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U.S. Army Combat Psychiatry

Chapter 7

U.S. ARMY COMBAT PSYCHIATRY

NICHOLAS L. ROCK, M.D., F.A.P.A.*; JAMES W. STOKES, M.D.†; RONALD J. KOSHES, M.D.‡; JOE FAGAN, M.D.§;

WILLIAM R. CLINE, M.D.¥; AND FRANKLIN D. JONES, M.D., F.A.P.A.¶

INTRODUCTION

The Mission of the U.S. Army

The Mission of the U.S. Army Medical Department

The U.S. Army Mental Health/Combat Stress Control Mission

History of U.S. Army Neuropsychiatry in Combat

U.S. ARMY COMBAT ENVIRONMENTS

Combat Troops

Combat Support/Combat Service Support Troops

The Medical Combat Health Support Troops

MEDICAL/PSYCHIATRIC ORGANIZATION AND THE COMBAT STRESS

COMPANY

The Mental Health Program

Basic Principles

THE FUTURE

SUMMARY AND CONCLUSION

*Colonel (ret), Medical Corps, U.S. Army; Formerly Chief, Department Psychiatry, Walter Reed Army Medical Center, Washington, D.C.;

Formerly Neuropsychiatric Consultant and Chief Drug/Alcohol Abuse, and Psychiatry and Neurology Consultant, Office of The Surgeon

General, U.S. Army

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

Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas 78234-6133

‡Assistant Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; President, Society of

American Military Psychiatrists

§Colonel, Medical Corps, U.S. Army, Special Assistant to the Deputy Director for Program Operations, Office of the Civilian Health

(CHAMPUS), Aurora, Colorado 80045-6900; Formerly Psychiatry and Neurology Consultant, Office of The Surgeon General, U.S. Army

¥Colonel, Medical Corps, U.S. Army, Walter Reed Army Medical Center, Washington, D.C.; formerly Neuropsychiatry Consultant, U.S. Army

Europe (USAREUR) and 7th Medical Command (MEDCOM)

¶Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past

President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; Formerly Psychiatry and

Neurology Consultant, Office of The Surgeon General, U.S. Army
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150

Samuel E.Alexander American Doctor II—Field Force Doctor Examines Vietnamese Child 1968

Samuel E. Alexander was a member of the U.S. Army Artist Program and was in Vietnam in 1967. His

painting depicts the other functions of U.S. Army Psychiatry in the theater of operations. When not

evaluating and treating combat stress casualties, or providing consultation services to commanders,

psychiatrists and other physicians routinely provide medical care to the local civilian population under the

MILPHAP (Military Public Health Action Program) which was unofficially known as the MEDCAP

(Medical Civilian Action Program).

Art: Courtesy of US Center of Military History, Washington, DC.
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U.S. Army Combat Psychiatry

INTRODUCTION

The Mission of the U.S. Army

The mission of the U.S. Army is to deter potential

enemies from using force against the interests and

security of the United States and its allies. If deterrence fails, the U.S. Army’s mission is to fight and

win the nation’s land wars, whether they be waged

with conventional weapons or weapons of mass

destruction. Throughout its history, and increasingly since the end of the Cold War, the U.S. Army

has also been tasked with numerous military operations other than war (MOOTW). These include

humanitarian and civil assistance, infrastructure

building, and disaster relief. Such missions can be

within the United States (classified as “domestic

support operations”) or in foreign lands; they do

not involve combat; and often involve medical personnel and medical units in lead roles.

Other military operations other than war are:

peacekeeping; noncombatant evacuation operations; search and rescue; intelligence gathering;

training missions to assist foreign countries with

internal and external defense; demonstrations or shows

of force; and the restoration of public order. In these

missions, it is hoped that U.S. forces can avoid or deter

combat, but must be prepared to defend themselves.

Missions to restore order, training missions in countries that are resisting armed insurgencies, and the

ambiguous category of “peace enforcement” can degenerate into sporadic low-intensity conflicts. The

U.S. Army must wage and “win” these armed conflicts short of war, although in these the political

objectives far outweigh the purely military ones.

Conflicts short of war include counterterrorism,

some counternarcotics operations, strikes and raids,

support for insurgencies, and counterinsurgency

(guerrilla) operations. Whatever the immediate

mission, all U.S. Army personnel of all branches

must be ready to perform their duties and defend

themselves in the extreme stress of combat.

The Mission of the U.S. Army Medical Department

The mission of the U.S. Army Medical Department (AMEDD) is to “conserve the fighting strength”

and to care for the sick and wounded. Patient care

responsibility is primarily to the active duty service

members, although the U.S. Army and the nation

recognize the importance of assuring quality medical care to retirees and to U.S. Army family members as part of sustaining a combat-ready force. U.S.

Army doctors, researchers, medical administrators,

and workers of many specialties have led the way in

preventive medicine. Contributions include sanitation and hygiene practices, the prevention and treatment of infectious diseases (from malaria and yellow fever to hepatitis and acquired immunodeficiency syndrome [AIDS]), and the identification of

the hostility (anger) factor as the chief contributor

to the risk of coronary artery disease in persons

with “Type A” personalities.

U.S. Army experience has stimulated dramatic

improvements in the acute stabilization, evacuation, and definitive treatment of severe physical

trauma. Recently, the combat support mission of the

U.S. Army Medical Department has been distilled

into six battlefield roles. From the front-line medic

to the continental United States {CONUS) hospital

staff, all AMEDD personnel must be prepared for

the personal stress of being in combat and for the

stress of caring for wounded combat casualties.

The U.S. Army Mental Health/Combat Stress

Control Mission

The primary mission of U.S. Army psychiatry

and the mental health team is to conserve the fighting strength by assuring a sane, stress-tolerant,

mission-effective force. This must be accomplished

in considerable part by assisting the chain of command (officer commanders), the chain of support

(noncommissioned officers), and the chain of concern (chaplains, other special staff, unit medical

personnel, rear detachments, and family support

groups) with professional advice, education, and

assistance. It also involves screening out the mentally unsuitable and psychiatrically disabled. Direct care involves treating or counseling soldiers

with temporarily distracting problems or disabling

mental disorders to quickly restore them to effective duty. It also involves initiating the longer-term

treatment of those who must be separated from the

military.

The U.S. Army Mental Health/Combat Stress

Control team in combat fulfills the AMEDD’s six

battlefield rules as delineated in Exhibit 7-1. In

1984, Combat Stress Control (CSC) was finally recognized as an autonomous AMEDD (and U.S. Army)

battlefield functional area. This was the delayed

culmination of an honorable history in which U.S.
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EXHIBIT 7-1

HOW COMBAT STRESS CONTROL FULFILLS THE ARMY MEDICAL DEPARTMENT’S

IMPERATIVE ROLES

Maintain presence with the soldier

The combat stress control concept places behavioral science experts forward on the battlefield and

throughout the theater, where they provide immediate, on-site training, mentoring and assistance to

leaders (especially at company grade), medical personnel and unit ministry teams, and the soldiers.

Maintain the health of the command

The actions of the combat stress control team prevent stress casualties, and enhance unit cohesion, soldier

performance, and organizational capability under stress. They enhance mental health effectiveness of the

command’s Family Support Groups, through regular advice and liaison. By contributing directly to

mission accomplishment, combat stress control also reduces other types of casualties.

Save lives

The combat stress control personnel save lives directly by identifying and stabilizing those neuropsychiatric

or stress cases whose disturbed behavior endangers themselves or others. In a world of lethal weapons,

suicidal, homicidal, or psychotic behavior can create mass casualties. Correctly diagnosing surgical and

medical emergencies which have been mislabeled as psychiatric behavior also directly saves lives. The

combat stress control personnel save lives indirectly by enhancing decision-making and mission execution through command consultation.

Clear the disabled from the battlefield

The combat stress control team contributes to clearing the battlefield by identifying and stabilizing for

transportation those psychiatric cases who need rapid evacuation, while screening out and treating the

much larger number of stress cases who can quickly return to duty far forward. Without combat stress

control, these cases overload the limited evacuation assets or interfere with operations.

Provide quality care

Combat stress control personnel assure appropriate quality of care at each echelon for battle fatigue and

psychiatric cases. For battle fatigue cases, premature evacuation can cause permanent disability, and

constitutes malpractice unless it is unavoidable under the tactical situation. Also, the American people

clearly expect the Army to take all feasible measures to prevent misconduct stress behaviors and posttraumatic stress disorders in our soldiers. Through their top priority consultation-liaison mission, the

multidisciplinary combat stress control team personnel train, mentor, and provide technical supervision

throughout the Army medical, combat service support, and combat arms systems to assure quality stress

and mental health care to all soldiers. Through their advice and liaison mission to unit leaders, family

support groups, and the supporting medical systems in garrison and Reserve Component units, they

extend this quality assurance to the Total Army family.

Return soldiers to duty

The combat stress control organization returns many soldiers to duty quickly. This reduces the burden

on the evacuation system and returns trained, seasoned soldiers to their own units, instead of unknown,

combat-inexperienced replacements who have to be flown into theater. It also benefits the casualties’

future mental health.

Army neuropsychiatry and its allied mental health

professions established doctrine, organization, and

an operational concept that was truly distinct from

the rest of U.S. Army medicine.

The American soldier of today is highly technically trained and not easily replaced in a short time.

The prevention of stress casualties and the early

return to duty of stress-disabled soldiers requires

Adapted from the Draft Concept Statement of the Combat Stress Control Panel, Medical Re-Engineering Initiative, AMEDD

Center and School, Fort Sam Houston, Texas, April 1994.
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U.S. Army Combat Psychiatry

more focus in peacetime on neuropsychiatry and

mental health programs in preparation for mobilization. The transition of mental health professionals from a civilian practice to military can take 6

months and may be too late to be effective at a time

of national emergency. The mental health personnel must master military-specific clinical and organizational skills which have no civilian counterparts. Direct application of civilian mental health

experience to combat stress cases or functioning

military units can cause harm. Military stress control expertise must be acquired by military providers working in the military unit context, not in a

garrison version of civilian direct-patient care. The

operational planning and coordination of stress

control in war and operations other than war requires that experienced mental health staff officers

and noncommissioned officers (NCOs) be integral

members of medical, U.S. Army, and joint services

command headquarters.

History of U.S. Army Neuropsychiatry in Combat

The history of U.S. Army neuropsychiatry is covered in considerable detail in Neuropsychiatry,1 the

history of neuropsychiatry in World War I, and in

Neuropsychiatry in World War II,

2,3 the two volume

series. Chapter 1 of this volume, Psychiatric Lessons of War, also discusses the history of military

psychiatry, especially in terms of the evolution of

concepts. The following discussion highlights the

important conceptual and historical developments

in military psychiatry while emphasizing the structural components of the delivery of patient care.

The materials presented draw heavily from those

found in the official histories.1-3

The U.S. Army began as the Continental Army

under the leadership of General George Washington. There was no subspecialty of psychiatry or

other mental health professions at that time, although chaplains supported the spiritual and moral

health of the troops. Dr. Benjamin Rush served as

the prototype Surgeon General from 1776 to 1778.

Rush advocated abstinence from alcohol. Later, as

a civilian physician at the Pennsylvania Hospital,

Rush preceded and paralleled the more famous

French physician, Philippe Pinel, in championing

the “moral treatment of the insane.” He advocated

asylums in the quiet countryside for the mentally

ill—clean buildings with bathing facilities, where

violent patients were kept separate from passive

ones and all were treated with kindness, work, and

diversion (occupational therapy). He wrote “We

assume that insanity has its seat in the mind. And

nevertheless we attempt with remarkable inconsistency to cure it by physical methods. The disease

affects the body and mind alike and can be cured

only by methods which reach both.”4(p28)

In the Continental Army and the U.S. Army which

it became, the importance of morale or “esprit de

corps” was recognized. It was needed to keep

soldiers steady in the line of battle and to prevent

desertion in the long periods of inactivity under

deprived conditions far from home, such as the

winter at Valley Forge during the American Revolutionary War. Also recognized were many of the

same mental health disorders seen today, although

without the current more elaborated diagnostic

understanding: alcohol abuse and alcoholism

(“drunkenness”), homesickness and chronic situational depression (“nostalgia”), and more overt

psychotic disorders (“insanity” and “melancholia”).

Joseph Lovell, the Surgeon General from 1817 to

1828 and an advocate of temperance who eventually succeeded in abolishing the daily rum ration,

attributed more than one half of the deaths in the

U.S. Army over that period to alcohol.5(p29)

In 1852, Dorothea Dix persuaded Congress to

fund the U.S. Government Hospital for the Insane

(now St. Elizabeths Hospital). The Government

Hospital was to receive the insane of the U.S. Army

and U.S. Navy. However, during the Civil War, so

many insane Union soldiers were discharged locally to find their own way home that complaints

led to an 1864 War Department order requiring

transfer to the Government Hospital until the soldiers’ families could come for them.

Nostalgia cases in the Civil War numbered 5,547

(with 74 deaths). It is likely that the differentiation

between nostalgia (“a species of melancholy or mild

type of insanity caused by disappointment and longing for home”) and physical diseases such as tuberculosis was not always made. Little treatment was

attempted, and most cases were discharged home.6

“Functional heart disease” was described by

DaCosta in 1862, who also termed it “the irritable

heart of the soldier.”7 The condition usually originated in combat as a prompt and persistent tachycardia (120–130 bpm) on slight exertion. DaCosta

reported that most cases improved with hospitalization and tincture of digitalis three times a day.

On one occasion when 4,900 soldiers were discharged from the Union Army, 2,300 were diagnosed as heart disease, of which 1,200 were “functional.” Today, a patient presenting with a

psychophysiological manifestation of hyperarousal
War Psychiatry

154

and conditioned anxiety might well be considered

an “evacuation syndrome.”8

The first formal training in psychiatry to Regular

Army Medical Officers began at the U.S. Army

Medical School, consisting of four clinical sessions

at the Government Hospital. There were also lectures in military law and malingering. By 1915, the

total training in mental illness had increased to 24

hours.

Perhaps the first organized military mental health

unit was with the Russians in the Russo-Japanese

War (1904–1906).9 During this war the Russian Red

Cross established mental health programs and recording of neuropsychiatric cases. In addition physicians, functioning as neuropsychiatrists, were put

as close to the front as possible to perform special

evaluations of nervous and mental cases. Eventually other countries developed such programs during World War I.

As World War I was waged in 1914 and 1915,

newspaper and journal reports of “shell shock” (“le

syndrome commotionnel”) aroused interest among

U.S. psychiatrists. Prominent American psychiatrists during World War I advocated to the U.S.

Army Surgeon General (Major General Gorgas) the

formation of a psychiatric organization. The plan

included developing psychiatric units in general

hospitals staffed by psychiatrists throughout the

United States.

Dr. Thomas Salmon,10 medical director of the

National Committee for Mental Hygiene, offered

the committee’s services to the U.S. Army. He and

others visited U.S. Army medical facilities supporting the operations against Pancho Villa in Mexico

and Canadian hospitals with psychiatric evacuees

from France. In 1917, Dr. Salmon visited England

for several months. By then, the psychological

nature of “war neurosis” and the value of forward,

brief treatment had been well documented by the

French and confirmed by the British. Dr. Salmon

recommended to the U.S. Army Surgeon General

that a similar echeloned system of prevention and

treatment be adopted. When the United States

entered the war, Salmon was commissioned a major. He was appointed Director of Psychiatry to the

American Expeditionary Forces (AEF) in December

1917, and immediately implemented his plan.1

The experience of the French and British medical

services showed, within a very few months after

the beginning of the war, that patients with war

neuroses improved more rapidly when treated in

permanent hospitals near the front than at the base,

better at casualty clearing stations and postes de

chirurgie d’urgence than even at advanced base

hospitals, and better still when encouragement,

rest, persuasion, and suggestion could be given at

a combat organization itself. It was for the purpose

of applying this well-established fact that plans

were made to station a medical officer with special

training in psychiatry and neurology in each combat division, since the division was to be the great

combat unit of the American Army in France. It

was deemed impractical to consider detailing a

consultant in neuropsychiatry to a combat unit

smaller than the division.1(p303)

By order of the chief surgeon of the AEF, the

division psychiatrists were under the direction of

the chief surgeons of the division, but were not

members of the division headquarters staffs. Rather,

they were attached to the “sanitary trains” (the

equivalent of the current medical units that are

organic to the division). Later, Salmon concluded

that putting the psychiatrists in the headquarters

under the chief surgeons worked better. The

psychiatrist’s specified duties included examining

all cases of mental or nervous diseases (including

malingering and self-inflicted wounds) and advising on their diagnosis, management, and disposition; forensic testimony when requested; giving

“informal clinical talks” to medical officers and

others on the nature, diagnosis, and management of

the disorders; keeping careful records of all cases;

and submitting regular reports to and advising the

chief surgeon.

The division psychiatrist was stationed at the advanced field hospital, or triage, and his range of

activity extended forward to the ambulance dressing stations and beyond as far as he cared to go and

backward as far as the rear field hospital, which

was the unit treatment center [ie, still within the

division]. The triage, or sorting station, was apt to

be anywhere from 2 to 9 miles, or more, from the

front line, and the treatment field hospital 4 to 7

miles further removed. The former was usually an

abandoned strong barn; and the latter, generally

under canvas, capable of caring for about 150 patients in five or six large tents. At the treatment

field hospital the division psychiatrist was generally able to count on one enlisted man...to care for

each 15 patients.... An assistant divisional specialist would have proven a valuable adjunct. It is true

that even with an active combat division there were

times when there was scarcely enough [patient

care] work to keep the division psychiatrist occupied; yet these periods were succeeded by days

or weeks of stress and strain...when the services of

a trained assistant would have been invaluable.

The small “pool” of neuropsychiatrists under the
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U.S. Army Combat Psychiatry

control of the corps or army [neuropsychiatry]

consultant proved a useful means of meeting this

need.1(pp309–310)

At the forward triage, the division psychiatrist

sorted all nervous cases, returning directly to their

combat units those who should not be permitted to

go to the rear and resting, warming, feeding, and

treating others, particularly exhaustion cases, if there

was opportunity to do so.1

Salmon had learned from British experience the

importance of not using dramatic or diagnostic

labels for stress casualties, and adopted the British

policy of using “N.Y.D.N.” for “not yet diagnosed

(nervous).” This avoided the suggestion of physical brain injury implied in the dramatic name “shell

shock” or the implication of mysterious psychiatric

illness implied by the official diagnosis, “war neurosis.” Under optimal conditions, over 70% of the

casualties held for treatment at the 150-cot field

hospitals in the division rear returned to duty within

5 days. However, when the tactical situation forced

the emptying of the field hospitals after only two

days of treatment, the return-to-duty percentage

dropped to 40%.1(p333)

The second echelon, only a few miles behind the

divisions, was the three neurological hospitals.

These were located in old French barracks buildings, staffed by general medical personnel and commanded and supervised by psychiatrists. The sole

function of these 150-bed units was to provide additional brief rest and intensive rehabilitation for those

NYDN cases who had had to be evacuated from the

divisions. About 55% of these cases returned to

duty after an average of two weeks.

The third echelon, further to the rear, was Base

Hospital No. 117, whose sole purpose was to provide several weeks of even more intensive reconditioning treatment to the soldiers who had not returned to duty from the neurological hospitals or

who had somehow slipped through the first two

echelons and been evacuated to regular hospitals.

Another base hospital, No. 116, was the neuropsychiatric specialty hospital dedicated to the “true”

neuropsychiatric cases who were judged not suitable for return to duty. Base Hospital No. 117 also

had a high rate of return to duty, although many

were to noncombat jobs in the rear. The staff of Base

Hospital No. 117 included psychiatrists, U.S. Army

psychiatric nurses, on-the-job-trained enlisted medics, and civilian volunteer occupational therapists.

The official history describes in detail the importance of the nursing staff in establishing and maintaining a positive, return-to-duty ward morale. The

occupational therapists provided both shop work

and outdoor work details; the official history emphasizes the importance of these tasks in restoring

confidence. In the last weeks of the war, occupational therapists were sent forward to the neurological hospitals where they enabled some soldiers

to return to duty who otherwise would have been

evacuated to Base Hospital No. 117.

In the continental United States, the American

Red Cross established a psychiatric social worker

program to aid military patients. Clinical psychology programs were not recorded at that time.

It should be apparent from this brief history that

the forbears of military psychiatry during World

War I knew much of what is known today about

combat stress casualties, and practiced prevention

and treatment very well. It was recorded in the

official history, but then forgotten.

From World War I to World War II hospital

psychiatry functions continued, but unlike the assignment of medical and surgical consultants, there

was no representation of the mental health specialties on The Surgeon General’s staff. At the beginning of World War II Harry Stack Sullivan, psychiatric consultant to the Selective Service Commission,

promoted policies that resulted in the rejection of

young men being conscripted if they showed any

taint of anxiety or neurotic tendencies, including

so-called “neuropathic traits” such as nail biting,

enuresis, or running away from home. These policies were also applied to soldiers after induction,

resulting in what Ginsberg et al11 labeled “lost divisions” of about 2.5 million men. Of 18 million

screened, nearly 2 million were rejected because of

an emotional or mental defect and another three

quarters of a million were prematurely separated

for the same reasons. The total ineffective group

included approximately one out of every seven men

called for service.11

Besides the absence of representation at the War

Department or even the Department of the Army

(DA) staff, the division psychiatric positions were

abolished in 1939 as unnecessary. In August 1940,

Lieutenant Colonel (later General) Patrick Madigan

was assigned to the Professional Services Division,

Surgeon General’s Office, but his duties were purely

routine and administrative. Not until February

1942, after the attack on Pearl Harbor, was he able to

upgrade his position to a Neuropsychiatry Branch

under the Professional Services Division. However, in 1941 troop clinics were established outside

of the hospitals and psychiatrists were assigned. A

training center at Fort Monmouth, New Jersey, developed a community clinic in early 1942 and had
War Psychiatry

156

an enlisted social worker and later an enlisted psychologist to assist the psychiatrist. This program

led to the establishment of the Mental Hygiene

Consultation Service (MHCS) at all replacement

training centers. Its purpose was to help the maladjusted trainee. This concept of MHCS continues to

the present in the Community Mental Health Services in the Medical Activity of each post.12

World War I style forward treatment was relearned during two battles of the Tunisian Campaign in March and April 1943.3 Captain Fred

Hanson, who served with Canadian forces prior to

U.S. entry into the war, was assigned with American forces in North Africa. Hanson may have been

familiar with Salmon’s principles because the British were using The Medical Department of the United

States Army in the World War, Volume 10, Neuropsychiatry in their planning.1

 He avoided evacuation and returned more than 70% of 494 neuropsychiatric patients to combat after 48 hours of

treatment, which basically consisted of resting the

soldier and indicating to him that he would soon

rejoin his unit. On April 26, 1943, in response to the

recommendations of his surgeon, Colonel Perrin

Long, and psychiatrists, Captain Hanson and Major

Tureen, General Omar Bradley issued a directive

that established a holding period of 7 days for

psychiatric patients and further prescribed the term

“exhaustion” as the initial diagnosis for all combat

psychiatric cases. The word exhaustion was chosen

because it conveyed the least implication of mental

disturbance and came closest to describing how the

patients really felt. Division psychiatrists were

hastily reassigned. This move proved its worth in

the Italian campaign.

The ineffective psychiatric criteria for screening

at initial entry were also tightened to disqualify

only the overtly psychotic or seriously mentally

retarded. A later study demonstrated that the “neurotics” who would have been screened out by the

earlier criteria were not significantly more likely to

become stress casualties or less likely to be decorated for valor than the men who had passed that

screening.

Colonel (later Brigadier General) William C.

Menninger became The Surgeon General’s Chief of

the Neuropsychiatry Branch in December 1943, and

the branch became a division, on an equal level with

medicine and surgery, in January 1944. A School of

Military Psychiatry, plus some civilian schools, addressed the serious shortage of psychiatrists. Initially, a 4-week course trained physicians who already had more than a year of psychiatric training.

Later, a 12-week course was conducted to prepare

physicians with no psychiatric training to function

in psychiatric positions.

By late in the war, the Mediterranean and European theaters had psychiatrists assigned to each

division, although some divisions received only

inexperienced general medical officers. Many maneuver battalions had “rest centers” in their “kitchen

trains,” where exhausted soldiers were monitored

by the nearby battalion surgeon. There were “exhaustion centers” in many regimental or combat

command “trains” (equivalent to today’s brigade

support areas), run by the adjutant but monitored

by the regimental surgeons. Combat exhaustion

cases were rested here for several days. In some

divisions, company commanders were even required to select some number of individual soldiers

for rotation back to these centers for brief “R and R”

(rest and recreation). It was the primary duty of the

division psychiatrist to train the battalion and regimental surgeons in the principles and practice of

combat psychiatry. Toward the end of the war a

distinguished group of civilian psychiatrists were

commissioned to evaluate U.S. military psychiatric

treatment in Europe. They found that about half of

the stress casualties were never recorded because of

the success of forward treatment at the battalion

and regimental aid stations and rest centers.13

During combat late in World War II, the division

psychiatrists in Europe triaged and treated more

severe combat exhaustion cases at the division clearing company in the division rear, holding them for

1 to 2 days. They then supervised their further

rehabilitation for 3 to 5 days at the division’s Training and Rehabilitation (T&R) Center. The T&R

Center was controlled by the Adjutant, and staffed

with combat veteran officers and NCOs, often ones

who were on profile with minor wounds or injuries

(including combat exhaustion!). The soldiers shared

pup tents and were led through a program of calisthenics and realistic combat drills, often conducted

in the ruins of nearby towns that had been recent

battlefields. Return-to-duty rates from the T&R

Centers ranged between 50% and 70%.14

Behind the divisions, there were U.S. Army-level

Neuropsychiatry Centers. These were 250-bed holding companies with supervisory psychiatric staff.

Like the World War I Neurological Hospitals, these

received the cases that the division psychiatrist

judged too disruptive for the division clearing company and T&R Center, plus those who failed to

respond sufficiently to the 5- to 7-day treatment,

and the overflow caused by tactical demands.
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U.S. Army Combat Psychiatry

The Neuropsychiatry Centers continued the

highly structured program of physical reconditioning, hot showers, good food and comfortable cots,

and recreational and work activities. Some of these

soldiers returned to their original units. Others

were sent to nearby combat service support units

for further useful “occupational therapy” and reclassification into support roles. The few who failed

to respond were sent to base hospitals with psychiatric wards. Approximately 90% of the stress casualties who received specialized psychiatric care were

returned to useful duty in the theater.

In addition to rediscovering the principles of

treatment applied so effectively in World War I, and

the ineffectiveness of large-scale screening, World

War II psychiatrists learned about the epidemiology of combat stress casualties. They documented

the direct relationship to intensity of combat, modified by physical and morale factors, and the importance of unit cohesion both in preventing breakdown and in enhancing combat effectiveness.

During the war, prospective studies conducted by

Stouffer et al15 conclusively showed that units with

good morale and leadership had fewer combat stress

casualties than those without these attributes when

variables such as combat intensity were comparable. Regarding combat intensity it was found that

there was a direct relationship between combat

intensity as measured by rates of wounded and

killed in action and psychiatric casualties.16

Another finding during World War II was the

chronology of breakdown in combat. It had long

been recognized that “new” and “old” men in combat units were more prone to breakdown. “New” or

inexperienced troops were more likely to become

stress casualties, and have usually accounted for

over three fourths of stress casualties; however,

with increasing exposure to combat after 1 or 2

combat months, an increasing rate of casualty generation also occurs.17 Beebe and Appel18 analyzed

the World War II combat attrition of a cohort of

1,000 soldiers from the European Theater of Operations (ETO) and found that the breaking point of the

average rifleman in the Mediterranean Theater of

Operations (MTO) was 88 days of company combat,

that is, days in which the company sustained at

least one casualty. A company combat day averaged 7.8 calendar days in the MTO and 3.6 calendar

days in the ETO. They found that due to varying

causes of attrition including death, wounding, and

transfers, by company combat day 50 in both theaters 9 out of 10 “original” soldiers had departed. In

their projections Beebe and Appel found that if only

psychiatric casualties occurred, there would be a

95% depletion by company combat day 260; however, due to other causes of attrition (transfer, death,

wounding, illness), the unit would be virtually depleted by company combat day 80 or 90, approximately the breaking point of the median man.18

From studies of cumulative stress such as these

as well as observations of the efficacy of a “point

system” (so many points of credit toward rotation

from combat per unit of time in combat or so many

combat missions of aircrews) used during World

War II, the value of periodic rest from combat and

of rotation came to be understood and applied in

the Korean and Vietnam conflicts with fixed

combat tours. The fixed tours did, however, result

in the “short-timer’s syndrome,” an anxious, tense

state not uncommon in combat participants during

the final weeks of the stipulated tour of combat

duty.19,20

The final and perhaps most important lesson of

World War II was the importance of group cohesion

not only in preventing breakdown, but also in producing effectiveness in combat.19 Cohesion is so

important in both prevention and treatment of psychiatric casualties that Matthew D. Parrish, an eminent psychiatrist who served in combat aircrews

during World War II and as U.S. Army Neuropsychiatry Consultant in Vietnam, has suggested it

as another principle of forward treatment that might

be termed “membership.”21

After World War II key commands kept neuropsychiatric consultants, particularly in Europe and at

the Department of the Army. The specialty of social

work officer was established along with the conversion of the enlisted psychologist from the Sanitation

Corps to an officer in the Medical Service Corps.

The experience of World War II was documented

in the two-volume official history, Neuropsychiatry

in World War II.

2,3 This included the plan for the way

that special neuropsychiatric teams would support

the division mental health capabilities and provide

backup and mobile consultative support in the corps.

However, the U.S. Army was substantially deactivated in the late 1940s, and the invasion of South

Korea by North Korea caught the United States

unprepared. Task Force Smith, hastily mobilized

from garrison troops in the Pacific area and reinforced by reactivated World War II veterans from

the United States, suffered heavy losses in killed,

wounded, and captured during the retreat to the

Pusan perimeter. Although the veterans remembered that combat exhaustion cases ought to be

treated in the combat zone close behind their units,
War Psychiatry

158

most were unavoidably evacuated to Japan. There,

proper treatment at the hospitals salvaged many for

combat service support duties, but very few returned to combat duty.

After the first months of the Korean conflict,

Colonel Donald Peterson, the Neuropsychiatry

Consultant, assigned Lieutenant Colonel Albert

Glass as the Neuropsychiatry Theater Consultant

for the forces in Korea. Glass22 immediately established a comprehensive mental health program. He

had served in World War II and was able, based on

his experiences, to quickly organize an effective,

forward program that has remained the basis for

current military mental health programs. The division mental health sections were trained to provide

active training to the regimental and battalion surgeons. In addition, the Table of Organization and

Equipment (TO&E) was developed for a mobile

psychiatric detachment. This new unit was designated a “KO Team.” “KO” was not an acronym.

Rather, it was only one in a series of “K” teams, with

“K” arbitrarily indicating that these were hospital

augmentation detachments. The first KO teams

were deployed to Korea, where they reinforced the

division mental health sections at times of heavy

fighting, and could enhance the use of a divisional

clearing company as a temporary exhaustion center. They also provided mobile consultation

throughout the corps and U.S. Army areas, like the

fictitious psychiatrist, Major Sidney Greenfield, did

on the television series “MASH.”

In April 1952, a third-echelon treatment facility

(equivalent to Base Hospital No. 117 in World War

I) was established near Seoul by adding a psychiatric detachment to a 300-cot medical holding company. This facility had an average census of 45

soldiers with an average duration of stay of 7.4

days. It returned 76% to duty.23

A comparison of treatment efficacy data near the

end of World War II and the 1953 Korean conflict

reveals the following: World War II—60% of psychiatric casualties were returned to duty within

their own division, while in Korea it was 88%;

World War II—90% were returned to duty somewhere in the combat theater compared to 97% in

Korea.23 In 1957, the first version of Army Regulation 40-216, Neuropsychiatry and Mental Health, codified the roles and responsibilities of division psychiatry in wartime and peacetime.

The first U.S. Army psychiatrist to be assigned in

Vietnam, Major Estes G. Copen24 provided support

to approximately 8,000 American advisors. He noted

the prevalence of misconduct and psychosomatic

complaints among the service support troops, in

contrast to those in combat units, that was to become the hallmark and curse of the Vietnam conflict. With the buildup beginning in July 1965,

divisions deployed to Vietnam, each with their one

division psychiatrist, and social work officer, plus

two enlisted specialists with their medical company

supporting each brigade. The enlisted specialists

were often college or graduate level draftees with

behavioral science training. They staffed mental health

consultation services at the division base area and

went forward when appropriate to the brigade and

battalion fire bases. The theater neuropsychiatrist

consultant established his office at Headquarters,

U.S. Army Vietnam in November 1965.

The first KO team to deploy was activated at

Valley Forge General Hospital in Pennsylvania in

October 1965, deployed by ship 29 November 1965,

and was operational by January 1966. It consisted

of three psychiatrists, one neurologist, two social

workers, one clinical psychologist, one psychiatric

nurse, and 12 to 15 enlisted social work, psychology, and neuropsychiatric specialists. Its mission

was to establish a “Psychiatry and Neurology Treatment and Evacuation Center” in Vietnam. (The

adoption of this title at that time is interesting in

that it emphasizes the two functions that current

doctrine, as practiced in the Persian Gulf War, would

deemphasize. The more “doctrinally correct” translation might be the “Psychiatry and Neurology

Evaluation and Return to Duty Center.”) The center

provided psychiatric and neurological evaluation

and treatment for up to 30 days as inpatients, if

necessary, prior to evacuation to the continental

United States or return to duty. The detachment

was assigned to an evacuation hospital 20 miles

northeast of Saigon, where it occupied its own

Quonset buildings. It quickly also established an

active MHCS for the many units in the vicinity that

lacked organic mental health services.

Despite its title, the Psychiatry and Neurology

Treatment and Evacuation Center aggressively applied the time-proven principles of combat psychiatry and returned about 90% of its inpatients to duty.

It maintained a military-, not patient-, care milieu

with strong expectation of return to duty. Although

distant from most of the tactical units, the center

maintained a psychological proximity and unit identity by requesting the parent unit to make regular

visits to its soldier, bring his mail, and give him his

pay on the ward. The ubiquitous helicopters made

this possible, and most line commanders cooperated fully with the visitation program.
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U.S. Army Combat Psychiatry

Less than 5% of the caseload presented with welldefined psychiatric illnesses. The majority of soldiers referred to the KO team had behavioral difficulties or somatic complaints. The latter were either

physiologic manifestations of stress (headache, back

pain, gastrointestinal symptoms, syncope and vertigo conversion-type symptoms affecting vision,

hearing, speech, pseudoseizures, “narcolepsy” or

somnambulism, and amnesias. The KO team also

provided extensive consultation to medicine and

surgery regarding stress and somatic symptoms in

soldiers recovering from physical wounds.

As the buildup in Vietnam continued, eventually

two KO teams were assigned in Vietnam. The

incidence of traditional “combat exhaustion” remained very low (below 2%). This was attributed to

the rotation policy (365-day tours), scheduled R and

R, the sporadic nature of combat in most of the

heavy artillery, armor, and air weapons support of

U.S. forces, the effectiveness of helicopter evacuation of the wounded, and the prevention (by division mental health and the KO teams) of a “psychiatric” evacuation syndrome. Another factor in the

low utilization of the “combat exhaustion” label

was the criterion that the soldier had to show “fatigue, whether produced by physical causes such as

exertion, heat, dehydration diarrhea and loss of

sleep...[or] anxiety and insomnia.” This effectively

excluded most of the anxious, depressed, conversion and dissociative subtypes who would now be

counted under the umbrella of “battle fatigue,” as

they would have in World War II.

As noted elsewhere in this volume, the division

mental health teams and KO teams were less successful in recognizing the contributing causes of

misconduct stress behaviors and in helping the

chain of command to prevent them. Measures such

as the individual 365-day tour, while protecting

against battle fatigue or combat exhaustion, fragmented unit cohesion. Liberal availability of alcohol, with frequent excess use, did not set a good

example for the prevention of marijuana, heroin,

and other illegal drug abuse, which became epidemic by 1970. Those factors, plus an unwise short

rotation policy for junior officers and the unpopularity of the war, led to epidemic indiscipline, including the threatening and “fragging” of leaders.

Failure to instill understanding and respect for the

Vietnamese (both South and North, friend, neutral,

and foe), the frustrating and ambiguous rules of

engagement, and the nature of terrorist guerrilla

war, led to numerous small and some major acts of

brutality and outright atrocity. The turmoil in the

U.S. Army only reflected that of the nation, where

violent political dissension, substance abuse, and

racial animosity and overt antimilitary demonstrations were rampant.25

Following the withdrawal of all U.S. combat forces

from Vietnam after the cease-fire signed by the

United States, North Vietnam, and South Vietnam

in Paris (1973), the U.S. Army entered the period of

the “hollow army.” While undergoing a major

reduction in force and maintaining supposedly

“fully manned” units to deter Soviet aggression in

Europe, the U.S. Army continued to be plagued by

drug abuse, indiscipline, low morale, and reduced

readiness. The division mental health sections (now

also including clinical psychologists) were too preoccupied with the daily referrals of disturbed, problem soldiers for most to train with their units much

in the field. While the mental health team was

valued for their ability to process problem soldiers

for administrative or “chapter” discharges, they

were also to some extent sullied by association with

their workload clients.

The KO team TO&E was redesigned about 1973

into the “OM Team.” (“OM” is also not an acronym.

The “O” signifies that it is one of a series of medical

teams that provide area support.) This designation

more properly defined the units’ mission than

had the “K” (hospital augmentation detachments). However, the issue was confounded by

taking inpatient services out of all the combat zone

deployable hospitals and adding it to the OM team.

The OM team had a small headquarters with a

psychiatrist commander, clinical psychologist, field

medical assistant (officer) and several enlisted. It

had three mobile consultation teams, each with a

psychiatrist, social worker, six behavioral science

specialists (91G), and two vehicles. The treatment

section had a psychiatrist, two psychiatric nurses,

eleven psychiatric specialists (91F), and a 91G.

Apparently, the plan was for OM detachments to

augment one or two evacuation hospitals in a theater (reinforcing the evacuation hospital’s one psychiatrist, one psychiatric nurse, and two psychiatric

specialists) to provide 25-cot psychiatric wards.

Other OM detachments might reinforce a general

hospital or two in the communications zone. In fact,

only one active component OM detachment was

authorized, and it had no personnel assigned. Six

OM detachments were established in the U.S. Army

Reserves, but no doctrine was written regarding

their expected employment. Not until 1984 did the

OM teams begin to take part in realistic annual field

training exercises.
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160

Belated recognition of the Soviet offensive NBC

(nuclear, biological, and chemical) threat to the

North Atlantic Treaty Organization (NATO), made

vivid by the intense fighting in the 1973 Yom Kippur War and the Israeli experience of stress casualties, led to renewed awareness of combat stress by

the senior U.S. Army leadership. Army Regulation

40-216, Neuropsychiatry and Mental Health,

26 was

updated in 1984, its first revision in 30 years. Staff

studies at the Academy of Health Sciences at Fort

Sam Houston, Texas, in the late 1970s and early

1980s, led to recognition of combat stress control as

an autonomous AMEDD functions area in 1984.

This finally put the combat mental health doctrine

organization and employment on a par with preventive medicine, combat dentistry and veterinary

medicine, if still less prestigious than hospitalization and evacuation.

In an intensive revision of all U.S. Army field

medical support to meet the Soviet threat and support AirLand Battle (later called Medical Force 2000

or MF2K), the AMEDD was held to a strict personnel ceiling. However, within this ceiling, the newly

proposed combat stress control (CSC) “companies”

and “detachments” were authorized a 400% increase in active duty slots and a 280% increase in

U.S. Army Reserve slots over those already available for modification from the old OM teams.

The TO&Es for the 85-person medical company

CSC, and the 23-person medical detachment CSC

were developed between 1986 and June 1989 and

forwarded for Department of Army approval. These

units have a modular design that packages a psychiatrist, social worker, and two enlisted, with vehicle, into a CSC preventive team that can reinforce

a division mental health NCO and officer at the

maneuver brigade level. A clinical psychologist, a

psychiatric nurse (clinical nurse specialist) and an

occupational therapist, with two each of their enlisted assistant and two more enlisted, are combined into an 11-person CSC restoration team. This

team can staff a program of 1- to 3-day restoration

treatment in the division rear, as well as sending

two to three person teams to provide consultation

in the vicinity or to reinforce the CSC preventive

teams forward on short notice.

The CSC preventive and restoration teams’ personnel can also be task organized in any combination to provide reconstitution support to units that

have been pulled back after suffering heavy attrition. The task-organized elements can also conduct

1- to 2-week reconditioning programs in the corps

area for slow-improving stress casualties. For more

description of CSC doctrine and units, see Chapter

10, Joint Operations.

In the area of CSC doctrine, paragraphs and

chapters were added to other medical field manuals

starting in 1991.27,28 Field manuals specific to the

combat stress control functional area were written

and staffed through multiple revisions starting in

1989, finally to be printed in September 1994.29,30

Meanwhile, however, events were calling for CSC

support to U.S. Army combat operations. In December 1989 through January 1990, Operation Just

Cause, the U.S. invasion of Panama, involved a

night air assault by U.S. Army Ranger battalions;

followed by an 82d Airborne Division brigade; the

air-landing of 7th Light Infantry Division forces;

reinforcing elements of those divisions; the 5th

Mechanized Infantry Division; a separate brigade;

and many other units already in Panama. There

were several days of intense, but brief and local

fighting, that included a number of psychologically

traumatic incidents.

No division mental health assets were deployed

to theater, although both the 82d and 7th sections

were ready to go. The garrison and hospital psychiatric/mental health assets already in Panama were

not readily adaptable or sufficient to the task of

postcombat preventive activities. Subsequent problems with post-traumatic stress disorder (PTSD) and

less obvious attrition or misconduct in a number of

units confirmed the importance of such activities,

preferably in the theater of operations, even after

brief, successful contingency operations in which

American and local civilian losses are sustained.

When Iraq invaded Kuwait in August 1990, the

new CSC TO&Es were still in queue awaiting their

Department of the Army staffing. The new field

manuals were circulating in preliminary draft form.

The mobilization for Operation Desert Shield (the

multinational show of force to deter further Iraqi

aggression and encourage withdrawal from Kuwait) first deployed the division mental health sections with their units, although some personnel had

had little or no prior field training. Each of the

Psychiatry Consultants was given copies of the

drafts of the first five chapters of this volume for

distribution. Fortunately they had some time in

theater to prepare themselves.

In September, the one active component

OM team was mobilized at Fort Benning, bringing together its Professional Officer Filler

System (PROFIS) officers, levied enlisted complement and second-hand equipment for the first

time. Anticipating the new CSC detachment TO&E,
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it incorporated an occupational therapist officer

and NCO in the place of other, unfilled specialties.

The unit deployed in late October, set up a restoration program at the one combat support

hospital then in Saudi Arabia, and immediately

began sending out mobile consultation teams.

Within days it had reversed the tendency to evacuate all “psychiatric cases” out of theater. As the

one preventive psychiatric unit for 18th Airborne

Corps, it quickly established a high degree of

credibility.

Two of the six U.S. Army Reserve OM Detachments were activated just after Thanksgiving

and deployed to Saudi Arabia the first week in

December. One became the CSC asset for 7th Corps,

that was then arriving from Germany. The second

was assigned to the echelon above corps at Riyadh,

and collocated with a general hospital. The neuropsychiatry consultant for U.S. Army Central Command (ARCENT) also reached Saudi Arabia in December. As planning for the expulsion of Iraqi

forces from Kuwait proceeded, the ARCENT psychiatrist and command surgeon concluded that the

OM team assets needed to be divided into their

mobile teams and sent forward as close behind the

combat maneuver brigades as the tactical situation

allowed. Projected estimates for U.S. wounded and

chemical injuries were high, if the veteran Iraqi

soldiers were able to put up a stubborn defense and

use their chemical arsenal and long-range artillery

despite the planned U.S.-led air campaign. Stress

casualties in such a scenario could equal one per

three or even two wounded, and one or two per

chemical injury.

Accordingly, ARCENT directed the two OM

detachments, which were allocated one to each

corps, to send their teams to join the “medical task

forces” that would go forward into Iraq behind

each division. It was judged that they did not yet

have the logistical capability and field experience to

try to accompany the maneuver brigades medical

companies, as the draft field manuals advocated.

As the air campaign progressed, the third OM detachment at Riyadh split into four teams. One team

remained in Riyadh, two were sent to reinforce the

OM teams supporting the corps, and the fourth

team established a second-echelon restoration/reconditioning center at one of the major hospital

complexes.31

During the short, fast-moving ground campaign,

the stress control teams from the OM detachments

moved forward with the surgical teams, holding

cots, and preventive medicine teams that collectively comprised the medical task forces. Most of

these were directly behind the maneuver brigades,

leaving the main support medical companies of the

division support commands far to the rear. Some

stress control teams in 18th Corps reached the

Euphrates valley. Few stress casualties were seen

during the successful offensive, as prior experience

predicts.

In the conferences that the AMEDD assembled to

formalize lessons learned, the ARCENT surgeon

stated that combat stress control had been one of the

success stories of the Persian Gulf campaign in

preventing unnecessary evacuations and returning

soldiers to duty. However, it was recognized that

there had been too few assets to simultaneously

support the combat divisions and the rear areas that

were subject to Scud missile attacks, as well as

stressful environmental conditions. The medical

leaders of 18th Corps, in particular, strongly encouraged the rapid fielding of the new CSC units,

doctrine, and training. This advocacy assisted the

expeditious fielding of these new CSC units, despite the downsizing of the U.S. Army following the

breakup of the Soviet threat.

Equally important was that the active duty detachments were authorized most of their officers

and all of their enlisted personnel full time (not as

PROFIS fillers with full-time duties in the hospitals). This enables them to train with the units they

support, to provide preventive stress control services to those units in garrison, and to deploy rapidly in war or operations other than war. In fact, the

first CSC detachment activated on schedule on 16

December 1991 and one half of its personnel deployed to Somalia for Operation Restore Hope on 5

January 1993. It maintained teams in Somalia until

February 1994.

Combat stress control detachment teams deployed to Haiti in September 1994, early in Operation Restore Democracy, and continued to rotate

there after the mission was turned over to the United

Nations. Another team deployed to Saudi Arabia in

October 1994, supporting a show of force and training exercise in Kuwait in response to threatening

Iraqi troop movements. In December 1994, part of

a CSC company, most of a CSC detachment, and the

neuropsychiatric ward of a combat support hospital deployed to Guantanamo, Cuba, to provide inpatient and outpatient treatment to Cuban refugees, as well as stress control support to the U.S.

troops running the camps. These missions demonstrated the versatility and value of CSC units in

military situations other than war, as well as war.
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U.S. ARMY COMBAT ENVIRONMENTS

The mechanized infantry normally work as integral members of the “combined arms team” with

armor. They travel in infantry fighting vehicles

(IFVs) or armored personnel carriers (APCs) that

enable them to keep up with the tanks. IFVs provide some ability to fire while on the move, but most

of the squad dismounts to fight on the ground when

assaulting or defending a position or clearing an

area. Mechanized infantry therefore share many of

the stressors discussed below for armor while having more logistical support (and logistical requirements) than other infantry.

Infantry make up the most numerous component

of most combat forces. Because of their relative

numbers and the degree of unprotected exposure to

enemy weapons and the elements, they usually

suffer the highest number of casualties and make

up a large percentage of the battle fatigue cases.

However, the percentage of battle fatigue casualties

to killed and wounded among well-trained infantry

units is typically lower than in armor, artillery, or

combat services support units. An average rate for

conventional combat is one battle fatigue casualty

per five wounded, with at least an equal number

treated and returned immediately to duty. Rates of

1:3 to 1:2 are seen in very prolonged and especially

static combat.

In the elite special forces, ranger, and airborne

units, the ratio has been strikingly low (less than

1:10 or 1:20) even in mass casualty battles. This is

attributed to the benefits of tough training, close

contact with trusted leaders and comrades (“vertical and horizontal unit cohesion”), and a sense

(most of the time) of having some personal control

over one’s fate. The ground is the infantryman’s

protection, allowing dispersion and shelter if wisely

used. To quote a Bill Maudlin World War II cartoon,

Joe is looking at a tank and says to Willie, “I’d rather

dig. A moving foxhole attrac’s the eye.” Mines,

booby traps, and chemical contamination of the

ground (requiring wearing of the protective ensemble) make the ground no longer a reliable friend,

and are therefore especially stressful.

Infantry soldiers are especially prone to combat

exhaustion as they are deployed rapidly and are

subject to extreme physical work, sleep loss, and

limits on available food, water, and hygiene. They

can often feel unprotected or unsupported in the

field of operations. Communication can get very

difficult, especially at night or in restrictive terrain

when visual contact with the rest of the unit may be

To be effective combat stress control consultants

and treaters, the psychiatrist and other mental health

officers and NCOs must have an exceptional degree

of military credibility and knowledge of the supported units. They must understand and be conversant in the unit’s missions, equipment, internal organization, special language and acronyms, and

typical stressors and stress profiles. In this regard,

CSC personnel are analogous to flight surgeons (see

Chapter 8, U.S. Air Force Combat Psychiatry). They

can only achieve the necessary expertise and credibility by “flying” some hours and days with similar

units in realistic field training and operations. This

textbook can only provide a brief overview and

introduction to a few of the major branches of the

U.S. Army.

Within each branch, specific types of units (and

specific officer areas of concentration and enlisted

military operational specialties) have their own

mission profiles and typical physical and psychological stressors. To advise a commander on how to

sustain and enhance his unit’s performance, or to

assure him that one of his soldiers is again ready for

duty, requires more than a second-hand knowledge

of what that performance and duty involves.

Combat Troops

Infantry

Infantrymen (there are as yet no infantrywomen)

are men who engage the enemy in close combat,

sometimes hand-to-hand, standing on their feet,

lying on the ground, or dispersed in holes which

they have found or dug in the dirt. In battle, and

sometimes between battles, they must carry everything they need to fight and survive on their persons. Infantry can be categorized by how much

they must rely on their own physical strength and

endurance, separated from mechanical support.

Special Operations Forces (the “Green Berets”) and

Rangers are all airborne (parachute) qualified, but

may undertake prolonged and grueling missions,

with only rare, air-dropped supplies. Airborne

infantry are delivered by parachute or airlanding,

but are reinforced by heavier units within a few

days and continue to fight as light infantry. Light

infantry and air assault infantry also must travel

very light on the ground, but usually have helicopters and a few light trucks for rapid redeployment

and resupply.
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U.S. Army Combat Psychiatry

nearly impossible. Often moving quickly through

difficult terrain or behind enemy lines, the special

operations forces (SOF), light infantry, or mechanized infantry soldiers can become separated and

anxious about being wounded and left on the battlefield. While this may heighten the soldiers’ sense of

unit cohesion, the effect of a lost or wounded member on the whole unit can be devastating.

It is in the field of battle that unit bonds are often

tested and an entire unit can be immobilized or

destroyed because of the one weak link in communication or trust. Prior to mobilization the unit

members must get to know each other and especially to be confident in each of their abilities to fight

together as a team. No unit should be deployed

without the commander’s having the opportunity

to portray himself as a thoughtful and knowledgeable leader; a unit without confidence in its leader

can fail, generating a large percentage of both emotional and physical casualties.

Because of the newer weapons technologies and

the rapidly moving forward edge of the battlefield,

fragmentation among infantry units can often occur. Devastation of life by enemy or friendly fire

may be great, and the exposure to dead and wounded

comrades as well as enemy is magnified. In this

setting, human soldiers must often charge ahead and

their sense of “neglecting” their buddies is intense.

Sensory overload under these conditions can only be

countered by the unit cohesiveness and bonding

developed long before the mission is begun.

Ongoing development and testing for the “digital battlefield” of the “Information Age” of the 21st

century proposes to give each infantry fire team

leader, and perhaps each infantryman, a global

positioning device that gives precise coordinates

for his location on the terrain and short-range voice

communication with other team members. There

may even be a “heads-up” display inside the visor

to his helmet that advises him of the locations of all

other friendly forces and identified enemies in the

vicinity, as well as much other information. Assuring that this technology increases combat effectiveness rather than creating distraction and dependency, especially in tired, fearful soldiers, will be an

urgent topic for combat stress control in future field

trials, training, and combat operations.

Armor

The armor branch soldier fights inside a tank—a

heavily-armored, tracked vehicle capable of rapid

cross-country movement on suitable terrain. The

tank has a heavy gun for destroying other tanks and

hard targets by direct (line-of-sight) fire, and machine guns for destroying exposed infantry and

other “soft” targets. Tanks are most effective in the

offensive in open country where, in combination

with mechanized infantry and supporting artillery

and air attacks, they can break through enemy defenses and spread havoc in the rear.

Much of the time, however, armor works in the

offense or defense on more restrictive terrain, moving from position to position in coordinated movements with each tank much like an individual infantryman. Unlike the infantryman, however, the

tank protects against bullets and artillery fragments,

giving a relative sense of invulnerability. Modern

tanks also have collective protection against chemical agents. Tanks are disabled (and less often destroyed) by other tank’s guns, by direct artillery

hits, by mines, and by a variety of infantry- or

vehicle-carried antitank rockets, many of them now

precision-guided.

Speed in firing first or in taking protective countermeasures (measured in seconds, if not split-seconds) can be crucial to survival. When the crew

compartment of a tank is breached or the tank burns

or explodes, escape may also be a matter of seconds,

and death can be especially gruesome. Battle fatigue rates are therefore high among the survivors

or witnesses of the deaths of fellow crew, relative to

the number of wounded who get out alive. Battle

fatigue to wounded ratios of 1:2 and 1:1 have been

reported when armored units were caught at a

disadvantage or unexpectedly found themselves

outclassed by superior tanks or infantry antitank

weapons.

Tanks, while giving the soldier a sense of confidence, can be sources of problems. Highly technical

in today’s U.S. Army, these weapons are at best

finicky, subject to heavy vibration and jolting in

operation, require continuous maintenance, and

demand specialized skills to operate. Armor crews

tend to be closely knit units, where deviance, defiance, and “specialness” are not readily tolerated.

Individuals working in tank crews have to rely on

the skills of their comrades, live for weeks to months

together in very close proximity, and often get to

know each other on an intensely personal level. The

operation of the tank is dependent on each person’s

doing his job; the tank does not operate fully if one

member of the crew is incapacitated. Maintenance

units that take care of the machinery have to be

reliable and known by the operators; “slacking off”

is not tolerated.
War Psychiatry

164

Tankers rarely see their human victims close up.

The mission of armor units is to neutralize other

similar or smaller-sized enemy weapons. Because

of this, tankers are prone to periods of heightened

enthusiasm and letdowns after the mission is accomplished. Debriefing is especially important and

the tendency to focus on the mechanical details of

the mission, create distance from the destruction, or

overpersonalize the killing, may be compelling dynamics with these crews that must be dealt with

constructively.

Modern tanks have night vision and infrared sights

and laser rangefinders that can make true combat

sensorially much like a complex team computersimulation task or arcade game. Individual crews

now train at their tasks in “high-tech” simulators,

“moving” over virtual-reality terrain and engaging

virtual-reality targets that, although still substantially abstracted, are not that different from what

would actually be seen. Multiple simulators can be

linked together so that three to five tanks in a platoon

can be maneuvering together on each other’s scopes.

The combined arms team can even train together

in virtual reality, with attack helicopter crews and

mounted mechanized infantry all in their own simulators (perhaps even located on distant posts) working in concert on the same computer-generated

terrain, supported by field artillery fire direction

centers who respond to calls for artillery fire that

the computer faithfully represents in real time.

Research and development for the “digital battlefield” is equipping each tank with global positioning devices linked by computers and computergenerated displays in each tank and at its higher

headquarters.

The successful integration of information technology into armored formations may be technically

easier than with dismounted infantry, but it will

still require extensive human factors evaluation

and training. It must be remembered that ground

war, more than air, sea, or space war, is fought

under very “dirty” physical and emotional conditions. Continuous and even sustained operations

are often required. Strict limits on the size and

weight of equipment demand compromises: air conditioning may be necessary for the computers, but

little has traditionally been invested to provide

comfort for the crew members. If the “high-tech”

systems break down under the strain of field operations, the crew must be capable of fixing them or

carrying on without them. Fear, grief, rage, guilt, or

simple sleep loss must not be allowed to impair the

crucial human components of the system.

Field Artillery

The mission of field artillery is to lob projectiles

of high explosives or other munitions to places

relatively far away and out of sight on the battlefield. Artillery crews are usually eight to ten people,

working in sections of three to four crews. Two

sections comprise a battery, the equivalent of an

infantry or tank company.

The towed, tube artillery are wheeled guns (technically “howitzers”) that can be air-transported to

support light infantry and are towed behind their

“prime movers” (relatively light-weight trucks).

They provide minimal protection for their crews.

Firing the large shells at a rapid rate is heavy physical work. Self-propelled tube artillery are large

howitzers mounted on tracked vehicles, less armored than tanks, but providing some crew protection. They are supported by other tracked vehicles

carrying additional ammunition. The latest versions provide more mechanization for moving and

loading the heavy shells. Missile artillery such as

the Multiple Launch Rocket System (MLRS) are also

tracked vehicles with considerable mechanization,

but still require substantial heavy work.

Field artillery batteries and sections may be stationary at “fire bases” in some low-intensity or

static combat scenarios. In “high-tech” combat,

they must be highly mobile, whether to keep close

behind the moving armor or to avoid the enemy’s

own “counter-battery fire.” Modern radars can

locate the source of artillery fire quickly, perhaps

even before the shells (“rounds”) have landed. The

addition of global positioning devices and on-board,

interactive computers to the most modern howitzers or rocket launchers greatly increases their ability to “shoot and scoot”—to stop, fire rapidly at a

mathematically determined location, and move elsewhere. Without this enhancement, emplacing the

battery is a very deliberate and precise process.

Like tank crews, soldiers in the field artillery are

highly specialized technicians, especially the NCOs

and officers. The potential for destruction by enemy action, while less than for infantry or armor,

may be catastrophic when it occurs. The potential

for error injuring one’s own crew or distant friendly

units is also great. Artillery units avoid direct

combat with enemy ground forces, but must defend

themselves against harassment and, rarely, by direct fire against infantry or armor attack (which

they are likely to lose). When casualties are suffered, the ratio of battle fatigue casualties to

wounded is likely to be higher than in the infantry.
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Certain psychological defenses must be encouraged and supported during these soldiers’ missions. Artillery soldiers have to closely rely on each

other for both support and technical expertise. Training constitutes a large portion of these soldiers’

days. The artillerymen have specific team drills

with built-in double checks to process technical and

mathematical data without error. As long as these

drills are followed, tired and stressed teams are able

to function accurately, if perhaps less rapidly. When

stress or overconfidence leads to taking short cuts,

disasters can occur, as shown in this case known to

the second author.

Case Study 1: Live Fire Error

On a U.S. Army post, one artillery shell killed several

infantrymen far from the allowable “impact area” on post.

Investigation revealed that an artillery battery had fired

that round with all seven bags of gunpowder instead of the

appropriate four bags. The battery was in the last hour of

a 3-day continuous operations field exercise and was

firing all of the remainder of its ammunition in a sustained

barrage. The enlisted soldier whose job in the drill was to

take three bags out and drop them on the ground had

simply failed to do so. The second soldier whose task was

to count the bags and throw them into a common pit had

fallen behind in his task. Bags had accumulated on the

ground, so that double-checking was not simple. While

the battery had had a sleep plan, both junior soldiers had

stayed awake during their last “down time,” helping out.

The defense lawyer called the second author for advice on

who was at fault.

Comment: This is the type of error of omission that is

most likely with sleep loss. The muscular work of rapidly

loading artillery rounds can have an almost hypnotic

rhythm, punctuated by the highly reinforcing “ritual” firing

and recoil of the howitzer. The final “crescendo” before

going home would have produced a euphoric “adrenalin

high” in the sleep-deprived brain. The ultimate responsibility has to fall on the crew chief (with some for the section

chief), first for failing to assure that every double-check in

the team drill was being faithfully performed and second,

for not having enforced the sleep plan. Predictably, the

officer and senior NCOs had not enforced the sleep plan

for themselves, and were substantially more sleep-deprived than any of their enlisted soldiers.

The coordination and computation of the firing

data are calculated for the entire battery by a Fire

Direction Center (FDC) team. These teams are

equipped with computers and radios, but can also

perform manual (chart) calculations. The following

case illustrates the potential effects of fatigue on

these and other types of Tactical Operations Center

(TOC) team performance.

Case Study 2: Fire Direction Control Research

Study

Fire direction teams of one officer and four enlisted

from an elite unit conducted sustained operations for up to

42 hours in a realistic mockup of an FDC tent. The

scenario provided a detailed sequence of events in a

combined arms operation across a map that provided

comparable measures of speed, accuracy, and preplanning

every 6 hours. The teams’ tasks (as in combat before the

fielding of special field artillery digital computers) was to

manually plot the location of targets called in over the

radio, and to derive range, bearing, angle of gun elevation, and charge. Some targets were called in with

requests for immediate fire (“fire missions”) while others

were called in to be plotted for firing “on-call” or at a future

scheduled time (“preplanned targets”). The FDC was also

expected to update its situation map based on messages

from the simulated units and to establish that targets were

not at the locations of friendly units, in no fire areas, or

otherwise requiring clearance from higher headquarters

under the rules of engagement. Ammunition requisition

and other self-initiated preplanning was expected.

Throughout the sustained operations, the teams’ ability to perform their highly practiced and precise team

plotting tasks, even under urgent time pressure, was

unimpaired. However, after about 24 hours, they fell

behind in updating their situation maps and precalculating

the positions and firing data for the preplanned target lists.

They lost their grasp of their place in the operation. They

no longer knew where they were relative to friendly and

enemy units. They no longer checked what they were

firing at. When called upon to fire at several urgent targets

concurrently that involved preplanned targets (which they

had accomplished well early in the exercise) long delays

and random serious errors occurred. Some of those

errors involved their fire falling on friendly locations.

Comment: Similar and even worse problems of

preplanning and internal and external communications

can be expected in the headquarters staffs and tactical

operations centers of infantry, armor, and higher echelon

commands whose tasks do not provide the highly practiced and double-checked drills of the FDC. The development of automated data processing (computers) will reduce the need to depend on memory or make mathematical

calculations. However, they may compound the problems

in communication, decision making, and preplanning by

lulling the staff into a false sense of security and concealing signs of system error until they are irreversible. Sleep

plans are essential for all command, control, communications, and intelligence (C3

I) staffs.32

Artillerymen can feel more important than the

average soldier because of the killing power of their

weapons, the supposed “smarts” required, and the

relative “luxury” of being able to transport comfort

items. Conflicts can arise because of this.

Artillerymen may also feel guilt (or defend against
War Psychiatry

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feeling disgust or guilt) at a killing process that, in

most situations, keeps them relatively secure and

comfortable. Mental health professionals must pay

attention to the possibility that anger and depression may be present in these soldiers as they alternately feel important and useless in the overall

mission on the battlefield. Another risk for

artillerymen is that of fatigue.

It should be remembered that forward observer

teams of artillery officers and NCOs deploy forward as integral members of infantry and armor

formations. They share all of their hosts’ environmental risks and stressors, with the additional stressor of being responsible for calling down devastation out of the sky, sometimes dangerously close to

themselves or other friendly units.

Air Defense Artillery

This branch is responsible for the defense against

enemy aircraft and ballistic missiles. Small teams

with shoulder-held anti-air missiles are attached to

infantry, armor, and field artillery units and share

most of their hosts’ stress environments. Teams

with “high-tech,” mobile missiles and ultra-rapidfire guns, supported by mobile radar teams, are

deployed to protect key targets such as the brigade

and division support areas and corps base defense

clusters. Larger missiles such as the Patriot are used

to protect key air bases and ports throughout the

theater of operations against ballistic missiles and

long-range aircraft.

Unlike the field artillery, which are rarely totally

idle, most air defense artillery in recent wars have

had to sustain vigilance with little or no opportunity to fire; the exception was the Patriot missile

units in the Persian Gulf War, deployed both in

Saudi Arabia and Israel. There, the political impact

of their presence far outweighed their actual (subsequently determined) performance, and placed

upon them a heavy burden of responsibility. Fatigue and stress became a significant factor for those

crews. The deployment of Patriot batteries to South

Korea in 1993 as a show of resolve suggests that the

responsibility will continue, and become even

heavier if a potential opponent is known to have

chemical, biological, or nuclear warheads.

Army Aviation

U.S. Army Aviation is currently restricted to

rotary (helicopter) aircraft. Because of their ability

to hover, fly “nap of the earth,” and land on many

kinds of terrain, helicopters are especially suited

to the close support of land battles. Attack helicopters are well armored and very heavily armed,

with “high-tech” target acquisition and navigation

equipment. Scout helicopters are lightly armed

and armored, and often work in teams with the

attack helicopters. Cargo helicopters are used to

ferry combat troops, ammunition and supplies,

sometimes into “hot” landing zones. They have

minimal armor, and may mount machine guns for

self-defense. Medevac helicopters are unarmed, in

accordance with the Geneva conventions. All helicopters are vulnerable, to a greater or lesser degree,

to small arms fire and especially to missiles from

the ground, as well as to other attack helicopters

and jet fighters.

A special pride is felt by soldiers who fly aircraft.

Perhaps the most technically trained and responsible soldiers, these men are proud of their contribution to the Persian Gulf War, and believe that

their “machines” are the best, the most sophisticated, and the most expensive. Fliers also rarely see

their victims close up. The thrill of hitting the target

in a gunship raid, sneaking through enemy lines to

guide troops and spot aggressors may be counterbalanced by unconscious guilt at the mass destruction caused, yet unseen. Aviators have to train as a

group, but when any group of young, highly trained

professionals converges, competition can become

quite intense.

Pilots tend to be highly aggressive and individualistic, as noted in Chapter 9, U.S. Air Force Combat

Psychiatry. Many of the author’s observations about

U.S. Air Force pilots also apply to U.S. Army pilots.

These soldiers must be subtly reminded that they

are part of a larger organization that they need as

much as it needs them. Fliers can be demanding,

privileged individuals who have to rely on the

cooperation of air support troops, those who service the craft and provide all logistical support.

Like U.S. Air Force aircrews, U.S. Army aircrews

have a unit flight surgeon to monitor their physiologic and mental status and ground them if they

have become unsafe. However, the U.S. Army

environment is more dirty, dispersed, mobile, and

spartan, perhaps leading to more fatigue and physiologic stress than in the U.S. Air Force.

Mental health professionals may have to take a

humble and reassuring stance when interacting with

pilots and others in the aviation corps to allow for

adequate ventilation of frustrations and anxieties.

Pilots are very concerned about being taken off

flight status if they admit to emotional problems
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(especially suicidal thoughts). They will not open

up to a mental health officer they do not know and

trust, as was also noted in Chapter 8.

Combat Support/Combat Service Support Troops

There is a poorly defined distinction between the

“combat arms” (who actively try to kill the enemy, as

attack helicopters do), and the combat support and

combat service support branches. Combat support,

in theory, refers to those who actively facilitate the

battle (such as the Signal Corps, Military Intelligence,

Engineers, Military Police, and the Special Operations

Forces’ Psychological Operations and Civil Affairs

units) while combat service support (CSS) refers to

those who sustain the ability of the combat arms to

fight by transporting the ammunition, fuel, food and

water, servicing and repairing the equipment, providing health care, sorting the mail and providing

other personnel and administrative services.

The distinctions between “combat” and “support” are often arbitrary and inconsistent across

soldiers within a branch or corps. The combat

engineers are a macho “combat arm” who share and

often exceed the risks of the infantry and armor as

they precede them into battle to clear minefields

and bridge or blow up obstacles. They rely on

sophisticated armored vehicles or brute strength,

and defend themselves or attack enemy positions

with personal and heavy weapons. The civil engineers use military versions of civilian equipment to

build roads, buildings, and other infrastructure in

the rear. The combat signalman crouches alongside

the infantry platoon leader under fire, while signal

battalions set up and operate the mobile subscriber

telephone nodes, satellite uplinks, and other communications throughout the theater of operation.

The military police may be far forward or far to the

rear, maintaining route security, securing and guarding enemy prisoners of war, or enforcing the Uniform Code of Military Justice (UCMJ) on U.S. service members who misbehave.

Mechanics can be found in contact teams operating recovery vehicles on the battlefield, in maintenance companies in the brigade and division support areas, and in large depots in the corps rear.

Truck drivers in infantry battalions drive forward

in convoys at night to deliver supplies at a rendezvous with the maneuver companies’ first sergeants,

scant kilometers from the enemy. Truck drivers of

division and corps transportation or petroleum distribution companies may drive cross-country

through minefields at night, trying to keep the

advancing armored formations supplied, or may

drive only along well-secured main supply routes

in the rear with military police escort.

Even the personnel clerks, supply clerks, and

cooks may be assigned in an infantry battalion

headquarters company, performing guard duty at

night for the brigade support area. Alternatively,

they may be in a corps headquarters or quartermaster ordnance or personnel administration unit, in a

“safe” rear area with only periodic charge-of-quarters (CQ) or staff duty at night. The cooks everywhere work extra-long hours. Of course, on the

modern battlefield, no place is totally safe. Even the

U.S. Army stevedores unloading ships at the port of

embarkation may be subject to ballistic missile or

terrorist attack.

Because most CSS troops are further from direct

contact with the enemy and further from enemy

artillery than the combat arms, fewer CSS troops are

killed and wounded in action. However, when they

do suffer attack, their ratio of battle fatigue casualties to battle casualties is typically higher than in the

“combat hardened” combat arms.

It can be hypothesized (but should never be presumed) that the combat support/service support

soldiers who are integral to forward combat units

will take on some of the typical psychological characteristics and stress profiles of their assigned units.

Those who are only habitually attached may be a

little less so inclined. Soldiers or teams who are

only temporarily attached or recently arrived far

forward will be in transition and under the highest

stress. Personnel who are in familiar units of their

own kind in areas with very low probability of

attack may come closest to fitting the stereotype of

the rear area soldier (the “REMF,” or Rear Echelon

Mother F—er, as the combat soldiers in Vietnam

labeled them).

The stereotypic REMFs are managers, not leaders. At his worst, the REMF is the petty (or senior)

bureaucrat who enjoys exercising arbitrary power

over others and uses the rules and regulations to do

so. The REMFs take advantage of their positions to

acquire even more benefits and comforts than their

rear-area positions naturally provide them, often at

the expense of the combat soldiers for whom those

comforts (supplies, equipment, R and R facilities)

were intended. Low-ranking REMFs who have no

power (and even some higher-ranking REMFs who

do) are prone to the disorders of frustration and

loneliness, as discussed in Chapter 3.

The rear-area soldiers (whether REMF or “regular Joe or Jane”) may feel not part of the battle,
War Psychiatry

168

unappreciated, and left out of both the excitement

and tragedy of war. Some secretly wish to participate in the battle and can feel inadequate, cheated,

and inauthentic as soldiers. They may take dangerous risks or violate regulations to gain macho souvenirs such as enemy weapons. They may have too

much boring time without meaningful duties, and

too much access to the temptations of substance

abuse, unsafe sex, or other misconduct. These misbehaviors need the special intervention of mental

health workers because they are contagious, and

because without supplies and other logistical support, the combat troops cannot fight.

Some features of the Persian Gulf War worked to

counteract many of the traditional causes of the

REMF syndrome. The strict prohibitions on alcohol, substance abuse, and nonmarital sex of the host

nation, and the deliberate segregation of most U.S.

units from the local population in Saudi Arabia

were protective, but will not occur in all future

deployments. The U.S. Army does have a strict

drug abuse prevention policy and may adopt a “no

alcohol-in-theater” or “only 2 beers at unit functions” policy, very different from the active pushing of alcohol in Vietnam.

The priority of deploying combat forces to

deter further aggression during Operation Desert

Shield (the mobilization phase of the Persian

Gulf War) meant that there was a very low proportion of combat service support troops, who accordingly worked extremely long, hard hours. Living conditions were initially as austere for the CSS

units as for the combat arms, and the senior U.S.

Army leadership deliberately kept it that way. They

did not build up a comfortable supporting base. In

part that was to reassure the host nation that there

was no intention to stay. The logistical system

was also too tasked with bringing in war materials

to bring in luxuries. The senior leaders also remembered, however, how much they and their

troops had resented the REMFs when they were

junior officers and NCOs in Vietnam. They deliberately lived spartanly themselves, and required austerity of all their subordinate CSS units. Some

leaders required their rear area CSS soldiers in safe

areas to wear helmets and even flak jackets when

there was no threat, as a symbol of solidarity with

the combat soldiers.

Finally, when the Scud missile attacks began,

and later when the ground offensive proceeded

with relatively few U.S. casualties, whatever guilt

or sense of unimportance many CSS personnel may

have felt was absolved. The senior leadership did

praise the logisticians part in winning the war.

However, many CSS units did miss out on the

victory parades and felt unappreciated by civilian

society when they returned home late after staying

to clear up the battlefield and store or ship the

equipment.

It should also be remembered that a large percentage of CSS units are in the reserves, and so face

the additional stressors of seriously disrupted occupational, financial, and family affairs. The importance

of building high unit cohesion and strong family

support groups in reserve units is obvious, but is not

easily accomplished except in units from small towns

with strong roots in the civilian community.

The following disguised case history illustrates

inadequacies of leadership and questionable conduct in a CSS unit, as revealed in a delayed end-oftour debriefing following the Persian Gulf War.

Case Study 3: Leadership Problems in a CSS Unit

A reserve transportation battalion was deployed to the

theater shortly before combat began. As expected, its

companies and teams were widely dispersed, attached to

other units for logistic and administrative support while

performing heavy, sometimes dangerous, duties. The

dispersed elements felt that their headquarters did not

keep track of them or assure their support. The commander was perceived as having several favorite officers

(all white males), while devaluing minority and female

officers and all NCOs. Rules were applied unfairly; for

example, even married enlisted couples in the unit were

denied conjugal privileges while it is alleged that the

favorite officers slept with whomever they could “persuade.” The battalion chaplain was perceived as the

commander’s spy, since retribution seemed to follow

soon after any complaints were shared with him.

All awards and decorations after the war went to

the white male favorites. The unit cooks who had been

levied to drive trucks in a heroic night convoy to take

supplies through minefields (illuminated only with blackout lights and following in the tread marks of the tanks that

had gone before) did not even receive certificates of

appreciation because “they were just doing their jobs.”

The company commander who had organized the convoy

but stayed behind at headquarters received the decoration for valor.

The unit was late in redeploying home, missing all the

victory parades. The soldiers rejoined unsympathetic

employers, families, and creditors who said they’d “only

been support troops, not in combat.” The commander and

favorite officers immediately left the unit, taking their

awards with them, and leaving the previously devalued

NCOs plus new officers in charge. Within a year, many

unit members were reporting symptoms of fatigue, trouble

concentrating, hair loss, joint pains, and other complaints.

They attributed their symptoms to exposure to antimissile

radar emissions (from an installation near their headquarters in the theater) or chemicals.
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Comment: The question of whether the symptoms

were caused by some exposure or exposures deserved,

and received, intensive medical evaluation. What was

unquestionable during the debriefings that these units

participated in over a year after their return was the open

anger and sense of betrayal expressed by the junior

NCOs and enlisted. The senior NCOs retained their

professionalism during the debriefings, but confirmed the

enlisteds’ memories of the events in private conversation.

The role of a sense of betrayal and injustice in the etiology

of PTSD has been emphasized by Shay.33 It was unfair to

accuse the chaplain of violating confidentiality—the commander could have simply been good at guessing, or

indiscriminately punished every suspect when the chaplain advised him of low morale and the reasons for it.

However, had the unit’s elements been visited routinely

by mental health/CSC (MH/CSC) teams while in theater,

the original poor leadership and questionable conduct

could have been corrected.

Evolving U.S. Army doctrine and organization30 calls

for the area support medical battalion mental health section, reinforced by teams from the CSC Company, to visit

every company-sized unit every few weeks to conduct unit

survey interviews with the troops. These structured interviews serve both a data gathering and a ventilating function. The MH/CSC teams’ command consultations might

have inspired the commander to improve his ways or, that

failing, have advised his senior commander.

The unit should also have had an end-of-tour debriefing and scheduled homecoming debriefings before redeploying home. The family support groups should have

been involved in posthomecoming activities that validated

the spouses’, and their own, honorable service under

hardship and (for some) real danger. Those measures

would have decompressed the anger and facilitated constructive action a year sooner.

One group of CSS troops deserves special attention from the MH/CSC organization and others.

These are the formal Mortuary Affairs units (previously called Graves Registration). Those who must

recover, process, and transport the bodies of the

dead and their personal effects are at very high risk

of developing post-traumatic stress disorder. This

is often of the delayed type because of the tough

emotional shell they form to perform their gruesome duties day after day. There are also many

other soldiers in all other branches and military

specialties who are temporarily detailed to body

recovery and disposition duties, or who are exposed to human remains. These include the tank

turret mechanics or ordnance specialists who cannot repair the tank until they have washed out the

remaining blood and pieces of tank’s crew, who had

been lying under the sun for several days. Chapter 10,

Combat Stress Control in Joint Operations, provides a summary (information card) on measures

these people should take to enable them to perform

their very important morale-sustaining duties and

return home feeling proud about what they have

done without being haunted by the dreams and

memories they may have for the rest of their lives.

The Medical Combat Health Support Troops

Combat medics share all of the stressors of the

combat arms units they support. Battalion aid stations (Level I care) follow close behind. Medical

companies maintain clearing stations and treatment

teams in the brigade support and division support

areas close to the front and at base defense clusters

in corps. These companies can move themselves

rapidly, tearing down and setting up within hours.

Although technically privileged against attack by

the Geneva Convention, they are often forbidden

by the tactical commanders from showing the red

cross on white background emblem.

Forward surgical teams (replacing the current

Mobile Army Surgical Hospitals) can reinforce the

medical companies as far forward as the brigades.

Dental teams set up to support troop concentrations. Preventive medicine and veterinary teams

routinely visit units to inspect sanitation, disease

vectors, and food supplies. Ground and air ambulances are prepositioned or deploy forward to bring

casualties quickly back to the clearing station (Level

II) and hospital (Level III) care.

The hospitals use Deployable Medical Systems

(DEPMEDS) expandable shelters, TEMPER (tent,

extendible, modular, personnel) tents, and prepacked sets to assemble a climate-controlled complex of wards, operating rooms, laboratory and xray radiographic facilities, pharmacy, administrative, and admission and disposition areas. The

hospital staff are usually quartered in general purpose (GP) large tents without climate control. Hospitals take days to set up and break down, and

many trucks from nonmedical sources to move.

They also require extensive logistical support to

operate. They are therefore normally located in the

corps, although some may be close to the divisions.

Hospitals normally do show the red cross, indicating privileged status.

Casualties with medical diseases and nonbattle

injuries may reach the aid stations, clearing stations, and hospitals at a fairly steady rate, barring

some epidemic illness or mass casualty accident.

The war-wound surgical caseload, like battles, are

likely to come in surges separated by lulls. It is the

role of the medical regulating officer at the medical

group headquarters to spread the casualties somewhat evenly, and to direct patients who need spe-
War Psychiatry

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cialty team care to the hospitals that have those

specialty teams. In major battles, all hospitals may

experience mass casualty conditions. Sick or

wounded enemy prisoners of war are also brought

to U.S. hospitals. The Geneva Convention34 requires that they be treated the same as U.S. casualties, according to the same triage categories.

What are some of the stressors unique to medical

units? The AMEDD professionals and specialty

technicians often do not train frequently under field

conditions, and so are unfamiliar with the sets, kits,

and outfits. They may not appreciate why they do

not have their familiar, latest drugs, sutures, and

diagnostic equipment, in field-portable form. They

may have difficulty acclimatizing to the dirt, discomfort and primitive hygiene facilities, as well as

to the separation from home and the potential of

personal danger. Many are PROFIS or IRR (Individual Ready Reserve) individuals who are joining

unfamiliar units that may or may not already have

a unit cohesion that incorporates them. The highly

specialized professionals and technicians are often

very concerned if they are unable to practice their

specialized procedures, lest they lose their skills

and their credentials.

Treating seriously wounded casualties is stressful, but justifies to the medical personnel why they

themselves are there. It quickly builds and sustains

unit cohesion unless something disrupts the patient

care. However, the casualties can arouse several

distressing ethical issues. How do different individuals deal with the moral dilemma of placing

patients in the “expectant” triage category, especially the patients they know they could save if they

only had fewer patients, more supplies, or the “hightech” equipment back in their stateside hospital?

How do they face the moral dilemma of saving the

grossly, pitifully disabled patient when they do

have the resources to do so, especially if the patient

begs to be given “grace” (euthanasia)? How do they

face the moral dilemma of returning soldiers to

duty, perhaps to be wounded again or killed, when

they themselves do not have to risk direct combat?

May they become overwhelmed or depressed by

their inability to relieve the suffering or save the

lives of so many young Americans with whom they

identify? How do they deal with their anger, hatred, and perhaps guilt, when treating the injured

enemy prisoner who may have been the one who

wounded those not-quite-so-urgently triaged

American soldiers next to him? May they be upset

at being forbidden to treat local foreign civilians in

need who are not the U.S. Army’s responsibility?

May they be horrified at receiving the victims of

atrocity, including women and small children, who

are their responsibility to treat, as when the Iraqi

Shiite victims of Republican Guard massacres in

southern Iraq were air evacuated to U.S. hospitals

in theater after the Gulf War?

Medical personnel often tend to deny stress in

themselves, and may have to be approached diplomatically or indirectly by mental health/CSC consultants. Special attention should be given to those

personnel who are not normally direct patient care

providers. Those persons usually have less “stress

inoculation.” They include the food service, maintenance, administrative, and laboratory personnel.

These are the ones most likely to be detailed to be

litter bearers for the severely injured, attendants for

the expectant patients, or handlers for the bodies in

the morgue.

Hospitals are nominally staffed for two 12-hour

shifts a day, but mass casualties can require continuous or sustained operations for periods of several days to weeks. Fatigue impacts heavily on

patient care as well as on morale and stress tolerance. Medical personnel can become battle fatigue

casualties, and require treatment according to PIES

(proximity, immediacy, expectancy, and simplicity), with the five Rs, as discussed in Chapter 10.

Stress and fatigue can also disrupt interpersonal

communication and cooperation, impairing unit

efficiency in subtle ways. Misconduct stress behaviors can occur. These include “self-medication”

with alcohol and with the drugs that are available

(by pilfering or “skimming”) in medical facilities.

Seeking solace in sexual relationships is a natural

reaction to loneliness and “living on the edge.”

However, fraternization (heterosexual as well as

homosexual) and adultery are criminal violations

of the UCMJ. Consensual heterosexual misconduct

has rarely been punished, but its occurrence in

medical units adversely impacts upon unit morale,

especially when unit leaders are involved. The

rumors and aftermath of “deployment affairs” can

also have harmful effects on families back home.

Monitoring these many stress issues and intervening when indicated is a command and leadership responsibility.29 The hospital or battalion chaplain can often be helpful. Responsibility is also

given, by doctrine,30 to the neuropsychiatric ward

and consultation service in the hospitals and to the

medical combat stress control company or detachment that is providing area support in the vicinity.

Interventions are reviewed elsewhere in this textbook.
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MEDICAL/PSYCHIATRIC ORGANIZATION AND THE COMBAT STRESS COMPANY

The neuropsychiatric and mental health team

consists of neurologists, psychiatrists, clinical psychologists, social workers, psychiatric and mental

health nurses, occupational therapists, and the various enlisted technicians in those specialties. Mental

health professionals in the Army Medical Department (AMEDD) are those commissioned officers

and enlisted personnel specialists trained and credentialed to provide the various mental health functions. In addition to those previously mentioned,

other professionals can be qualified for these specialized services such as physician assistants (PA),

counselors, and chaplains. Para-professionals or

technicians are the behavioral science specialists

(91G), psychiatric specialists (91F), and occupational

therapy specialists (91L).

The Mental Health Program

The mental health program of the military is

somewhat different in peacetime from that during

mobilization. The U.S. Army regulation that is the

basis for both is Neuropsychiatry and Mental Health.

26

The regulation prescribes and refines policies and

concepts regarding neuropsychiatry (NP) principles

for mental health staff and facilities. This directs

the neuropsychiatry/mental health staff to advise

and assist command to conserve and maintain manpower at maximum efficiency. While the emphasis

is on mobilization, it is important during peacetime

to prepare by employing common neuropsychiatry

and mental health principles. Neuropsychiatric

and mental health personnel must be ready and

responsive for mobilization and other missions as

required.

Basic Principles

Based on experiences gained during World War

I and World War II, the Korean conflict, and the

Vietnam conflict, the following principles have

evolved for the prevention, treatment, and administrative management of neuropsychiatric and

stress disorders. Major emphasis is placed on preventive psychiatry and mental health programs

that lead to early recognition and preventive treatment of potential mental health problems. This is

similar to preventive medicine concepts. Neuropsychiatric personnel make a primary contribution

to this program by fulfilling the appropriate responsibilities outlined in the U.S. Army mission.

While neurology and psychiatry functions are

generally separate during peacetime, in mobilization the neuropsychiatric emphasis collocating neurology with psychiatry is used. Both battle and

nonbattle injuries and illnesses are thus coded in

those categories. In addition, the “neuropsychiatric” term clearly includes the organic (physical) as

well as the functional (mental) types of disorder.

This is particularly important in trauma, and nuclear,

biological and chemical (NBC) scenarios. In Medical Force 2000, the only neurologist is in the general

hospital. In the proposed Force 21 AMEDD, neurologists may not be included in the TO&E of deployed hospitals or CSC units, but will be available

to provide consultation via telemedicine.

In combat, treatment of battle fatigue and other

types of neuropsychiatric casualties will be instituted early, as near the unit of origin as practicable.

Proper psychiatric treatment of neuropsychiatric

casualties requires a military environment rather

than a traditional hospital atmosphere. Mild “duty”

cases should be treated and returned to duty immediately from the battalion aid station, brigade, or

division or area support medical company medical

treatment section or hospital admissions and dispositions section, or in nonmedical units whenever

the tactical situation permits.

Early return to duty is the therapeutic objective.

This can be accomplished only if the medical officer

accepts full responsibility to make often difficult

diagnostic or disposition decisions objectively and

without delay. Neuropsychiatric referrals from

supporting or noncombat troops should be made to

the nearest mental health personnel who are often

stationed forward of the combat service support

unit. Moderate “rest” cases who cannot return to

their units immediately but who do not need medical or mental health observation and treatment or

both should be sent to rest for 1 to 2 days.

Patients suffering from severe battle fatigue (hold

or refer), or other neuropsychiatric patients who

cannot be returned to duty at the forward facilities,

are to be channeled to the division medical support

unit(s) having mental health/CSC capability. These

teams must have a capability of providing rest and

restorative therapy for up to 72 hours prior to return

to duty. Those casualties who prove to need longer

treatment will be evacuated to a 7- to 14-day reconditioning program at CSC facilities in direct or

general support of the unit. After that period, the

individual will be returned to duty or evacuated to
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the communications zone or CONUS Level-IV reconditioning program.

In noncombat situations the evaluation, treatment, and disposition of nonpsychotic psychiatric

patients, except in unusual cases, will be on an

outpatient basis. Their retention on duty status facilitates therapy and reduces ineffectiveness. In

both combat and noncombat situations, direct communication and liaison among neuropsychiatry (MH

and CSC) staff (for example, between division psychiatrists and the theater neuropsychiatry consultant) through technical channels as approved by

appropriate command surgeons, are indispensable

to monitoring evacuation and issuing policy. Such

communication must be actively encouraged.

The rapid communication of technical information, especially in combat, is essential to an effective

mental health program. It should be recognized

that the greater the combat pressure, the more difficult it becomes to maintain necessary communication. Therefore, maximum use of direct forwarding

of technical reports must be done, consistent with

good judgment and propriety.

The overall effectiveness of any neuropsychiatry

program is dependent on the proper numbers, distribution, and assignment of qualified mental health

personnel. It is essential that the staff promote

training and make accurate evaluations of mental

health personnel to assure their appropriate assignment. Neuropsychiatry personnel should ensure

that all medical personnel have some familiarity

with basic combat psychiatric principles.

All mental health combat stress control personnel should be cross-trained in specialized topics

and techniques to include:

• Briefing on CSC unit status, functions and

capabilities.

• Educating leaders, chaplains, and medical

personnel on stress casualty identification,

management and disposition; substance

abuse; suicide prevention; family violence

prevention.

• Teaching stress management, relaxation

techniques, coping skills, grief and anger

management, conflict resolution, parenting.

• Facilitating small team after-action debriefings by unit leaders.

• Leading critical event debriefings of functioning military teams.

• Conducting individual and small group debriefing of stress casualties.

• Assessing interviews, basic mental status,

and recognition of signs requiring additional

mental or physical status workup by specialists.

Each of the five MH/CSC disciplines also brings

areas of special expertise, which may be partially

cross-trained to the others. The psychiatrist, as

working physician, practices psychiatry in the triage, diagnosis, brief intervention treatment, and

disposition of soldiers and patients. The psychiatrist assists with triage and acute trauma life support during mass casualties, and assists with routine sick call and care of the ill, wounded and

injured, especially those with return-to-duty potential. The psychiatrist should be ATLS- (Advanced

Trauma Life Support) qualified by the Combat Casualty Care Course, and have completed the NBC

casualty care course.

The occupational therapist (OT), assisted by the

NCO and enlisted specialist, increases the capability to evaluate physical and mental functional capacity related to combat duty performance; prescribes

and supervises therapeutic work and recreational activities for recovery battle fatigue cases in support of

the host medical facility; and assesses alternative

duty assignments for soldiers who cannot returnto-duty in their original specialty. The OTs also

advise unit commanders regarding work schedule

organization and time management, constructive

structuring of rest and tension-relieving activities,

and use of work assignments in preventing battle

fatigue and misconduct stress behaviors and in

restoring recovered cases to full duty. The OTs

provide rehabilitative care for minor orthopedic

injuries, especially of the upper extremity.

The psychiatric nurse (66C)/clinical nurse specialist (66C7T), assisted by the 91Fs, greatly increases the capability to stabilize and hold potentially disruptive cases at forward locations for

further evaluation. Some cases can be returned to

duty at this echelon, if they improve in 24 to 36

hours with sleep and a structured military milieu,

instead of having to be evacuated immediately to a

hospital in the corps area. If the position is filled by

a clinical nurse specialist, as authorized by the TO&E,

this nurse may be credentialed to prescribe selected

psychotherapeutic drugs. The psychiatric nurses

are especially suited for consultation and preventive interventions with other medical and nursing

staffs in medical facilities. Psychiatric nurses in the

corps hospitals provide further stabilization for either transfer to CSC reconditioning programs or for

air evacuation out of theater.

The social work officer, assisted by the 91Gs,

applies the principles, knowledge and skills of
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social work to the psychosocial systems of

U.S. Army units and their Family Support Groups.

They are prepared to coordinate with other Department of the Army, Department of Defense, and

civilian support agencies. The social worker provides mental health assessment and treatment,

coordinates support for division soldiers and

families, and has expertise in prevention/intervention for family violence and substance abuse

control.

The clinical psychologist, assisted by 91Gs, provides diagnostic assessment, and can administer

and interpret psychological and neuropsychological tests to diagnose problem cases and assess potential for recovery. The psychologist’s treatment

and consultation skills include the behavior therapies and focused applications of learning theory.

Doctoral-level psychology training in research methods and statistics contributes in unit surveys and

the analysis of trends.

The U.S. Army’s battlefield tenets of initiative,

agility, synchronization, and depth are designed to

surprise and overstress enemy forces.35 They make

the enemy incapable of cohesive action. Those

same tenets demand high-level mental skills from

leaders and soldiers at every echelon. It is these

mental skills that are most vulnerable to degradation by stress. The enemy seeks to impose stress on

U.S. troops, and U.S. Army planners, in turn, accept

stress as a calculated risk in the U.S. Army’s plan to

impose greater stress on the enemy.

Control of stress is the commander’s responsibility. Before, during, and after operations, the commander is aided in this responsibility by specialized

AMEDD CSC/Mental Health personnel. These

personnel work in concert with the NCO chain of

support, the chaplains, unit medical personnel, and

principal and special staff. Commanders and their

other supporting personnel must give priority to

their primary missions. Stress control is so important to mission accomplishment that AMEDD mental health personnel have been assigned in every

war since World War I with combat stress control as

their primary duty.

Evolving doctrine calls for the United States to

use technological superiority to win decisively on

the digitized battlefield. These weapons systems

call for an extremely high level of knowledge, skill,

and sustained mental acuity on the part of every

soldier. Human error due to stress can lead to

devastating failures in “high-tech” systems, such as

that seen on the U.S. Navy guided missile cruiser,

the Vincennes. Combat stress control—the continual monitoring of stress levels and prompt intervention when indicated—takes on increased importance in the “high-tech” environment.

The combination of highly lethal, mobile, and

interspersed weapons systems from different

branches, services, and allies, with interpretation of

enemy doctrine and movements, creates an intrinsic risk of friendly fire casualties. This risk must be

calculated and the stress consequences, which extend far beyond the involved units, must be assessed and controlled. The combat stress control

system assists this process.

Advanced communications technologies so vital

on the battlefield also make modern warfare a very

public enterprise. News, video, and private telephone can take the battle to the homefront almost

instantaneously, complicating operations security

and bringing battlefield stressors into living rooms

across the country and around the world. Telephones and media can also bring homefront stressors to the soldier overseas. The interaction between unit leaders and their units’ families is vitally

important to mission readiness. Active Family Support Groups have been effective in decreasing the

historically large percentage of battlefield stress

related to issues back home.

The U.S. Army will continue to leverage existing

and emerging technological capabilities to enhance

support operations across the full range of military

operations. Application of technologies to enhance

and assure communications is vital to the CSC concept.

THE FUTURE

SUMMARY AND CONCLUSION

The basic concept in management of neuropsychiatric casualties is increasingly higher, multitiered echelons of care. Mental health personnel

and programs must be flexible and mobile. Assessment and triage at clearing stations by trained specialists and professionals is essential. Exercise in

peacetime of all elements of the program is important. Communication nets are critical if coordina-
War Psychiatry

174

tion is to be effective. Successful capability of the

various elements to hold and carry transient casualties needs planning and practice. Developing a

personnel program to return soldiers to duty will

require staff action at various headquarters. Ability

to provide rest and restorative care (sleep space,

food, and so forth) in a protected but accessible area

must be planned early. Personnel needs above the

standard TO&E requirement must be anticipated if

sufficient augmentation is to be made possible. Training in basic stress management for neuropsychiatric

problems and cross-training in life saving techniques

is essential. Education of all health professionals in

basic neuropsychiatric concepts is important.

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