitation about touching him.”

Another medic was dropped by parachute at a

considerable distance from where men were hit: “I

wasn’t where I should have been.” There were also

a few who expressed survivor guilt: “Why was it

him and not me?”

When a unit suffered casualties, soldiers tended

to cling to each other emotionally. One squad
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leader expressed a feeling shared by others: “There

was tighter bonding. We tried to give more as

squad leaders.” A seriously wounded platoon sergeant ignored his own injuries in his anxiety about

his men: “All my soldiers are still out there. You’ve

got to get to them.” After casualties were evacuated a

survivor said, “The squad huddled together all night.”

A medic reported that in the aid station: “The wounded

guys kept asking each other, ‘Are you all right?’” The

friend of a man who was hit said, “After he was

wounded he wanted to stay with the unit but it was

better that he was evacuated.” A platoon sergeant

had a man hit near the end of an operation: “I

hugged him after he was hit, and told him to squeeze

my hand if the pain got too bad.”

After sustaining casualties, most units persevered

in the mission, but with heightened care and caution. A squad leader spoke for many, saying: “Everyone acted different. Functioned better. They

worried about each other. They paid attention to

detail. They kept going; no one gave up.” A soldier

whose friend had been killed said, “We were prepared for this; we expected casualties and we had a

job to do.” Another soldier who had lost a squad

mate said, “We were nervous, alert to each other;

we still had a mission to do.” A platoon sergeant

described his men as: “Looking for reassurance in

their tactics. They knew it could be them next.” One

company commander who was grief-stricken by a

death described his soldiers: “They put their loss

behind them. They haven’t forgotten but they continue to perform.” A soldier who had had a comrade killed beside him said, “We didn’t want to go

on, but we did.”

Anxiety, Irritability, and Nightmares

Witnessing the death or maiming of a comrade

heightened the survivors’ awareness of their own

vulnerability. In these cohesive units they looked to

each other for reassurance and for a restored sense

of strength. They also used the mission to distract

them from becoming fully aware of their feelings at

the time of the event. These responses were adaptive both for the accomplishment of the mission and

for the mental well-being of the soldiers. They

provided both time and opportunities to talk

through, or share silently, the losses they had suffered, the horrors they had seen, and the fears they

had experienced.

But neither time nor comrades erased the memories of killing, losing friends, guilt, shock, and fear.

Several soldiers reported post-traumatic stress

symptoms. Flashbacks and nightmares were a problem for some: “I had insomnia, and I was irritable.”

“I was angry at battalion, I jumped a lot, had nightmares, and I kept a weapon within reach.” “I keep

dreaming that I see him explode.” “Several times I

have woken up and found myself low-crawling on

the floor.” “I keep getting pictures in my head; I

wonder what could I have done to keep from getting wounded.” Almost all of the soldiers who

described stress symptoms said they kept them to

themselves: “We never mention nightmares or none

of that stuff. It could hurt your career.” “In this

outfit they think you’re pussy if you have psych

stuff.” “My wife listens, but she doesn’t have any

idea what I’m talking about.”

Chaplains and commanders reported that there

were increases in both maturity and acting out.

There was a rash of marriages and of conception of

children in some units after return. In other units

there was increased drinking and fighting. Soldiers

had not only to manage their acute reactions to their

experiences, they had to readjust to peacetime training and routines, and the married ones had to readjust to living with their families.

Reintegration to Peacetime Garrison and Family Life

Historically many men who went through combat have found that there were aftereffects that

complicated their return to peacetime pursuits.

Research conducted on veterans of World War I

found that even those who had the best postwar

outcomes—those who were in good health, selfsupporting, and happy—reported they were irritable, quick to anger, excitable, nervous, forgetful,

restless, and plagued by headaches and dizziness.44

Reintegration processes for veterans of short wars,

who stay in the armed services and have to prepare

for the next intervention, have three characteristics

that distinguish them from the processes associated

with long wars. First, the intense emotional experience of combat has not been blunted by time and the

erection of defenses. This makes the letdown from

war to peace more intense.

Second, service members who remain on active

duty after combat lose the sense of personal significance and potency associated with a “real world

mission” and do not have it replaced by a qualitative change in identity from soldier to civilian.

They are still in the service, but instead of being on

the cutting edge of national policy they are involved in simulation, make-believe, and bureaucratic procedures. Several soldiers made comments

such as, “Down there we were men; back here they

treat us like children.”
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A third factor is that there is no perception that

the job is done, the misery is over, and there is an

end to terror. Professional military personnel know

that there is a high probability that they will be

called into combat again, probably soon. These

factors did not affect many servicemen at the ends

of the big wars or those who finished tours of duty

in Korea or Vietnam. The research team from Walter

Reed found several clusters of long-term issues

associated with reentry. They can be grouped under five rubrics: (1) horizontal cohesion, (2) vertical

cohesion, (3) command behavior, (4) persistent stress

reactions, and (5) relationships with families.

Horizontal Cohesion

Military personnel who fought together were

tightly bonded with each other. They trusted one

another and felt safe with each other after having

survived dangerous situations together. One commander described his men: “They’re closer after the

stress plus 50 days of propinquity plus the satisfactions of participating successfully in an important

event. People feel better about working together.”

A senior NCO noted:

“Now we are real relaxed. The men talk about

their experiences and joke. The mood is lighter,

there is less bickering, and they tolerate each other

better. They know the other guy will watch their

back. They don’t hold grudges. Everybody is a

little bit closer after 74 days of hell.”

From privates’ perspectives: “We pull for each

other, we check one another. It’s live or die.” “The

squad is tight, real tight. We were close before we

went, but it is really a different kind of closeness

now. We know we can depend on each other.”

Soldiers varied in their responses to returning to

combat from, “I never want to go through anything

like that again” to “I’d go back in a heartbeat.” But

they were almost unanimous in saying, “If I have to

go back, I want to be with these guys.” This medley

of feelings led to a congeries of psychosocial issues

as replacements came in and veterans either left the

service or were transferred. The salient themes

were: “I trust the guys I went to combat with, but

not the new guys” on the one hand and, “We train

with the new guys and help them; everyone has a

battle buddy; we need them and want them, so we

do for them” on the other. In some squads there was

a feeling of loss and despair as trusted comrades

transferred out and clumsy rookies took their places:

“They came from no-stress basic training. They’re

weak and don’t want to learn.” “It’s too bad we

can’t stay together. We could mature together but

instead each guy who leaves takes some experience

with him.”

The receptions for new men were generally positive: “Peers help the newcomers out a lot.” “Nobody is lording it over the new guys.” “Most of us

don’t even wear our CIBs [Combat Infantryman

Badges], except on our Hollywood uniforms.” “Oh,

there was a little hazing, but it was good-natured.

The new guys are okay.” “The squad hasn’t changed.

We still bullsh__ around. The new guys are fitting

right in.” The new men saw things differently: “It

was awesome joining a squad where everybody

had been in combat.” “This COHORT unit was harder

to break into than either of the other two units I have

been in. The major reason was that I had not been to

Panama with them.” “They let me in, but I really had

to show them that I would put out.”

Because of the life-or-death nature of combat,

men who did not do well found themselves extruded. Squads bonded tightly with all of the members keeping the one perceived to be a slacker on the

outside. “There were some guys who didn’t do

their share. They’re isolated by the rest of the unit.”

“When we attacked, he hid under a boat. Nobody

talks to him anymore.” A platoon leader said, “I

had some guys who failed in combat. It was their

big chance, and they blew it. What do I do with

them?”

Vertical Cohesion

Postcombat turnover among junior leaders had

the heaviest impact on vertical cohesion. A battalion commander reported, “We had 8 new NCOs

waiting for us when we got back, and we’re turning

over 40 more in the next couple of months. The new

ones may have trouble getting accepted. It will

work out if they can do their jobs. I worry more

about the NCO turnover than anything else.”

From the privates’ viewpoint the worries were

justified: “We have had four squad leaders in 4

months.” “The sergeant who replaced our squad

leader who was killed is too familiar; he is trying to

fit in too fast.” “Since all the NCOs were wounded,

we have all new squad leaders.” “A sergeant came

in from another division that had also been in

Panama. We advised him to take off his combat

patch from that division.” These problems could

involve many NCOs in the same unit.

Sergeant X isn’t here half the time, he’s at school.

Sergeant Y was our best team leader and now he’s
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a squad leader in another platoon. He takes time to

talk about our problems, he shows us how things

work. Instead of writing you up, he squares you

away. Sergeant Z knew his sh__, how to navigate,

what needed to be done, how to take care of soldiers. He was busted and transferred. Sergeant Q,

who cracked in Panama, is still a sergeant.

New officers joining a unit that had been in

combat had problems, but they were less severe.

One lieutenant said:

I told them I was depending on the veterans to train

the new guys. That was all it took. I guess they were

pleased that their experience was being recognized.

Of course, I was one of the new guys. They trained me

but nobody said that in so many words.

Command Behavior

It is difficult to separate vertical cohesion from

command behavior because the former is a product

of the latter. The essential distinction in this argument is that under the section on vertical cohesion

new leaders’ problems of being accepted were discussed, whereas in this section the behavior of leaders, whether new or veteran, is the topic. The most

critical issue facing commanders upon reentry is

engaging the veterans’ interest and effort for training after they have done the job in combat. A

company commander complained: “I’m having a

hard time playing the game. I’m tired of retreading

the same territory.” A lieutenant said: “It is like

starting spring training after you have been to the

Super Bowl.”

Soldier after soldier echoed these sentiments, but

with more pungency: “Why are they putting us

through this Mickey Mouse bullsh__ when we’ve

shown we can do it?” “The highers are actually

serious about training for NTC [National Training

Center]. Can you believe it? As if it was something

real.” “The training is bad. We go charging off 100

miles per hour in the wrong direction. It’s more

like being disciplined.” “Battle drill may be needed,

but they’re going about it wrong. Instead of building on Panama they are like saying, ‘Forget

Panama.’” “It’s the same old horsesh__. Ever since

we got back we’ve had people on our backs about

barracks arrangement, micromanaging, telling us

things we want are impossible when we know perfectly well they are possible.” “This so-called training is nothing but repetition of things we already

know. No one is reenlisting.” “We don’t feel we’re

doing any useful mission here. We felt fulfilled in

Panama, but not here.” “Training doesn’t have the

same seriousness or level of importance it did before.”

Not all units had problems getting troops interested in training. A lieutenant said: “Things can’t

just stop. You owe it to the soldiers to train them to

be as proficient as possible. But you have to be

sensitive about Panama, too.” Privates in another

battalion reported: “Panama was the highest gear

we had been in. We went home, showed off, and

came back ready to get back to training, get ready

for the SQT.” “I have a different attitude toward

training. We got back because we knew our sh__.”

“I’m more serious. I train harder now.” “There’s no

pressure in this battalion for unrealistic standards.

You try to beat your own standard.” Squad leaders

in the same battalion added: “We’ve had no problem converting back to training because we need to

work on our weak points. We have a meeting at

1600 each day on what we’ll do tomorrow. I stay a

little while with the troops to see if they have any

problems.” “After Panama there was a different

attitude toward training; it had been hard, but it

registered on them that if you got it right, your

chances of coming back are better.”

Another issue was the question of time off for

decompression. There was general agreement that

there should be time off, that the soldiers should go

on leave, and that the pace of training should be less

intense. But there was wide variation in how much

was enough. Commanders expressed satisfaction;

a typical comment was: “The battalion went on

block leave as soon as we had recovered our equipment. When we came back I declared a number of

4-day weekends, and we held to those rigorously.”

The rank and file had different perceptions: “Other

battalions got 10 days administrative leave; we had

to use our own leave time.” “Ten lousy days is all

we got. We had missed Thanksgiving and Christmas and New Years.” “Who the hell wants block

leave in February?” “We had been down there 4

months and been on duty 7 days a week and all we

got was 14 days leave.” A thoughtful officer described the dynamic in his platoon:

There should be a policy that after combat or a

prolonged, stressful deployment soldiers get time

off. They need to dream, filter away the combat.

They should maybe be allowed to take more leave

if they need it. It takes a couple of months. When

we got back we got one day off and then back to

work. Is training that critical? Stuff builds up—

administration, housework, kids. They need to feel

the establishment is behind us.
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Persistent Stress Reactions

The flashbacks and nightmares described under

acute reactions to combat were a continuing problem for some soldiers. NCOs were most articulate

in describing their own symptoms. They tried to

deal with them by keeping busy—for distraction

and so they could sleep at night. When asked about

increased irritability, they reported being angry but

not at any specific persons or situations. They were

mad at “leaders,” mostly at battalion level, for “dog

and pony” shows and having to “buy new fatigues

to look nice.” Paratrooper sergeants reported fears

of jumping, especially at night.

Comparatively few privates reported having

symptoms. Some of their NCOs said they were

concerned about them. Most said they had not had

time to ask their soldiers how they’re doing. They

agreed that the “quiet ones” seem to have more

problems. They think that many soldiers on their

return from Panama had problems with what they

had seen and done. No one had debriefed them or

provided them information about combat reactions.

(For a further discussion of debriefings, see Chapter

11, Debriefing Following Combat.) They think this

would have been helpful and a good idea. They

would have heard that others shared their feelings

and experiences. A platoon sergeant described a

soldier who had intrusive memories and who

thought he was crazy. Another told of a soldier who

had nightmares about having a dead soldier’s blood

all over him. No one had told them that nightmares

and flashbacks are normal.

There was evidence of a need for mental health

services in theater in connection with the operation and its aftermath. A psychiatrist reported,

“We had two combat stress casualties.” A first

sergeant said, “Three of our guys had symptoms—

nightmares and such. They had all been hurt

and evacuated away from the unit.” Another told

the team, “One soldier cared for a dying comrade

for several hours; he went to the psych unit after

his friend died.”

But most soldiers and leaders in line units

shunned mental health services after their return to

home base. There were several apparent reasons;

fear of the unknown realm of psychological functioning was one. One company commander said,

“Psychologists don’t go over well in my unit. They’re

too ‘touchy-feely.’” Another officer noted, “In the

religious community, Freud equals evil.” A perceptive sergeant major observed, “People fear mental

health workers. They might make them look at

themselves.”

Another reason was anxiety about having their

thoughts probed by a staff officer from higher headquarters. A platoon sergeant told the team, “The

psychiatrist offered to come to the unit, but command dragged its feet.” Another reported, “A mental health team came to the unit. Someone told them

to give the information to the chaplain. They didn’t

want a stranger in the unit.”

There were also practical issues such as worry

about the impact of a psychiatric report on a service

record, and concern about possible psychological

malingering. To even mention a psychological problem was seen as a potential black mark. Several

NCOs said they thought their men would not go to

the troop medical clinics for fear of being labeled “a

psychiatric case.” With respect to malingering, one

platoon sergeant noted that there had been an article in the post newspaper from the division psychologists about availability of assistance for those

with Post-Panama Stress Syndrome: “I didn’t approve; I thought it would just put thoughts into

guys’ minds.” In one unit a thoughtful group of

NCOs expressed a worry that talking with the team

from Walter Reed would “Just bring it all back.”

Relationships with Families

The deployment and combat put severe strains

on wives and children. When the soldiers returned,

the role adjustments the wives had made while

their husbands were away had to be renegotiated.

These strains were exacerbated by the irritability

and tension the men brought back with them and, in

some units, by their disillusionment with the return

to military garrison routine and an uninspired training regimen. The results were an increase in the

incidence of divorce, the return of some wives to

their parents, and a few cases of spouse abuse. The

principal buffers that facilitated soldiers’ reintegration with their families were family support groups,

a period of uninterrupted leave together, and, in a

few units, more predictable on-duty and off-duty

schedules.

Family support groups provided information,

practical assistance with the tasks of living and

raising families, and social support. The more effective family support groups were successful in

strengthening wives’ morale and mitigating their

hostility toward the U.S. Army and their husbands

while they were away and upon their return. These

factors were important determinants of the ability

of the soldier and his family to reintegrate. The

effectiveness of family support groups was in turn

a function of the degree to which they were demo-
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cratically organized, open in communications, and

focused on the wives’ needs rather than on matters

of interest to the U.S. Army.45,46

There was a positive side to the experience of

combat with respect to soldiers’ ability to reintegrate with their families. Several soldiers reported

to the research team or to their chaplains or

comrades that their feelings about fundamental issues had undergone changes that put higher values

on their families. One sergeant major said: “A lot

of these kids grew up. They don’t sit around and

drink and waste time anymore. They don’t want to

embarrass the unit or themselves.” Several chaplains reported a sudden upsurge in marriages, and

there was more subtle evidence in the form of an

increase in the numbers of children conceived. One

chaplain said: “They went through a life and death

experience; now some of them are making decisions for life.” The accuracy of his analysis was

born out by the statements of several privates: “I see

life as more special, valuable. We should spend

time doing what matters.” “I have, like, a reverence

for life.” “I’ve changed emotionally; my buddy

died.” “When I came, I questioned things. Now I’m

more pliable, serious. I dig in.” “I learned a lot

about myself.”

There were other behavioral changes—besides

marrying and conceiving children—to implement

the changes in values. Several soldiers opted to

leave the service to, as one new father put it, “Not

put myself and my family in jeopardy.” A group of

platoon sergeants described their struggles with

whether or not to stay in the military after encountering the “life and death moral dilemmas that have

to be addressed in combat.” A substantial proportion of the soldiers interviewed gave evidence of

moral growth during the brief period of the invasion of Panama. In some cases they outgrew their

need for the U.S. Army; in others that portion of the

U.S. Army with which they were associated matured along with them to meet their new patterns of

needs. One of those needs was validation—which

is the topic of the next subsection. On a broader

level, the process by which military mental health

professionals can contribute to the institutional

maturation of the U.S. Army will be the subject of

the concluding section of this chapter.

Validation

Soldiers in combat experience a plethora of unpleasant emotions that can cause post-traumatic

stress disorders unless they are managed intelligently. Validation of their experiences, behavior,

and feelings is an essential part of the management

process. Comrades, leaders, subordinates, friends,

families, the public, and members of the mental

health/spiritual health community play roles in

validation.

The painful emotions that follow combat include

reactions to physical distress—hunger, fatigue, cold,

heat, prolonged exertion, heavy burdens, wounds,

and injuries. They include psychological distress—

fear, loss, shame, and guilt. Fear takes more forms

than can be counted: fear of death or injury, fear of

making a mistake, fear of abandonment, fear of

leaving loved ones in the lurch, fear of cowardice,

fear of being afraid and showing it—each soldier

has his personal closet of terrors. Losses include

friends, one’s own innocence and idealism, one’s

fantasies about oneself. Shame is more often for

feelings than behavior; most soldiers perform well,

but remember how much they wished they could

escape from having to perform. Guilt has many

facets—what they did, who they hurt, and hurts

that befell others but not them.

No one can escape these feelings; repressed they

can fester and give rise to future psychopathology.

Validation makes it easier to bring them out and

confront them, and can detoxify some of them. The

veterans of Panama reported three categories of

validation that were useful when they were available, and that they longed for when they were

absent. The first is symbolic validation—gestures

by people or institutions that defined the soldier’s

miseries and actions as virtuous. The second is

validation of losses by expiating guilt and reconciling the loss. The third is substantive validation—

interactions that integrate the individual soldier’s

sufferings into a stronger unit or army.

Symbolic Validation

Approval expressed by a remote, depersonalized

entity such as the U.S. Army, the media, or the

public is an important source of validation because

it is perceived as absolute, as independent of human judgment or prejudice. Herein lies the power

of medals, television coverage, and welcome-home

banners. Soldiers dealing with the shock and horror of what they have seen and what they have done

or failed to do feel better if an “Olympian” voice

proclaims their deeds meritorious and their cause

worthy. Infantrymen often feel that the hardships

of their branch set them apart, and that no one has

the right to pass judgment on what they do. Sometimes they turn up their noses at awards. But a

medal is a statement by the U.S. Army that what the
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soldier did was good, and to that extent it helps in

the reentry process.

Many soldiers who had fought in Panama felt

that they and their comrades were denied medals

because there had been a furor after the invasion of

Grenada in 1983 because the press reported that

more medals were awarded than there were people

participating in the operation: “We got shortchanged on awards because the [U.S.] Army was

embarrassed over Grenada.” Though the cultural

ethic is that “medals don’t mean sh__,” there was

bitterness in most units over the paucity of awards:

“The only guys who got awards were the ones who

got hit.” “PFC W spoke Spanish, so he was out in

front on every patrol. He never knew where the

bullet would come from, but he knew it would be

aimed at him. But he kept going out because we

needed him. He got zip.” “The first sergeant was

the most important person in the success of our

company. He was put in for a bronze star, but got

nothing.” “I was given a quota of four awards for

the company.” “I put in 47 guys for awards. We got

six. The colonel said the descriptions showed that

my people deserved the medals I had recommended, but there was a quota.” “The medals bit

was all politics. We didn’t have a general to fight for

us so we got very few.” Awards are the most

effective symbolic aid to validation the military has

at its disposal. Overdoing is a mistake, so is

underdoing. Because awards support successful

reentry, a liberal policy is less likely to do harm than

a restrictive policy.

The services have less control over the validation

provided by the media than they do over their own

system of recognition. A certain division may get a

disproportionate share of media coverage for any

number of reasons, including the influence the reporter covering it has with his superiors or the

interest his editors have in military affairs. Soldiers

in most of the units in Panama perceived that battalions from only one division got television coverage,

and that the others “might as well not have been

there.” Service members in Panama and the Persian

Gulf watched television and knew which units were

covered and which were not. Many soldiers expressed the feeling that because the activities of

their units were not reported in the visual or the

print media, their efforts had no significance. This

perception was not trivial; not to be covered was not

to exist. The impact of television as a source of

validation in American culture needs to be taken

into consideration.

Public opinion is a force yet less under the control of the armed forces than are the media, but it is

the third “Olympian” source of validation. The

high incidence of successful postwar adjustments

following World War I and World War II was probably a result of the intense national support for the

wars and the men who fought them. The prevalence of post-traumatic stress disorders following

the Vietnam conflict is most often said to be a result

of negative attitudes among the public toward returning veterans. It is interesting to note that the

single most pervasive and gratifying source of validation involved in Operation Just Cause was neither the American people, nor television, nor the

Army; it was the grateful and admiring behavior of

the Panamanians.

Validating Losses

The most difficult psychological problem veterans have to cope with is the death or maiming of

comrades, especially close friends. There is the

helpless feeling of loss: “I was looking at him and it

kept going through me, ‘He’s dead!” “I was giving

him CPR, and the medics were saying, ‘He’s gone.’

‘You can stop now.’ They tried to pull me away but

I shook them off. I couldn’t let him go.” Equally

difficult is survivor guilt: “He took my bullet.”

Leaders and medics had a particular kind of guilt

about not having done their utmost: “I keep going

over it in my mind, what could I have done differently so it wouldn’t have happened.”

Of particular importance from the reentry standpoint is that the dead should not have died in vain,

and that they not be forgotten. These are difficult

issues, because a death in battle is obscenely and

obviously a waste. Soldiers realize that it is all too

easy to forget those who are gone. They are horrified at the prospect that they, too, could die in vain

and be forgotten. Soldiers in Panama found memorial services and physical memorials to be important to them: “We had a memorial service the next

week. The guys in the squad organized it with the

chaplain and the first sergeant. It helped us to

realize that we didn’t have him anymore.” “We had

a last role call and taps. There wasn’t a dry eye in

the company. We had to go through it, and it

helped.” “His best friend and his squad leader

spoke. There wasn’t no brass in it. It was our

service.” Most units that lost members put together

monuments or trophy cases in the company to commemorate their fallen comrades. “Each time we go

in the dayroom we’ll think of him. It’s sort of like

he’s still in the company.” “We’re going to have a

plaque on a rock in front of the barracks. It’ll look

real sharp.”
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Postcombat Reentry

Senior commanders had different perspectives

about memorial services compared to enlisted men

and officers in companies. Junior personnel opined,

“The company service in Panama was healing. But

then we had another back here, and another for his

folks. What is all this?” “The colonel wanted

another memorial service back in the States. He

said it was for his friends back here to say good-bye

to him, but it looks like a photo opportunity. All the

senior brass came, and the press.” “The battalion

commander didn’t come to the memorial service in

Panama, he said his feet hurt. Then he made us turn

out for a formal service back here with photographers and all. The general came. Bunch of PR

bullcrap.”

The fates of wounded soldiers were a matter of

concern that had an impact on reentry. Soldiers

who were wounded but conscious often did not

want to leave the unit, and their comrades did not

want them to leave. Good sense always prevailed

and those whose injuries were serious were evacuated. But their comrades worried about them and

were persistent in their efforts to find out what had

become of them. Finding out was difficult because

they were evacuated by air to Texas, and there was

no direct way of getting word about them: “He was

evacuated and that was it. No one knew where he

was or how he was. It really bugged us.” Their

absence and condition remained an open point of

anxiety for the men in their units, and those who

returned were welcomed back.

Many soldiers who were too seriously injured to

stay in the service visited their units, or came back

to outprocess: “He came back. He was in a wheelchair. Christ, that was hard to take. He loved the

[U.S.] Army. But at least we could say good-bye.”

These reunions were important. The best situation

was when recuperating soldiers were on the same

post as their units, and they could visit each other.

One lieutenant said, “They’re going to be medically

discharged, but they’re still my men. I visit them

whenever I can, and they come do things with the

platoon when they’re able.”

Substantive Validation

Substantive validation not only helps the soldier

to manage his feelings and reenter the peacetime

world with minimal psychological distress, but also

strengthens the unit by reinforcing cohesion and

exchanging information gained through combat experience. The primary process of substantive validation is talk—talk among peers, between leader and

subordinate, and among the members of a squad or

platoon. The talk can be formal or informal, it can

be about military matters or about feelings. For it to

be effective it has to be forthright and honest. It can

only take place in a climate of trust.

The most important sources of substantive validation for a soldier are the men who shared the

battle with him. Foremost are his comrades in his

primary group; if his squad mates approve of his

behavior most soldiers can survive psychologically,

though they may be embittered that the approval

is not more general. There was a case in Panama

in which a soldier accidentally killed one of this

friends. He was devastated by the loss and horrified that he was the agent of his friend’s death. In

addition, he was placed under arrest, interrogated

by the criminal investigation authorities, and

faced a court-martial. There were no sources of

support from outside his squad. But his squad

mates, though they had liked the dead man, still

stuck up for him, insisted that it was an accident,

and maintained their bonds with him. This support

facilitates the psychological process described as

“concurrence,” which helps the soldier see that he

and his squad mates are alike and that he is not

an isolate. Concurrence is essential to psychological survival.47–50 It illustrates the power of the primary group bond. If his squad mates reject him, a

soldier is in a psychologically vulnerable situation.

External sources of validation can provide some

support, and it is essential that they be mobilized

fully and quickly.

Leaders who participated in the battle are usually the second most important source of substantive validation. Their effectiveness in the validation

process is a function of the esteem in which they are

held and the degree to which they shared their

subordinates’ danger and privation. Leaders who

are perceived as trustworthy and genuinely interested in their subordinates are credible sources of

validation. Together with primary group members,

they can alleviate much of the guilt and shame

soldiers bring with them out of combat. The mechanisms are listening, talking the battle through, sharing feelings: “We sat around with Sergeant P and

went over what we did. He’d say things like ‘That

must have scared you,’ and I’d think, ‘Yeah,’ and

somebody else would say he felt scared and then it

would seem okay, I wasn’t any more yellow than

anyone else.” “We had a secret place for the platoon

and we fixed it up. We’d go there at night and talk

it through. The lieutenant always came. Little by

little I got less uptight.”

The system of after-action reviews (AARs), that

is standard procedure after any operation to bring
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308

out the military lessons to be learned, is also an

important validation mechanism. Intended to enhance performance by a frank, mutual review of

what everyone did, AARs serve to get the sources of

guilt and shame out in the open. One soldier said:

“I thought I had really blown it when Smitty got hit,

but we went over it in the AAR and everybody said

they would have done the same thing I did.” The

AAR, conducted routinely by the team leader, will

be discussed later in this chapter.

Mental health professionals and chaplains

can provide substantive validation by helping veterans to interpret their experiences in psychological

or spiritual terms through debriefings or religious observances. In a way, these validations partake of the symbolic in that the chaplains invoke

the blessing of the deity and the mental health

professionals invoke psychological processes, all

of which are remote from the day-to-day world of

the soldier.

Successful reentry following the invasion of

Panama was the result of teamwork between line

leaders and members of the helping professions.

Because the concept of reentry is new, few members

of either community had worked out comprehensive plans for it. Inevitably, successes were episodic, but lessons can be derived from failures as

well as successes. This section is a compilation of

the positive and negative lessons that may lead to a

provisional program of mutually supportive action

by command and the helping professions.

Because of the paucity of mental health professionals in the armed forces, they are limited in the

number of soldiers they can help with reentry

through individual or group therapy or counseling.

Their effectiveness can be multiplied by sensitizing

chaplains, commanders, and unit medical personnel to reentry issues and their management. It is of

the utmost importance that the mental health staff

of a division or comparable headquarters respect

the battalion, squadron, or ship’s surgeon. The unit

medical staff shares danger and discomfort with the

combatants, and enjoys their trust. There is no

quicker way for a mental health team from a higher

headquarters to lose all influence than by treating

the unit medical staff—which is often headed by a

physician’s assistant or by a lieutenant or sergeant

without professional medical education—as inconsequential. On the other hand, if the mental health

team earns the respect and endorsement of the unit

medics, its acceptance by the combatants is much

more likely.

During peacetime training there are opportunities for the command mental health staff, unit medical officers, and NCOs to get to know each other

through case referrals and ongoing education programs. It is important for the mental health professional to be active and supportive in these interactions. Whenever possible, the division mental health

and supporting corps-level combat stress control

(CSC) unit teams should deploy to the field with the

line units. For on-post exercises this could be as

simple as an overnight, 2-day visit. Even better are

scheduled deployments to the combat training centers (National Training Center [NTC], Joint Readiness Training Center [JRTC], and the Combat Maneuver Training Center [CMTC]) during which the

mental health teams provide active mobile consultation. The mental health personnel in the Medical

Department activities (MEDDACs)—the Community Mental Health Services (CMHS) and the Departments of Psychiatry, Psychology, and Social

Work may not be able to deploy to the field, but can

conduct education and consultation activities in the

supported units’ work areas in garrison.

The program laid out here is designed to maximize the ability of military psychiatry to exert a

positive influence on successful reentry through a

combination of command consultation, participation in unit reentry programs, and direct psychiatric treatment.

Consultation on Command Action

Most of the work leading to successful reentry is

done by leaders from senior command (division,

corps, theater/fleet/air command) down through

squad and work group supervisors. Further, most

of the work that leads to successful reentry is part of

the normal routine of leadership and command.

The role of mental health professionals is to advise

commanders and to monitor those aspects of leadership behavior that are conducive to successful

reentry to see that they are not neglected or off-track

due to the leaders’ own stress or personal issues. In

the process of advising, military psychiatrists and

mental health workers can make themselves part of

commanders’ teams at every level and work toward

undermining the antipsychiatry bias they are likely

to find in most military units. There are four spheres

THE ROLES OF MENTAL HEALTH PROFESSIONALS
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Postcombat Reentry

of command activity on which the psychiatrist and

his staff should focus: (1) debriefings (called afteraction reviews [AARs] in the U.S. Army), (2) dissemination of lessons learned, (3) memorial services for

deceased members, and (4) decompression leave. (See

Chapter 11, Debriefing Following Combat.)

After-action reviews are prescribed techniques

in the U.S. Army for learning from mistakes and

successes. In training exercises, an AAR is to be

conducted following each phase of activity. In

combat, it should be conducted as soon as it is safe

for the leader to bring the team together. The AAR

is informal, solicits input from all participants, and

is nonpunitive. It has as its immediate purpose

finding out what worked, what needs to be improved, and how to improve it. A broader purpose

is to so improve the fighting capacity of units that

they can accomplish missions with minimal loss.

Along the way several intermediate purposes are

achieved such as strengthening cohesion, cementing trust, and opening communications. Members

of units in which AARs are a normal part of life are

accustomed to admitting when they were confused,

uncertain, or frightened, having their human weaknesses accepted, and getting help from comrades

and leaders on how to manage, overcome, or compensate for them. AARs following combat provide

superb forums for reliving and getting support for

the inevitable fears, failures, and guilt with the

people whose acceptance and approval are most

important. They provide firm foundations for successful reentry. Prior to combat, military psychiatrists and technicians should support commanders

in requiring open, honest, fear-free, professional

AARs. They can train the leaders to expand the

routine AAR into a team after-action debriefing

(AAD) which deliberately works through the emotional as well as operational issues, as discussed in

Chapter 11, Debriefing Following Combat.

The process of disseminating lessons learned by

combat veterans to new members of the unit or to

other units provides a means for validation as well

as enriching the combat know-how of those who

were not participants in the action. The combatant’s

perception that what he did is sufficiently important that it merits the attention of the service as a

whole goes a long way toward alleviating aversive

emotions attendant on combat. Because the future

of military operations is likely to include fairly

frequent short-duration, force-projection operations,

only parts of the armed services will be involved in

each of them. Those not involved will be eager to

learn what went on and what worked so that they

will be better prepared when their turns come.

Again the role of the military psychiatrist and mental health worker is to support commanders in their

resolve to use veterans in cross-pollinating other

units. It is good for the service, and it helps resolve

reentry problems for the veteran.

Memorial services are helpful for veterans in

coming to terms with losses. As noted above, they

can backfire if they are perceived as opportunities

for senior commanders to be photographed expressing their grief. Memorial services that were perceived by the rank and file as public relations events

drove deep wedges between commanders and subordinates, including subordinate commanders.

They were perceived as obscene exploitation of

subordinates’ deeply felt losses. Memorial services

must be for the service members who knew and

loved the deceased. Memorial services offer opportunities for the mental health workers and chaplains to cooperate in a sphere in which their interests are congruent. Their combined influence can

support commanders in using memorial services to

solidify vertical cohesion and facilitate the management of grief.

In this connection it is worth mentioning that

chaplains outnumber psychiatrists in a division by

a ratio of about 20:1, and the entire division mental

health team by 2:1. The chaplains are likely to have

much higher credibility in companies and battalions. The battalion chaplain is there for the soldier

in emotional and spiritual distress. He is part of the

unit, not some staff officer from division. Most of

them have won some measure of trust and acceptance in their units. They help soldiers’ families,

show up in the field, and are the channel for action

and solace when family tragedies strike. The folklore about chaplains includes heroism on the battlefield rescuing the wounded and comforting the

dying. Complimentary comments about chaplains

in Panama ranked just behind the almost worshipful love for company combat medics: “The chaplain

must have balls of solid brass to parachute into

combat without a weapon.”

On the other hand, no one had ever heard of a

“shrink” on the battlefield. A visit to the psychiatrist was usually perceived as a way station en route

to chapter action. When psychiatrists compete head

to head with chaplains for influence in military

units, the psychiatrists lose. On the other hand,

an alliance between the two enhances the effectiveness of both. They can catch a commander who

tends toward being indifferent to his subordinates’

needs between two fires. Chaplains are usually

easier to get time with than commanders, and

can provide access to commanders through the
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310

chaplains’ already established channels. Memorial

services are only one of many ways in which

chaplains and psychiatrists can help commanders

bring their units through reentry stronger than they

were before.

The mental health team has an important role in

supporting the chaplains, who are themselves subjected to extreme stress by the nature of their pastoral duties, especially in combat. The mental health

professionals can mentor and train the chaplains to

recognize serious psychiatric disturbance and know

when to refer soldiers for medical/mental health

evaluation. The mental health personnel and chaplains can debrief each other, to share the emotional

burden.

Decompression is the process by which soldiers

separate themselves progressively from the tension, fear, and horror of the battlefield. It includes

AARs, talking about combat experiences with comrades and with others who were not there, dreaming, and doing things totally different from combat.

After Panama there was a great deal of urgency on

the part of several commanders to get back into

training. (As the researchers talked to veterans of

Panama they recalled the British Regular Army

major who on 11 November 1918, was quoted [in

reference to the end of World War I]: “Well, at last

that’s over. Now we can get back to some real

soldiering.”) The longest leave identified in any

battalion was 14 days. A number of senior NCOs

and junior commanders were of the opinion that a

longer period would have brought the unit back

together with more zest for the next phase of training. One platoon leader said:

The battalion should have shut down for a month,

and part of the leave time should have been nonchargeable administrative leave—a kind of “thank

you” from a grateful nation. Personnel who felt

unready to return after a month should have had

the option of taking additional leave.

The short decompression leaves after Panama

left a number of soldiers feeling badly used. Further, they were still so keyed up from combat that

they saw the training as boring and beneath them

as veterans of real combat. Chaplains, company

medics, junior officers, and senior NCOs are in the

best position to judge the burned out state of their

people and how much leave they should have for

the unit to return most quickly to peak psychological readiness. The role of the mental health technicians and psychiatrist is to support commanders

in getting the leaves authorized using psychological

arguments.

Participation in Unit Recovery Processes

Mental health professionals can assist in the reentry process directly by limited participation in

some of the programs undertaken by units to facilitate the management of postcombat emotions. The

small number of mental health professionals available makes it impossible for them to participate

regularly in most of the programs, but they can

provide some direct support according to the guidelines in this chapter. There are three functions that

are within the capability of the mental health staff:

(1) short-term concentration on small units, (2) initiation of some group processes, and (3) occasional

participation in after-action reviews, end-of-tour

debriefings and prehomecoming information

briefings. Their effectiveness in all of these functions will be enhanced in scope and in duration to

the extent that they can sensitize and train the

battalion medical staff in psychologically supportive processes.

End-of-tour debriefings (EOTD) should be conducted by all small units before deploying home.

The unit leaders lead a discussion which reviews all

phases of the operation—notification or alert, mobilization, deployment, and the significant actions

up to the present. All participants are encouraged

to talk about what went well and what did not, the

good times and bad, noting lessons learned and

working through unresolved, painful, or controversial issues. Like the AAR, this must be well-led

to assure a positive sense of completion or closure at

the end. Trusted chaplains and mental health personnel can facilitate the process.

Prior to redeployment from the theater, all units

and soldiers should receive a prehomecoming briefing. This reviews what changes and expectations

are commonly encountered when soldiers, spouses,

and children are reunited after a prolonged separation. It provides tips on how to deal with these

predictable stresses. The families at home should

receive their version of the same briefing. Pocket

cards summarizing the briefing have proved useful

for both the service members and the families.

Sample cards are provided in Exhibits 12-1 and 12-

2. These briefings are often conducted by the unit

chaplains in the theater, and by the unit support

groups at home base, with input and attendance by

mental health personnel.

When units return from combat one at a time, the

mental health professionals should focus on them

for a week or at least a few days. Mental health

technicians should be informally available for soldiers to talk to. They should hang out in the mess
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Postcombat Reentry

EXHIBIT 12-1

HOMECOMING AFTER DEPLOYMENT DEALING WITH CHANGES AND EXPECTATIONS

With deployments come change. Knowing what to expect and how to deal with changes can make reunion

more enjoyable and less stressful. Below are some hints you might find helpful.

Expectations for soldiers

You may want to talk about what you saw and did. Others may seem not to want to listen. Or you may

not want to talk about it when others keep asking.

You may miss the excitement of the deployment for a while.

Some things may have changed while you were gone.

Roles may have changed to manage basic household chores.

Face to face communication may be hard at first.

Sexual closeness may also be awkward at first.

Children have grown and may be different in many ways.

Spouses may have become more independent and learned new coping skills.

Spouses may have new friends and support systems.

You may have changed in your outlook and priorities in life.

Expectation for spouses

Soldiers may have changed.

Soldiers, used to the open spaces of the field, may feel closed in.

Soldiers also may be overwhelmed by noise and confusion of home life.

Soldiers may be on a different schedule of sleeping and eating (jet lag).

Soldiers may wonder if they still fit into the family.

Soldiers may want to take back all the responsibilities they had before they left.

Soldiers may feel hurt when young children are slow to hug them.

What children may feel

Babies less than 1 year old may not know you and may cry when held.

Toddlers (1–3 years) may hide from you and be slow to come to you.

Preschoolers (3–5 years) may feel guilty over the separation and be scared.

School age (6–12 years) may want a lot of your time and attention.

Teenagers (13–18 years) may be moody and may appear not to care.

Any age may feel guilty about not living up to your standards.

Some may fear your return (“Wait until mommy/daddy gets home!”).

Some may feel torn by loyalties to the spouse who remained.

Source: US Department of the Army. Homecoming after Deployment: Dealing with Changes and Expectations. US Army

Medical Department Center and School, Combat Stress Actions Office, Fort Sam Houston, San Antonio, Texas. Modification

of materials prepared by 101st Airborne Division Mental Health Section for the Persian Gulf War (1991).

hall, day room, and barracks, for example, and

initiate conversations. Their purpose should be to

validate feelings and experiences. When opportunities present, these informal conversations could

expand into group discussions with the mental

health worker as facilitator. The psychiatrist should

dedicate his time to the battalion for the week, and

should focus on sensitizing leaders and working

with those individuals and primary groups that

experienced the most severe traumata.

When the simultaneous return of several units

precludes concentration on a single battalion, the

mental health staff should focus all its assets on

initiating group processes in squads and other primary groups in several battalions simultaneously.

The ease with which this can be done will be a
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312

EXHIBIT 12-2

HOMECOMING AFTER DEPLOYMENT TIPS FOR REUNION

Reunion is part of the deployment cycle and is filled with joy and stress. The following tips can help you

have the best possible reunion.

Tips for reunion with children

Go slowly. Adapt to the rules and routines

already in place.

Learn from how your spouse managed the

children.

Be available to your child, both with time and

with your emotions.

Let the child set the pace for getting to know you

again.

Delay making changes in rules and routines for a

few weeks.

Expect the family will not be the same as before

you left; everyone has changed.

Focus on successes with your children; limit

your criticisms.

Encourage children to tell you about what

happened during the separation.

Make individual time for each child and your

spouse.

Tips for soldiers

Support good things your family has done.

Take time to talk with your spouse and children.

Make individual time for each child and your

spouse.

Go slowly when reestablishing your place in the

family.

Be prepared to make some adjustments.

Romantic conversation can lead to more enjoyable sex.

Make your savings last longer.

Take time to listen and to talk with loved ones.

Go easy on partying.

Tips for spouses for reunion

Avoid scheduling too many things.

Go slowly in making adjustments.

You and your soldier may need time for yourself.

Remind soldier he is still needed in the family.

Discuss splitting up family chores.

Stick to your budget until you’ve had time to talk

it through.

Along with time for the family, make individual

time to talk.

Be patient with yourself and your partner.

Source: US Department of the Army. Homecoming after Deployment: Tips for Reunion. US Army Medical Department

Center and School, Combat Stress Actions Office, Fort Sam Houston, San Antonio, Texas. Modification of materials prepared

by 101st Airborne Division Mental Health Section for the Persian Gulf War (1991).

function of the level of trust and openness already

developed in the various units, in the degree of

hostility toward mental health professionals preexisting in the unit, and in the quality of the relationships between members of the division mental health

staff and the battalion medical platoon. The objective of the mental health staff is to get the groups up

and talking, and then turn them over to their own

leadership. With more than 30 primary groups in

each battalion it is imperative for the mental health

workers to move on as quickly as possible. In

battalions with strong traditions of AARs conducted

throughout the deployment, there may be little for

the mental health staff to do—members of those

battalions will already be working through their

feelings. In battalions with weak traditions of AAR

and unit medics who are not psychologically oriented, the mental health people will have to come

back to the same squads repeatedly. The psychiatrist will have to divide his time among all the

battalions to keep up to date on problems identified

by the chain of command and to maintain access for

his teams.

Mental health workers can assist units conducting AARs or end-of-tour debriefings to expand their

scope to include feelings as well as behavior,

making them after-action debriefings. The psychiatrist will usually have to solicit invitations to AADs

or EOTDs by explaining to commanders the

importance of the emotional dimensions for the
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successful reentry of the unit. The role of the mental

health worker at an AAR is to listen to the process,

and when given an opportunity, assist members

who appear to be repressing strong emotions

to express them. He can explain the potential of

AADs to help individuals manage their feelings

and to help units achieve a higher state of psychological readiness. The presence of mental health

personnel can be explained as an opportunity for

the latter to learn what real combat involves so that

they can be helpful to other combat soldiers in the

future. By emphasizing the readiness component it

is sometimes possible to convert the perception of

emotional expression from the realm of unmanly

and unmilitary “touchy-feely” to the realm of military competence. If after AARs, AADs, and EOTDs,

it is clear to the unit leaders that there are still

unresolved issues and bad feelings, those leaders

can be encouraged to schedule a critical event debriefing (CED), to be led by mental health personnel

trained in debriefing. While such debriefings are

best conducted within days of the critical event,

even weeks later may be better than not at all. The

acceptability of CEDs, like that of the critical incident stress debriefing (CISD) which are now widespread among civilian police, fire, and other emergency response agencies, has improved as they have

become common practice and proved their worth.

If at all possible, the CED should be conducted

while the unit is still in the theater, even if the

mental health team needs to be flown in for it. Such

activities are unlikely to be well received if they

must compete with reunions with families at the

home station.

Psychiatric Treatment

Though the emphasis so far has been on assisting

the relatively stable members of units to avoid serious psychiatric distress by seeding primary

groups with knowledge of how to conduct their

own group therapy, there will be individuals and

units that require concentrated support, or longterm support, or both from mental health professionals. The reasons are legion: particularly horrifying experiences, heavy casualties, inept leadership, poor precombat intragroup trust or communications, or preexisting psychiatric vulnerabilities.

The reason does not matter. The goals are to restore

the unit to a state of psychological readiness, and in

the process to relieve psychic suffering. The methods are standard group therapy and individual

therapy.

The critical issue is creating a climate of readiness to look to psychiatric staff for help. Sometimes

the distress is masked by various forms of denial or

acting out. The tasks of the psychiatrist are to alert

commanders to be on the lookout for aberrant conduct in individuals or primary groups, and to develop in commanders a readiness to support psychiatric intervention. In many cases it may be

advisable to seek the participation of all of the

members of a squad if one of them is in particular

distress. The individual may be the “designated

sickie” for the squad, or he may simply be the one

who was most affected. The task of the mental

health worker will be facilitated, and probably shortened, if he can engage the squad in the recovery of

one of its members.

SUMMARY AND CONCLUSIONS

The most common missions of the armed forces

of the United States have been and are likely to

continue to be rapid force projection operations of

short duration. Because history indicates that the

frequency of these operations is likely to increase,

the Army Medical Service must anticipate repeated

commitment of the same units and personnel to

combat.

Generally speaking, combat veterans function

more effectively and suffer fewer casualties than

green personnel, so repetitive commitment is not

fundamentally a problem. However, rapid deployment operations entail rapid transitions from peace

to war and back to peace, and these transitions have

been found to cause stress reactions that vary with

the individual and with the nature of his experiences. It is the task of military mental health professionals to take the lead in managing the emotional

aspects of short wars in ways that preserve and

strengthen the psychological readiness of units so

that they can perform with peak efficiency in the

next encounter.

Successful reentry following force-projection

operations has been the product of a partnership

between commanders, chaplains, the unit medical

staff, and mental health professionals. The psychiatrist and his staff are likely to understand the dynamics of reentry most clearly, but they are few in

number and they do not always enjoy acceptance

among military personnel. To gain acceptance,

mental health professionals should endeavor to

work with commanders, battalion surgeons/phy-
War Psychiatry

314

sician’s assistants, and units before combat. Alliances with the chaplains and the battalion medical

staff are effective ways to gain entry, and are essential if the mental health staff is to win the trust of the

combatants. But some chaplains will perceive the

mental health staff as competitors for the souls of

the members of the unit, and some unit medical

personnel will have negative attitudes toward psychiatry and all its works. If this cannot be overcome

by positive education and commitment, the mental

health staff may do better to devote its limited

resources to other units and let word-of-mouth

testimonials from those who have been helped by

the mental health team’s good work convince the

suspicious.

To compensate for their small numbers, the members of the mental health staff can transfer some of

their skills and understanding to chaplains,

commanders, junior leaders, and unit medics. The

best time to do this is before combat during training and practice deployments. Assisting commanders in developing mutual trust and confidence

across ranks, in including emotional material in

after-action reviews, and in restoring troubled soldiers to productivity can create a climate of readiness to confront mental health issues honestly

and without fear. When such a climate exists in a

unit, or in some of its subelements, many leaders

and medical aidmen will be able to acquire quickly

many of the supportive skills of mental health

professionals.

A second way to make the most of limited resources is to dedicate all of the mental health staff to

one unit for a restricted period of time—primarily

to transfer skills to leaders, but secondarily to alleviate anguish among members of units that have

been severely traumatized. This approach is feasible in peacetime, following a war in which only a

portion of the units in a command were committed,

or when committed units return on a staggered

schedule.

The psychiatrist and the other mental health professionals can be most effective when they operate

concurrently on three levels—staff, unit, and individual. On the staff level the psychiatrist supports

senior commanders (flag and general officers) in

policies that facilitate the management of reentry

processes: (a) decompression leave, (b) cross-pollination of lessons learned, and (c) validation through

awards, media coverage, and public information

programs. Advocacy of constructive reentry policies is likely to entail conflict with other staff officers with equally compelling agendas. The psychiatrist must be prepared to demonstrate that his

colleagues’ objectives are more likely to be achieved

if reentry is managed effectively.

On the unit level the mental health staff supports

intermediate commanders (brigade, group, battalion, squadron, and ship) by advising them on how

to develop trust and cohesion before commitment

to combat, and helping them work constructively

with postcombat reactions. These reactions are often

contradictory: heightened anxiety in some, new levels

of confidence in others; indifference to training, or

total commitment to training; abuse of spouse and

children, or decisions to marry and conceive; reluctance to ever be in combat again, or insatiable zest for

combat. Different types of behavior are required of

commanders, chaplains, junior leaders, and members of primary groups to ameliorate the dysphoric

reactions and foster the positive reactions.

The mental health staff can be most effective in

helping members of units sort out their postcombat

emotions if they have helped the unit in peacetime

to develop habits of open communications and readiness to deal with feelings during their AARs. After

combat, the mental health staff can support commanders in keeping primary groups intact, validating combat behavior, conducting memorial services

that promote rather than undermine cohesion, and

organizing training that manifests respect for the

combat achievements of the veterans.

On the individual level the psychiatrist and the

mental health staff assist individuals and groups

that have responded in dysfunctional ways to the

experience of combat with individual therapy, group

therapy, and unit therapy. Some of these interventions may be prolonged; others may lead to medical

separation. Their objective is to restore the psychological readiness of the individual and the unit for

combat. This does not mean brainwashing personnel to get them back into action at whatever cost to

their mental health. It does, however, add some

dimensions to classic psychotherapy. In the first

place, the therapist has allies not usually present in

a therapeutic setting—the service member’s comrades and leaders. In most cases these people will

have both a practical and an emotional interest in

restoring the patient’s effectiveness and balance. If

they are not interested in him, it is unlikely that he

will ever be able to function satisfactorily in the

service, and discharge is indicated. Another dimension is that military life is a rough business.

Each individual has his limit, and some reach it

early. The psychiatrist does neither the individual

nor the service any good if he returns to duty a

service member who is likely to decompensate in

the presence of further stress.
315

Postcombat Reentry

One final word about unit therapy. Whenever

possible it is helpful to treat a soldier who is distressed in the context of his primary group. The

methodology partakes of family therapy, and appropriately so; a small military unit functions emotionally as a family—and the unit medic is usually

a member of that family. However therapeutic the

goal of the intervention, the mental health practitioner must avoid the use of the term. Military

personnel do not take kindly to being labeled sick—

especially sick in the head. Euphemisms such as

“debriefings” or “development workshops” might

be seen through, but they are better than “group

therapy.” The approaches that have been most

successful emphasized strengthening combat readiness and psychological preparation of the group for

combat. Before battle, a soldier who describes himself, or who is defined before the group, as psychologically weak, will be extruded. His comrades

would feel that they could not depend on him; they

could not predict his behavior. After combat, manifestations of combat stress are accepted and the

group will participate in “helping Joe.” But the

other members of the group will not accept being

classified at the outset as having psychological problems—even when most of them do.

Mental health professionals have a decisive role

to play in managing reentry in ways that preserve

the emotional integrity of military units. Their

success will be a function of their sensitivity to

fighting men’s fears of emotional vulnerability, and

of their ability to help combat soldiers accept themselves and their vulnerabilities. It is a particularly

challenging facet of mental health work; it is one

that will pay immediate dividends in trust and

intimacy within units, and in lives saved.

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