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U.S. Air Force Combat Psychiatry

Chapter 8

U.S. AIR FORCE COMBAT PSYCHIATRY

DAVID R. JONES, M.D., M.P.H.*

INTRODUCTION

SUPPORT OF FLIERS IN COMBAT

“Fear of Flying” and Combat Fatigue

The Use of Rest for Prevention and Treatment

The Role of the Flight Surgeon

Summary

SUPPORT OF NONFLYING PERSONNEL IN COMBAT

First-Echelon Measures

Second-Echelon Measures

Summary

CONCLUSION

*Colonel (ret), Medical Corps, U.S. Air Force; Chief Flight Surgeon, Aeropsych Associates, 4204 Gardendale, Suite 203, San Antonio, Texas

78229-3132; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Professor

of Psychiatry, University of Texas Health Science Center at San Antonio, Texas
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Peter Hurd Aerial Gunner, England 1944

Peter Hurd was a Life Magazine artist during World War II, assigned to cover the action on Ascension Island

and also in England. His painting depicts a gunner standing in front of his turret on the belly of a bomber.

For sheer terror, few jobs in the U.S. Army Air Forces in World War II could compare to his—relying on his

own composure, wits, and agility to shoot down enemy aircraft, while totally exposed to return fire

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

INTRODUCTION

The U.S. Air Force mission and its possible combat scenarios differ considerably from those of other

services. Traditionally, the people at risk in the

U.S. Air Force have been the fliers—the pilots, navigators, weapons systems operators (WSOs),

electronics countermeasure operators, radio operators, gunners, loadmasters, flying crew chiefs, and

other highly skilled and carefully selected personnel. These fliers have been the tip of the arrow,

supported by the rest of the U.S. Air Force. Thus, at

a 3,000-person airbase, only the 300 or so fliers

might be exposed to combat. Security police armed

with light weapons provide perimeter security

against small attacks, but most of the personnel on

base are usually not even issued personal weapons.

The U.S. Air Force has no tradition of arms, little

training in the use of rifles and pistols, and essentially no tactical field training in self-defense. In

case of ground attack, most personnel are expected

to take cover and wait while some other military

service or the base’s own aircraft and security police

fight off the attacking enemy. Leadership training

of U.S. Air Force officers and noncommissioned

officers (NCOs) does not address handling troops

in deadly peril, and the average service member

knows little about how to behave under attack. Few

role models are available, either through tradition

or in real life.

Thus, two differences come immediately into

focus when comparing the U.S. Air Force role to the

roles of the other services1

:

1. In the past, the brunt of battle has been

borne by a select, highly trained small group

of U.S. Air Force fliers, with whom the mass

of troops may not be able to identify personally.

2. In the event of enemy attack, most U.S. Air

Force members will have to take cover and

wait while others decide their fate. This

passive role carries with it a particular vulnerability to combat reactions. [This is further discussed in Chapter 6, A Psychological Model of Combat Stress.—Ed.]

The combat stresses borne by the fliers and by

those nonflying members who may have to suffer

through a ground attack on the base will be considered separately, drawing examples from wars of the

past in order to develop and discuss future preventive and therapeutic measures to preserve the fighting strength.

The nature of war dictates that, certainly in

the beginning phases and perhaps for several

weeks, fatigue is the order of the day. Operation

Desert Storm, the combat phase of the Persian Gulf

War, followed that rule, and so, no doubt, will the

next conflict. As usual, all did not go according to

plans. The uncertainty of the length of deployment

contributed to general tension. Combat air patrols

up to 8 hours long could be followed by alert

scrambles of equal length. Tanker schedules sometimes consisted of 12 hours flying, 12 hours rest,

and 12 hours of alert. Some crews flew 36-hour

crew days. Sleep was interrupted by aircraft noise

and Scud missile alerts. Some line commanders

seemed not to understand the effects of stress and

chronic fatigue. Some flight surgeons felt that aircrews were pushed to the limits of their endurance,

to the point where flying safety suffered. Fatigue

was a consideration in at least two noncombat fatal

accidents. Other problems included missed meals

because of scheduling conflicts, crowded billeting

of crews flying different schedules when all fliers

were brought on base for security reasons, and

environmental stressors such as heat and isolation. The pace of the war was so rapid that there

seemed to be no time to deal with emotional reactions to the deaths of squadron mates.2

 In brief, the

emotional aspects of war have not changed much in

the last 40 years.

Most of the literature concerning the effects of

combat stress on fliers derives from World War II;

little was written on this subject during the Korean

conflict, and there is essentially no psychiatric literature on the U.S. Air Force experience in Southeast Asia during the Vietnam conflict. No significant publications on this topic have emerged from

recent U.S. Air Force operations in Libya, Grenada,

Panama, or Kuwait and Iraq. This is a regrettable

lack, for several demographic factors have changed

during this period.

SUPPORT OF FLIERS IN COMBAT
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180

Fliers today differ considerably from their predecessors. The fliers in World War II were wartime

volunteers, high school graduates or college students commissioned through the Aviation Cadet

Program, trained in a specific aircraft, and sent into

combat with perhaps 200 flying hours altogether.

Most of these fliers separated from the service after

the war, having no intention of a career in military

aviation. Some joined the reserves, probably thinking that they would be recalled to active duty only

in the unlikely event of a national emergency.

The call came sooner than anyone expected. Many

of the reservists were reactivated in 1950 for the

Korean conflict. This “police action” did not generate the sense of national unity that World War I and

World War II had, and many reservists were quite

bitter about having their lives and careers interrupted to fight in a war not linked to a clear threat

to the nation. (Their feelings were expressed in the

sardonic song, “Here’s to the Regular Air Force,

they have such a wonderful plan: They call up the

Goddam Reservists, whenever the shit hits the fan!”)

Somewhat older, not as committed, and with considerably less motivation to fly, those recalled fliers

became a problem because of their increased incidence of refusal to fly combat missions due to “fear

of flying.”3–5 Harking back to lessons learned during World War II, flight surgeons would check such

fliers to assure that they had no psychopathology,

and then clear them medically for flying duties.

Any further refusal to fly was handled administratively rather than medically.

The demographic characteristics of U.S. Air Force

fliers have continued to change since the mid-1950s.

All fliers (indeed, all officers) must have a college

degree, and most obtain their commissions either

through the U.S. Air Force Academy or through

Reserve Officers’ Training Corps programs. Many

go on to obtain master’s degrees after entry on

active duty. Except for the few older officers commissioned through the old Aviation Cadet Program

or Officer Candidate School, this was the complexion of the force in Southeast Asia. These young,

bright, well-educated fliers had thus spent at least 5

years (4 in college, 1 in flight training) directed

toward the goal of becoming a U.S. Air Force officer

and flier. Many were seriously considering 20-year

careers, and most of those who were not were hoping for careers as airline pilots. Thus they went to

war older and better educated, and with a longer

career view than their predecessors. Many were

fairly “high-time” fliers when they arrived in Southeast Asia, although the younger ones might arrive

with only 200 to 300 flying hours. The professional

fighter pilots were a subgroup of the U.S. Air Force,

a tactical cadre that rotated between Southeast Asia,

the Tactical Air Command in the United States, and

tactical fighter wings in the U.S. Air Force, Europe

(USAFE). Some of these men served two, three, or

four tours in Southeast Asia. These fliers differed

from the U.S. Army helicopter pilots, who were

younger, less educated, and more like the World

War II volunteers.

The U.S. Air Force today has continued its policy

of producing highly selected, educated, and trained

pilots. The increasing complexity of aircraft (frequently called “weapons systems” to underline this

complexity) requires continued high-grade training. Many frontline pilots, navigators, weapons

systems operators, and electronic warfare operators are in their 30s, and some are in their 40s. They

are, as stated earlier, considerably different from

their predecessors in World War II, and more like

those who flew in Southeast Asia. Yet there are

almost no specific data about combat reactions of

fliers in action in Southeast Asia, the Libya raid, the

invasions of Grenada and Panama, or the Persian

Gulf War, or about the types of support most effective in maintaining their morale and fighting spirit.

Thus, any ideas or plans for furnishing such support in a future conflict must be based on the reports

of U.S. experiences in World War II and Korea,

along with anecdotal data and reminiscences from

Southeast Asia, data obtained from the performance

and support of fliers from the U.S. and other nations

in the more recent conflicts, and projections of all of

this information onto present U.S. Air Force fliers.

Added to these changes will be the effects of the

drawdown of the U.S. Air Force since the collapse of

the Soviet Union, the increase in the proportion of

women and their new roles, and the outcome of the

present debate about homosexuals and lesbians in

the service. Still, one may reasonably assume that

principles of support to morale and flying efficiency that have been effective in a variety of past

conflicts are probably basic enough to prove useful

when flexibly and thoughtfully adapted to the particular circumstances of future conflicts.

U.S. Air Force fliers may fill a number of roles in

a combat situation. Some tactical fighters will fly

air-to-air combat missions to establish air superiority over the battlefield by attacks on enemy aircraft.

Others will fly tactical air-to-ground missions, attacking enemy troop concentrations, armor, artillery, supplies, and equipment. These aircraft may

be single-seat (pilot only), or may be crewed by a

pilot and a weapons system officer. Forward air

controllers will coordinate some strikes and will
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U.S. Air Force Combat Psychiatry

identify targets. Reconnaissance pilots will take

photographs before and after air strikes to use in

planning missions and to assess damage. Tactical

helicopter pilots may fly special missions, inserting

or extracting troops, rescuing downed fliers, and

carrying patients to the rear. Tactical transport

crews will airlift supplies, delivering them from the

air by parachute or by special low-altitude extraction systems, or by landing to off-load in the conventional way.

These and other tactical aircrew will be exposed

to specific dangers: ground-based small-arms fire,

surface-to-air missiles, conventional antiaircraft fire,

and attack by enemy aircraft. The threat of chemical

or biological warfare at base or just prior to takeoff

may act as a stress multiplier. Tactical missions

tend to be fairly short, lasting from 1 to 4 hours, and

thus the aircrew may fly two, three, or even four

missions in a day. Israeli fighter pilots in the 1967

war, expected to fly an average of three or four

sorties a day, flew an average of seven a day; some

pilots flew as many as 10.6 The dangers of such

missions may vary considerably; some are the proverbial “piece of cake” while others may be extremely lethal. At times the danger—or lack of

danger—will be familiar to the fliers. Other missions or target areas will be known as unpredictable, thus adding the considerable stress of uncertainty to all the other stresses of combat.

For the tactical fighter pilot, the success both of

air-to-air and air-to-ground missions depends on

personal skills. Dual-crewed aircraft such as the F15E integrate the weapons system officer into the

equation, but the skill of the pilot is still paramount.

Whether a pilot lives or dies in such combat depends upon personal prowess to a degree that may

be unique in modern warfare.

Such a pilot must have supreme confidence in

personal skills and a strong narcissistic component

recognized when he is selected for training. This

narcissism, an almost magical sense of personal

invulnerability, is nourished by the U.S. Air Force’s

system of training. It displays itself in the “typical

fighter pilot personality” that is immediately apparent to the most casual observer of human nature.

This pilot’s effectiveness in battle depends on boldness, self-sufficiency, situational awareness, and an

internal locus of control. Such pilots may depend to

some extent upon a wingman and a squadron for

support, but deep in their hearts, each knows that

one can ultimately depend only upon oneself. Maintenance of this narcissism in the face of mounting

losses to the enemy of friends—fliers who were

known to be skillful and brave—requires a healthy

initial motivation to fly, a strong ego, and welldeveloped denial skills to defend against personal

fear and sense of mortality. Magical thinking and

superstition may also be observed. Deaths are

briefly acknowledged and then consciously suppressed in order to continue the squadron mission.

Support of tactical fliers in the combat arena has

been similar during each of America’s last four

wars. Airfields have been reasonably free from

enemy attack in most cases, and fliers have lived in

a base environment in which a great deal of effort

has been devoted to their personal comfort and

support. Nourishing meals available 24 hours a

day, specified crew-rest periods with exceptions

granted only by higher headquarters, personal

health care and welfare overseen by a squadron

flight surgeon and his staff, quiet quarters that are

air-conditioned or heated—all these amenities and

more are provided by regulation, if not always in

fact.

Transport crews will be affected by some but not

all of these considerations, with added stresses deriving from their particular mission profiles. Tactical transport aircraft, particularly the C-130s and

the cargo helicopters, may be used for resupply

under fire of troops and bases, or of besieged civilians receiving humanitarian aid. The resupply of

the besieged Khe Sanh defenders during the Vietnam conflict is an example of such an endeavor.

Not only the pilots’ skills count here, but also those

of other aircrew members and even the ground

crew who must help off-load the aircraft under fire.

The stress of flying in such a large, unarmored,

defenseless “sitting duck” target during the approach, landing, taxiing, off-loading, takeoff, and

departure under fire is enormous, especially because each of these activities must take place in

a location known in advance to enemy gunners,

whose weapons may already be ranged and sighted

in. Transport crews may be called upon to make a

half-dozen or more landings during a day’s missions, and their vulnerability to ground fire leads

to a constant state of arousal; there are only

limited options to counter such fire when it occurs.

Flying such missions when attack by enemy aircraft is possible will add to the strain. This was

exemplified by the slaughter in April 1943 when

American fighters caught about 100 JU-52 transports carrying troops to reinforce the German Army

in Tunisia, shooting down 52 of them over the

Mediterranean Sea.7

Strategic bomber crews may face different perils.

Penetration of enemy defenses depends upon surprise, electronics countermeasures, such techno-
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182

logical advances as the cruise missile, and whatever

escort aircraft may be used. The venerable B-52s are

neither fast nor maneuverable when compared with

air-defense aircraft or with surface-to-air missiles.

Presumably, their airfields will be far enough from

the conflict on the ground to be safe from attack

with conventional arms and will be vulnerable only

to long-range missiles, to enemy strategic attacks,

or to saboteurs.

Strategic bomber crews had the highest proportion of combat losses among fliers in 1944, 7.7 per

1,000 hours flown, compared to light bombers (3.4)

and fighters (1.1).8(p10) The B-52 experience in Vietnam shows the difference in attacking targets with

and without air defense. Between June 1965 and

August 1973, the Strategic Air Command flew more

than 124,000 B-52 sorties against targets in Southeast Asia, losing 29 B-52s altogether. All of the 17 B52s lost to hostile fire were shot down over North

Vietnam; none were lost to hostile fire over the

lightly-defended South. (The other 12 were lost

through accidents or midair collisions.)9

Fifteen of these 17 were shot down during the 11

days of Operation Linebacker II, when some 740

sorties were flown against targets in Hanoi and

Haiphong in December 1972.9 These B-52s were

based on Guam and in Thailand, secure from enemy

attack, but the cumulative and rapid losses caused

considerable concern among the fliers involved.

According to their flight surgeon, this concern manifested itself as a rapid and forceful statement up the

chain of command of the need to change tactics over

the target, a statement that quickly led to the needed

changes.10

In addition to the operational factors already

mentioned, three other matters distinguish the support of U.S. Air Force fliers in combat. One is the

similarity between the “fear of flying” syndrome,

which may occur in peace as well as in wartime, and

the signs and symptoms usually associated with

combat fatigue.11 The second is the use of rest as a

primary preventive and therapeutic measure. The

third is the specific relationship between the fliers

and the flight surgeon who is directly responsible

for furnishing their preventive health measures and

medical support. These three factors will be considered separately.

“Fear of Flying” and Combat Fatigue

“Fear of flying” has been called a symptom without a disease.12 Recognized early in the history of

powered flight, it was the subject of two of the nine

chapters in one of the first textbooks of aviation

medicine.13 Through the years, it has had about as

many synonyms as has combat fatigue itself:

aeroneurosis, chronic fatigue, staleness, aviator’s

neurasthenia, flying phobia, and others.14 The crux

of the problem appears to be that humans have an

instinctive fear of falling, which is overcome to

some extent during the early years of muscular

development as children learn to control their environments by their own efforts. Some youngsters

conceive of flying as the ultimate mastery and power

(“Put out my hand, and touched the face of God”)

and thus present themselves for flying training

saying, “I’ve wanted to fly as long as I can remember” (ie, since age 5 or so).

The central unifying force through the Air Corps is

the intangible yet powerful devotion to aircraft felt

in different degrees by all its members....Planes

receive an almost libidinal investment of interest...the aircraft became anthropomorphized

....This devotion and enthusiasm for aircraft is of

such a compelling force that it to some extent

supercedes military discipline.1(p99–101)

Other fliers may be motivated less by such a

long-lived desire than by their perception of flying

as a way to enhance a career in the U.S. Air Force. In

other words, motivation to fly may be largely emotional, or it may be largely cognitive.11 Most fliers

are probably motivated by some mixture of the two,

and fliers at either end of the motivational spectrum

may serve complete careers in the cockpit, honorably and well. Yet the underlying instinct to avoid

heights persists. Many pilots joke about being mildly

afraid of heights in the ordinary sense, but show no

carryover of this fear to flying in their aircraft.

Through their desire to fly, they deny, suppress, or

repress their primitive anxiety about heights. “You

can get killed just crossing the street” is their common response to questions about their view of the

dangers of flying.

Still, the dangers are real and, with continued

exposure to the world of flying, a military flier’s

ability to deny them is slowly eroded. “There are

old pilots, and there are bold pilots,” goes the old

saw, “but there are no old, bold pilots.” Youthful

enthusiasm is tempered by maturity and the lessons

of experience. “Flying is 99% boredom and 1% pure

terror.” The jokes and sayings reflect the realities.

As youthful fliers begin to comprehend the realities, the strength of their motivation is tested. When

it is flawed, it fails early.

A few fliers are driven by psychologically

overdetermined factors—an anxiety-driven need to

“prove” something to someone (usually father) may
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be seen in some. When success is near, the primitive

symbolism of succeeding (defeating father) arouses

basic anxieties that interfere with successful flying,

and the flier either quits, fails through “lack of

adaptation,” or presents with disabling medical or

psychiatric symptoms.

Others fail in less spectacular ways, with symptoms that are similar to the effects of combat on

infantry. They may be restless and irritable, with

nerves on edge. They may have insomnia, and

whatever sleep comes is light or fitful, disturbed by

unpleasant dreams or actual nightmares. They may

report profound dread or apprehension about flying, with tremors, sweating, and palpitations. They

may have difficulty with concentration, begin to

experience airsickness, or report that they are so

preoccupied with their fears that they must concentrate on not activating the ejection seat in normal

flight. Symptoms may be of disabling and phobic

proportions, or they may be mild and only slightly

distressing. At times, symptoms may have begun

with a specific and clearly recognized traumatic event,

such as a personal close call or the crash of a friend.

Other cases may begin as the accumulation of stresses

which gradually and finally overcome a strong

motivation to fly and the flier comes to the reluctant

realization that the joy is gone from flying.11

Some fearful fliers, having no conscious recognition of their underlying anxiety, may also present

with psychophysiologic disorders. Headaches, vasovagal syncope, obscure visual problems, gastrointestinal upsets, and many other systemic complaints may be presented for diagnosis. The astute

clinician may note that the chief complaint is presented in a framework of “I’d like to fly, but ... “

which indicates that the flier has linked the symptoms with a hoped-for result of not flying. This

attitude distinguishes this particular flier from the

other fliers who complain about possibly being

grounded, or conceal their symptoms, fearing that

they will lose their flying status.11

All this and more occurs in military flying in

times of peace. U.S. Air Force doctrine15 calls for

evaluation to determine whether medical or psychiatric disease is present. If so, medical grounding

and treatment are in order. If no physical or mental

disease is present, the flier is returned to his or her

commander as medically cleared to fly. Further

refusal to fly is handled administratively and may

result in simple reassignment to ground duties (especially if the precipitating event is acknowledged

to be catastrophic and the resultant fear understandable to all), or may involve adverse administrative action.

Estimates of the incidence of such cases of fear of

flying (the U.S. Air Force term for this symptom in

the absence of psychiatric disease) are difficult

because they are not routinely tabulated through

medical channels, but the best guess was about

seven cases per year during the period from 1975 to

1984.16 Thus, fear of flying may be regarded as a

peacetime paradigm for combat fatigue, admittedly

on a much smaller scale. Such cases are difficult to

handle in the local fishbowl environment of the

squadron.

The author, in his past capacity as a psychiatrist

at the U.S. Air Force School of Aerospace Medicine,

has worked with flight surgeons in the field who

were wrestling with the problem of a flier—and

friend—who developed some manifestations of fear

of flying. Such fliers were not mentally ill, in which

case they would be medically grounded; they had

simply lost their motivation to fly and presented

themselves as no longer safe. Every instinct cries

out against requiring someone to fly who no longer

wants to do so; such a flier will clearly be unsafe,

and requiring one either to fly against his will, or to

face possible adverse administrative action seems

the height of folly. How much more difficult, then,

will it be for a flight surgeon to take similar action

to require a flier to fly into combat? Yet this is

exactly the kind of judgment required, to extract

from each flier every possible combat mission before allowing him to step down to nonflying duties

or to return to noncombat flying. Thus the role of

the flight surgeon in maintaining the operational

strength of the squadron must be considered.

The Use of Rest for Prevention and Treatment

As fatigue is a primary underlying pathologic

process, rest is a prime restorative. Rest may be

used in several ways that may be stated as “rules,”

if those responsible understand the need for exceptions in individual cases.

Crew Rest

The major problem with research in this area

derives from the lack of any agreed-upon objective

measure of fatigue. Many biochemical and behavioral factors have been studied in this regard, and

recently such manifestations as characteristics of

eye blinks, voice stress analysis, and rate of mistakes in flight simulators have been studied to see if

they could be quantified. However, the final “gold

standard” is the flier’s subjective appraisal of his

condition. Further adding to the complexity are the
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184

numerous combinations of work-rest-sleep cycles

available.

Hartman17 reviewed some of the current literature and discussed some of the differences between

various kinds of missions: tactical, strategic, airlift,

and ground-based control centers. Briefly, his opinions are:

• Tactical missions involve brief multiple sorties in one day. The special stresses include

high workload environments, highly hazardous missions, acute fatigue effects (the

physical results of pulling high-G loading,

for instance), and rapidly cumulative chronic

fatigue. Circadian factors are also involved

in all-weather aircraft.

• Strategic missions (bombers, AWACS [Airborne Warning and Control System aircraft],

tankers) may involve longer missions, in

some cases extending beyond 24 hours. Inflight work/rest cycles become a factor, as

do reasonable in-flight rest facilities, nutrition, and the different jobs performed by

flight crew and mission crew in AWACS and

command post aircraft.

• Airlift missions may involve multiple short

sorties (tactical) or long-range missions crossing many time zones (strategic). There is

more scientific information on such flights

and also on the use of multiple crews for one

aircraft. One particular problem involves

“ramp-pounding,” a pernicious and frustrating form of nonwork experienced while

waiting for an aircraft to be loaded, repairs

to be made, passengers to be rounded up, or

during any of the many other occurrences

that may delay an aircraft for minutes, hours,

or days. Circadian stresses cause a small but

appreciable decrement in performance, but

may be magnified by other stresses. The

conventional wisdom of the many studies in

this area is reflected in U.S. Air Force crewrest regulations.

• Ground-based centers (command posts, towers, radar sites, and the like) may have unique

stresses based on workload, the facility itself, its location, its dangers, and other unforeseen factors.

Rayman18 reported on a heavy flying schedule

for C-130 crews during a 2-month emergency airlift.

The crews flew almost 180 hours per month (the

usual limit is 125 h), involving three or four shuttles

per day. He defined “fatigue” as cumulative effects

that were not relieved by a single day’s rest and

“tiredness” as the acute effects that were. His practical conclusions, listed below, are applicable to all

flying circumstances, regardless of their complexities, because they derive from the subjective effect

of daily stress, yet allow for a reasonably objective

aeromedical judgment.

• Understand that crew duty limitations are

due to variables and must be established by

experience and precedent, as well as by local

needs. Be flexible.

• With good motivation and good support,

aircrew members can exceed normal crewrest requirements for at least 2 months.

• Routine aeromedical surveillance suffices for

the first month. Extra surveillance (defined

as the flight surgeon’s meeting each aircrew member before each takeoff and after

each landing) is necessary after that.

• Assess fatigue frequently. One may do this

by daily contact; occasional anonymous

questionnaires; aircrew briefings on fatigue

factors; assuring the best available crew-rest

quarters, food, and in-flight provisions; and

establishing rapport with aircrew and supervisors.

• The decision to restrict an aircrew member

temporarily from flying because of fatigue

should be made jointly by the flight surgeon,

the operations officer, and the aircrew member. Remember that grounding one flier

means more work for another.

• Aircrew members should be relieved of all

additional duties, so as to direct all their

energies to the flying mission.

• Bend every effort toward flying the schedule as scheduled; avoid needless changes,

delays, and excessive ramp time. Quarters

near the flight line (but not so near as to

cause the crews to be kept awake by the

noise) reduce wasted travel time.

• Incentive pay for extra effort is a strong

motivating factor for paramilitary flying.

Each U.S. Air Force major air command has its

own crew-rest regulations. Variables that contribute to these regulations include size of crews, type

of aircraft, flying hours each day, hours of rest

between flights, hours of nonflying duty, and hours

flown each month. All of these factors may be

waived if the exigencies of the situation demand it,

but the wise commander will consult with the flight

surgeon before doing so, and the wise flight sur-
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geon will look at the fliers on an individual basis

before giving advice on the subject. The difference

between granting a crew-rest waiver for a singleseat fighter mission and a similar waiver for a transport mission where one pilot may take a nap in a

bunk during the mission is immediately apparent,

even in principle.

The literature is specific, however, that one must

consider more than the hours of crew rest available.

Sleep disturbances are a consistent early symptom

of cumulative combat stress in fliers, and thus the

flight surgeon must discuss the quality of their

sleep with individual fliers. If sleep is disturbed by

nightmares or insomnia to the point that the flier

remains as tired upon awakening as when going to

bed, the cumulative fatigue after 2 or 3 days may

well render him or her ineffective at best and unsafe

at worst.

The social role of alcohol in the ambiance of

combat fliers deserves brief consideration. The

drinking habits of aircrew are the stuff of legends.

The stories, the songs, the customs, the superstitions, the very social fabric of the squadrons of old

are celebrated and, in the opinion of this author,

reasonably accurately presented in plays, movies,

books, television, and folklore. For more than 30

years to which the author can attest, flight surgeons

in training have been urged to go to the bar with

“their” fliers in order to meet them socially, to learn

what’s really going on, to find out what makes them

tick. From the 1940s through the 1970s, at least, the

Officers Club bar was a center of aviation society.

These habits are changing as American society

changes, as the realities of working spouses and

modern family dynamics have affected the social

structures of flying squadrons, and as the incredible

demands of modern military aviation have demonstrated that “you cannot hoot with the owls if you

want to fly with the eagles.” Still, the tendency of

many fliers to treat their fatigue symptoms with alcohol has been well-observed in the past, and will probably continue in the future. Many books attest to this.

Gene Basel’s Pak Six19 contains repeated references to

bar conversations, and the personal experiences of

the author’s generation of flight surgeons in Southeast Asia corroborate Basel’s writings. One does

not need a postgraduate education to understand

that alcohol abuse is dangerous in such circumstances. It is not necessary to belabor the point

beyond observing that drinking serves several purposes: as a self-administered and socially acceptable psychotropic medication, as a social lubricant

to allow personal conversation among somewhat

emotionally distant people, and as a sedative.

There is one specific observation, based on the

author’s experiences as a flight surgeon, that may

not be quite as intuitive as “Alcohol abuse is bad for

flying safety,” or “Alcoholics should be identified,

grounded, and treated.” That observation stems

from the use of alcohol as a sedative. If a flier takes

a couple of drinks late in the evening to help get to

sleep, that amount of alcohol may be seen as benign

and insignificant. The flier may, however, go to

sleep easily, dream extravagantly, and awaken feeling refreshed and invigorated. Glancing at the

clock, the flier notes that it’s only 0130; 2 hours of

sleep have passed, not a whole night, and there’s

plenty of time left to sleep after all. But now the flier

can’t go back to sleep, or sleeps only fitfully, with

many awakenings, and much punching of the pillow. Finally, perhaps about 0430, the flier does fall

hard asleep for an hour, only to be awakened at 0530

to prepare for the day’s flying. A couple of cups of

coffee help, although the flier may feel a bit dulled

all day.

This is not really a big deal, once. But repeat that

drinking pattern for a week or two, and the flier’s

edge is definitely dulled. Fatigued, he continues to

take a couple of late evening drinks as a sedative,

not getting drunk, but interfering with the normal

sleep cycles on a chronic basis.

The giveaway is the extravagant dreaming early

in the night’s sleep. Alcohol may produce a selfsustaining dysregulation of the normal sleep cycle.

Its effects are complex, but the end result is a diminution of concentration and memory, and an increase in fatigue, anxiety, and irritability. These

changes can persist even after the drug is no longer

present.20,21

It is this author’s opinion that aircrew should

be taught this signal: if they dream and awaken

early in the night, they’ve had too much to drink

and should change their pattern. Again, it’s no big

deal once in a while, but common sense indicates

that interfering with the normal sleep cycle on a

recurrent basis is not good for the flier who must

be sharp and prepared for anything that combat

flying (or, for that matter, ordinary flying) should

bring along.

What should the flight surgeon do to help aircrew sleep? Should hypnotic agents be allowed?

The general rule is that one should not use hypnotic

agents unless, using mature and informed judgment, one decides that it is less dangerous to use

them than it is not to use them. The British used 20

mg of temazepam (Restoril) as a hypnotic for fliers

during the South Atlantic (Falkland Islands) campaign. Group Captain Michael Fisher commented:
War Psychiatry

186

We were particularly impressed by a short-acting

drug for ensuring our aircrews adequate sleep before flights. Very often they were having to get

their sleep at unusual hours of the day under very

noisy, cramped conditions. [Temazepam] is rapidly excreted, though it’s rapid in its effect. People

were able to sleep and wake up and go flying

without any sort of hangover effect. Aircrew eventually were permitted to fly within only six hours of

taking the drug.22(p10)

The decision to use temazepam during the South

Atlantic campaign was based upon British recognition of demanding operational workloads, the need

for extension of permissible flying hours, and the

potential for these conditions to continue for several weeks. Their experience included transport

crews logging up to 150 hours in 24 days, with

single bomber missions lasting up to 28 hours. Even

without the use of test doses, they encountered no

problems with this medication.23

Temazepam is a short-acting benzodiazepine

most active 20 to 40 minutes after oral administration, with peak effect in 2 to 3 hours, and a biphasic

half-life with a 30-minute short peak and a 10-hour

terminal half-life. Temazepam does not affect rapid

eye movement (REM) sleep and somewhat decreases

slow wave sleep. Exigencies of combat may dictate

its use, or the use of a similar short-acting benzodiazepine, but only after ground testing by administration to the individual flier on a night prior to a

nonflying day, in order to detect any unusual or

idiosyncratic effects on the ground rather than in

flight. A new, nonbenzodiazepine hypnotic,

zolpidem tartrate (Ambien), may offer some advantages over benzodiazepines(BDZs). It is important

to remember that many BDZs induce a retrograde

amnesia that could interfere with last minute instruction before sleep.24

Amphetamines have been used by pilots during

deployments and on prolonged combat missions

for several decades. Most recently fighter pilots

deploying from the United States to Saudi Arabia

were permitted their use, and 5 mg dextroamphetamine tablets were made available to tactical pilots

for combat air patrol missions. Of 464 fighter pilots

surveyed by the Tactical Air Command after the

Persian Gulf War, 65% said they used amphetamines during Operation Desert Shield (the mobilization phase of the war), and 57% during Operation

Desert Storm (the combat phase of the war). The

U.S. Air Force subsequently decided to reevaluate

this policy, and authorization for their use was

withdrawn effective 13 March 1992. No untoward

occurrences or reactions were reported, but a decision was made “to make sure that what we were

doing was correct.”25(p3)

Lyons and French et al26 published an aero-medically-oriented review of modafinil, a nonamphetamine stimulant developed in France. Unlike

the amphetamines, it apparently has a low abuse

potential. It also has minimal peripheral side effects at therapeutic doses. The authors concluded

that this medication might be an ideal replacement

for amphetamines in short-term operations in which

fatigue might be a limiting factor. They recommend

further study of modafinil, or a similar alpha 1

receptor agonist.

In the opinion of this author, sedative and stimulant medications should only be used when, in

the best judgment of the most operationally

experienced line and medical authorities available, it is more dangerous not to use them than it

is to use them. Further, they should be used only

by fliers who have been previously ground-tested,

and who (a) have had no untoward effects, (b) are

familiar with their primary effects, and (c) wish to

use them.

Also in the author’s opinion, tactical pilots—

especially those who fly single-seat aircraft—should

be ground-tested regardless of the current policy

allowing or not allowing their use in flight, because

such policies can change quickly, and the circumstances mandating the change may not allow time

for proper ground-testing.

Ground-testing is carried out in the following

manner. Information about the medications to be

used is gathered by the flight surgeon from the most

up-to-date sources available. A questionnaire is

developed that inquires specifically after primary

effects, secondary (“side”) effects, and any significant idiosyncratic reactions. Open-ended and

nondirective questions are added for anything else

the flier may have noticed, desirable or undesirable.

On a Friday when the flier will dependably not

be flying until the following Monday, he (alone, or

in a group briefing) is informed about the groundtest and its purposes. Alcohol is specifically forbidden during the test, and, needless to say, the flier

should take no other medications during the test.

At the agreed-upon hour (say, 2200), the flier

takes the sedative medication and retires 1 hour

later. Upon awakening the next morning, the flier

notes the quality and quantity of sleep, and fills out

the questionnaire regarding medication effects.

If all is well, the flier then takes the first dose of

stimulant (at, say, 0800). Four hours later, the flier

notes any reactions on the questionnaire. If all is

well, the flier then takes the second dose. Four
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U.S. Air Force Combat Psychiatry

more release of anxiety for fliers than will an individual day off. Exigencies of combat, however,

rarely allow such a policy.

The author’s conversations with Southeast Asia

combat fliers have underscored the value of trusting the flier’s own judgment in determining when

one should not fly a given mission because of fatigue. A flier in a well-run squadron may be allowed to take his name off the flying schedule every

now and then without question if that flier feels not

fit to fly that day. Clearly, any flier whose overuse

of such a privilege points to an unwillingness to do

his share should be evaluated by the operations

officer or flight surgeon. Giving the fliers a bit more

control, balanced by the self-policing action of a

well-integrated squadron, may enhance morale and

delay combat fatigue.

Rest and Recreation

A prolonged combat tour should be split by a 1-

week rest-and-recreation (“R and R”) break. Realistic flight surgeons recognized during World War

II, and again 20 years later in Southeast Asia , that

fliers do not necessarily rest on R and R. It is wise

not to schedule them to fly for 1 day after they

return from R and R, but to use this period to

accomplish ground training or administrative duties.29 Some fliers will object to time off, wishing to

hurry through their tour and get home. If the rest

causes more stress than it relieves, such a schedule

may be modified a bit. In general, though, its

beneficial effects will be obvious throughout the

squadron.

Tour Length

The length of a combat tour is a decision that

should be made by line commanders at the highest

level. It is discussed here because of its immense

importance to fliers’ morale and its epidemiologic

role in shaping the patterns of susceptibility to

combat fatigue.

In World War II, the tour length for heavy and

medium bomber crews depended upon the number

of missions flown, with the “magic number” being

predicated on giving each aircrew member a betterthan-even chance of surviving the tour. The Twelfth

Air Force determined “the maximum effort of the

average flier,” essentially based upon attrition rates,

to be based on a 60% to 80% chance of completing a

tour, if the military situation permitted.8 Attaining

the desired number of missions or flying hours

became a valued short-term goal for fliers, and the

hours subsequent to that, the flier notes any further

observations. He uses no further medications, and

no alcohol, that Saturday evening.

Sunday, no medications are taken.

Early Monday, the flier sees the flight surgeon (or

vice versa), individually goes over his questionnaire, and confirms its information. The flight surgeon asks any follow-up questions indicated.

The flier and the flight surgeon both sign the

questionnaire, which is placed in the flier’s medical

records. The bottom line (literally) is that the flier is

signed off as ground-tested and approved for the

supervised use of the two medications tested while

flying, or the flier is not approved for their use.

Two points should be stressed. First, not being

approved for their use does not disqualify the flier

for anything—any mission, any flight, any profile.

Second, even if approved for their use, the actual

choice to use medications is always left up to the

flier. The flight surgeon may only offer to make

them available for certain missions. No one—commander, flight surgeon, or anyone else—may order

the flier to take them. The flier is now familiar with

the medications, and may make up his own mind

about their use.

The Interval Between Missions

World War II flight surgeon reports generally

agreed that missions should not be flown on more

than 3 consecutive days.27,28 All involved were

aware that standing alert was as wearing as flying

an actual mission, if not more so, in that there was

no release of anxiety through action. Further, flight

surgeons reported that the period between learning

about a mission and flying the mission was the most

stressful. Weather holds, slipped takeoff times, and

scrubbed missions were extremely nerve-wracking

and, at least from the point of view of generating

combat fatigue, should be counted as a mission

day.28

A day off must be off, with no duty requirements

whatsoever. Further, the flier should know about it

ahead of time, so that its relaxation may be anticipated as a short-term goal. Specific recommendations for time off in the Eighth Air Force area were

10 to 15 hours of operational flying per week, 24

hours of leave per week, 48 hours of leave every 2

weeks, and 7 days of leave per 6 weeks.29 Grinker

and Spiegel commented on the strength of the group

identification among fliers, that there was little

relaxation available to a flier on the ground if his

friends—or especially his crew—were flying.1 Thus,

if possible, a wing stand down will provide much
War Psychiatry

188

demoralizing effects of shifting the magic number,

always upward, furnished one of the themes for the

novel Catch-22.30 The uncertainties of when personnel deployed for the Persian Gulf War would return, and the effects of those uncertainties on morale, recapitulated this theme.

The knowledge that the combat tour has a finite

duration becomes more important in maintaining

tolerance of the growing anxiety, and

[E]xperience...repeatedly demonstrated that this

factor has been responsible for many individuals

achieving the expected level of operational missions. Without this certainty of relief, the ego in

many instances would have succumbed much

sooner, and an appreciable decrease in the number

of combat missions flown by available personnel

would have resulted.31(p9)

How long should such a tour be? The answer

depends on many factors: (a) the type and severity

of the flying operation, (b) losses to combat and

accidents, (c) the physical conditions of the bases,

and (d) the realities of the combat needs. However,

once a tour is announced, it should be changed only

for absolutely critical reasons, and such a change

should be accompanied by a responsible explanation to the fliers of the exigencies leading to the

decision.

From a pragmatic point of view, a combat tour,

usually measured in number of missions, should

allow each flier at least a better-than-50% chance of

going home in one piece. In the author’s opinion,

odds less than 50% should apply only in last-ditch

efforts, such as in the Philippines in 1942.

Completing a combat tour in prior wars was not

without a striking psychological and psychosomatic

cost to the fliers. The prolonged tension led to

progressive loss of normal personality features.

Aircrew became quieter, more serious and cautious, sometimes seclusive and depressed, with loss

of interest in other pursuits, loss of spontaneity, and

a decreased love of flying. Sleep disturbances included insomnia and nightmares, with battle scenes

a frequent theme. Fliers would have little appetite

for food, but their intake of coffee, cigarettes, and

alcohol would increase. Their increased tension

would also be manifested as irritability, jumpiness,

and tremors. Fantasies of omnipotence and invulnerability would be replaced by obsessive fantasies

of death and ruminations about lost friends. Physical fatigue in periods of prolonged or intense flying

would accelerate this process and might lead to a

clearly visible decline in a flier’s ability to fly and to

fight, which the whole squadron would recognize.

At this point, if not removed from operational flying, the flier would either experience such severe

symptoms as to develop full-blown combat fatigue,

or might become so ineffective as to be at special

risk in combat.

The Role of the Flight Surgeon

As this discussion has demonstrated, fliers are

different from other combat troops. This difference

extends to their medical support, which is provided

on a highly personal and individualized basis by

the squadron flight surgeon. Thus, morale support

and first-echelon mental health care may well be

furnished by the flight surgeon rather than by enlisted medical technicians or by “buddy care” from

peers. The flight surgeon is an intrinsic part of the

squadron’s internal support system and should be

present on a day-to-day basis to furnish primary

medical care and to advise the squadron commander

on matters of preventive medicine, including matters of morale.

Flight surgeons have only a few tools with which

to slow the inevitable progress of combat fatigue in

fliers, but these are powerful therapeutic agents if

properly used. Above all, flight surgeons must

understand that combat fatigue is a normal reaction

of a normal group of people to a dreadfully abnormal situation. As a normal reaction, combat fatigue

cannot be prevented or avoided, but may be delayed.

The frame of reference must not be “Does anyone in

my squadron have combat fatigue?” but rather, “I

must understand how each of my fliers is dealing

with this stress and watch for defenses that are

crumbling.” With this attitude, the flight surgeon is

ready to support the flying mission by helping each

flier to fly as long and as effectively as possible.

Combat Flying for Flight Surgeons

The flight surgeon must fly combat missions, if at

all possible. This sets in motion a complex set of

tried-and-true interpersonal dynamics that pay off

with several specific benefits.27(p81)

Understanding the Mission. Flying the mission

will enable flight surgeons to understand the stresses

of combat at a visceral level. By thoughtful reflections upon their own reactions, a level of understanding develops that would not otherwise be

possible. Good flight surgeons identify strongly

with “my” squadrons and “my” fliers. The use of

the possessive pronoun is universal among the

best flight surgeons, who are much like fliers in

their own personalities. Yet they must recognize
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U.S. Air Force Combat Psychiatry

that they are not pilots, navigators, electronic warfare operators, or gunners. Overidentification can

lead to prostitution of medical ethics and to fuzzy

professional thinking. It can also lead flight surgeons to think that flying, rather than caring for

the fliers, is their own mission. How much should

a flight surgeon fly? That depends on the aircraft,

the mission profiles, and the press of other duties.

In general, based on the author’s experience in

Vietnam, a flight surgeon should log not less than

one nor more than two missions per week during

duty hours, except in support of aeromedical

evacuation. After-hours flights should be negotiable with the squadron or wing commanders, depending upon the flight surgeon’s being able to

sleep normally and to be fully functional in all

medical duties.

Credibility. By flying the squadron mission, the

flight surgeon establishes credibility. The fliers

know that the flight surgeon flies and the flight

surgeon can “speak the language” without being

awkward or pretentious. More importantly, the

flight surgeon can discuss his own personal fears,

anxieties, and reactions in such a way as to give

these strong (and often unacknowledged) feelings a

legitimacy of expression. Such modeling of openness is quite healthy. A flier who is terrified, and

who is also ashamed of that terror, may experience

considerable relief in laughing with the flight surgeon who says “I thought I was going to wet my

pants on that one!” Other fliers may have had

precisely the same feeling but were unwilling to

admit it, each feeling like the only coward in a

group of heroes.

Acceptance. The flight surgeon, by flying and by

being accepted by the fliers as “one of us,” assumes

a symbolic importance within the squadron, perhaps second only to that of its command echelon.

Such a flight surgeon is a person whose judgment is

trusted, a confidant of the commander and the operations officer. Understanding, tolerant, noncritical, realistic, yet firmly committed to the squadron

goals, the flight surgeon develops an image as an

important person, one whose good opinion the flier

values. Giving sympathy, affection, and protection

to the fliers, still the flight surgeon expects of them

dedication, perseverance, and a willingness to continue the mission. The excellent flight surgeon does

not overidentify with the squadron, does not fear

their rejection (a healthy personal sense of selfesteem comes from within), and deals adaptively

with personal internal conflicts between protective

drives and the need to keep the fliers flying even if

some die. This requires a well-integrated personality structure, buttressed by professional skill, and a

strong personal value system.31

Intercession. The flight surgeon who flies combat missions can see firsthand the reactions of the

troops to real-life combat stress, can observe their

discipline, sees the fliers in vivo, as it were, and can

then use the information to keep the commander

informed about morale. These words may look a bit

cynical in print, but the matter is quite practical. As

a flight surgeon with an Air Commando wing in

Vietnam, the author flew with enough different

crews to appreciate how the fliers behaved in routine flight and in combat. He carefully avoided any

actions that smacked of “informing” on specific

fliers, but was able to keep the wing commander up

to date on how well his fliers followed crew rest

procedures, in-flight safety measures, and general

flight discipline. Being known and trusted both by

the commander and the fliers, the author was able

to explain and interpret each to the other, informally and nonthreateningly. He represented a way

by which petty gripes and problems could be taken

outside the chain of command to the one who could

fix things, in matters that might have led to hard

feelings if official action had been necessary. The

credible flight surgeon thus may become a sort of

ombudsman within the squadron and the wing,

able to get things done that need to be done, and to

interpret—and occasionally to soften—policies imposed from above. Such an outlet, serving also as a

safety valve, may contribute considerably to the

fliers’ morale.

Ventilation, Observation, and Early Intervention

In common with combat troops in other situations, some psychological relief may be afforded

aircrew by allowing them to ventilate after missions

and by participating in group activities. These

functions are served to some extent by the intelligence debriefing that takes place after combat missions for fighter and bomber crews and by the

natural tendency of crews to gather at the bar at the

end of a day’s flying. Again, excessive drinking is

a danger to be guarded against, but such activities

in moderation have a cathartic and mutually supportive role for the squadron and are of real value in

the world of the flier. If conditions allow, an intramural sports program (softball, volleyball) has a

similar value, as well as serving as a physical outlet.

Such activities must be voluntary, however. Some

troops can lose themselves in reading, and a library

or other source of books and magazines is a useful

asset. Informal reports from the Persian Gulf War
War Psychiatry

190

also indicate the value of hand-held computer

games. The value of mail from home cannot be

overstated.

The flight surgeon may also keep in touch with

the reactions of individual fliers to the combat situation. Any group of fliers reflects the strain of

combat, and the flight surgeon will have to become

acquainted with the ways that fliers show the strain.

Most of the literature on combat fatigue speaks of

the effects of war on infantrymen who are exposed

to death for days, weeks, or months at a time,

without letup. The flier goes on a mission, faces

death, sees comrades die at a distance (or, rarely, on

the same aircraft), and returns to a generally safe

environment.

The ego of the flier uses various strategies to cope

with the stress of combat. These strategies are

familiar from the peacetime environment, but are

generally discussed only in the context of psychopathology, rather than as useful adaptive mechanisms. During the prolonged combat tours of World

War II, flight surgeons became familiar with a pattern of coping mechanisms in fliers progressing

through their tours. Ignorance or denial of the

realities of combat protected the fliers’ egos against

fear at first, because their perceptions of dangers

were only intellectual and theoretical. This attitude

would disappear after a few flights, as the realities

intruded. Fliers might feel some anxiety, but the

continued flying, the acquisition of combat survival

skills, and the reassurance of peers and of the flight

surgeon would generally suffice to keep the anxiety

tolerable. Successful aggressive action against the

enemy served as a powerful way to discharge anxiety and helped the flier maintain some sense of

control over the flying environment.

The individual aircrew member would identify

strongly with a unit or with his crew (a small group

of men to whom he might ascribe almost magical

powers) or even with a single flier. Similarly, some

would identify strongly with an aircraft as a powerful and deadly champion. It was but a short step to

superstitions about flying as magical defenses:

“lucky” items, rituals, and so forth.32(p16) (The recent

movie Memphis Belle showed several examples of

such superstitions, rituals, and amulets.) Freedom

from anxiety in flight depended upon the fantasy of

the aircraft as safe and upon a flier’s identification

with its strength and invulnerability. Fliers also

identified with leaders and with particularly skillful comrades. Such identification might be badly

shaken if an accident or combat loss claimed these

magical objects, because the identification was now

with a wounded or dead person, rather than with an

invincible, potent one. Some magical feeling of

immunity and omnipotence would also help carry

the flier along, strengthening ego defenses against

reality, because many elements in aerial warfare are

truly beyond anyone’s ability to control.1

 Denial of

these realities (“They’ll never get me!”) would bolster such magical fantasies for a while, but the

accumulation of combat experience would gradually erode this fantasied invulnerability and the ego

would begin to lose its power to protect itself against

crippling anxiety.

Not one man in a hundred looked forward to an

operation with relish, although most of them derived considerable satisfaction from doing an operation well and returning safely...all that most

aircrew wanted after furnishing their reports was

breakfast and bed and sleep. They did not remember vividly every detail of all their operations, but

they were conscious of no urgent desire to forget

them....Their attitude to losses and the death of

friends was particularly striking; it was one of

supreme realism, of matter-of-fact acceptance of

what everyone knew perfectly well was inevitable.

They did not plunge into outspoken expression of

their feelings, nor did they display any compromise with conventional reticence about violent

death. They said “Too bad...sorry about so-andso...rotten luck.” Their regret was deep and sincere, but not much displayed or long endured.

They were apt and able to talk of dead and missing

friends, before mentioning their fate, just as they

talked of anyone else or of themselves. It took the

loss of particular friends or leaders, flight commanders or squadron commanders to produce a

marked reaction among a squadron. Then they

might feel collectively distressed, have a few drinks

because of that, go on a party and feel better.32(p15)

These words were written about British night

bomber crews in World War II, but they apply just

as well to the Air Commandos (now Special Operations) and tactical fighter pilots with whom the

author worked in Vietnam. The men had seen

friends die in aircraft accidents before the war, and

combat losses were regarded in much the same

light. There was some corporate acknowledgment

of those who were killed, but relatively little grief

was expressed. Spontaneous expressions of anger

or acute grief at the loss were heard as the news was

delivered, and then the old mechanisms of denial,

intellectualization, rationalization, altruism, humor,

and magical thinking reasserted themselves and

the loss was thenceforth discussed more coolly.

Toasts might be drunk in the bar; a few (but by no

means all) of the squadron would attend a memorial service; and the war went on. Symonds33 speaks
191

U.S. Air Force Combat Psychiatry

of the mental state (“confidence”) that carries a flier

through such experiences, ascribing it to a blend of

resolution, bravery, and frankness. As frankness

ebbs (as reality intrudes), bravery and resolution to

see the job through keep the flier going.

Still, fliers did, and will, break down in combat.

A number of authors in World War II and Korea

commented on a pattern that most likely will be

seen in future prolonged aerial conflicts.1,3,28,32,33

There will be a few fliers who suffer disabling

symptoms of anxiety early in their combat flying

(Group A). A few of these fliers may be returned

to flying, but most seem not to have the capacity

to tolerate combat flying and may need to be relieved from duty. These fliers may represent the

U.S. Air Force equivalent of the U.S. Army’s early

breakdowns among men with immature, dependent, or other maladaptive personality structures34

as discussed in Chapter 1, Psychiatric Lessons

of War, and Chapter 2, Traditional Warfare Combat Stress Casualties. Other cases of combat fatigue tend to occur in two clusters: toward mid

-tour (Group B), and as the tour nears its end

(Group C). Finally, there will be a scattering of

fliers who undergo extremely stressful events, who

then break down in consequence (Group D). Such

events may be scattered throughout the tour.

Stafford-Clark32 and Symonds33 concur that the prognosis is poor for Groups A and D, and better for

Groups B and C.

Some of the fliers in Group A are described in

terms that today would place them among those

having antisocial personality traits: lack of allegiance to others than themselves and little regard

for the social conventions or expectations of the

squadrons. One would hope that most potential

fliers with such personalities have been detected

and eliminated by the preselection interview with

the flight surgeon, the Adaptability Rating for Military Aviation (ARMA).35 If not, such fliers may

show their true colors during the extensive flying

training and combat crew training process or by

their behavior in squadron operations during peacetime. Failing that, there is no way to treat such an

ingrown personality pattern, and these fliers must

be administratively eliminated from flying status if

they are detected.

It is axiomatic that it is impossible to predict who

will do well in combat and who will not, until they

are actually exposed to enemy fire. Some fliers will

be unambiguous in their refusal to fly combat missions. Because they are not psychologically conflicted about their determination not to fly into

danger, they do not become symptomatic. (Symptoms arise from unresolved internal conflicts.) They

may even express their surprise that no one understands their feelings and excuses them. Appeals to

duty, to squadron or personal loyalty, or to pride

will have no effect. Such aircrew must be grounded

in disgrace by their commanders. The wise flight

surgeon will counsel administrative authorities that,

if these fliers are not punished, they should at least

not be rewarded by being administratively

grounded and given a job seen as desirable by

squadron members.

Whether combat fatigue occurs early in the tour

or toward its midpoint, the first contact of the anxious flier will be with the flight surgeon, who certainly does not need to be a psychiatrist to deal with

most such cases. The flier may come in of his or her

own accord, or the flight surgeon may have noted

the classic early symptoms: gradual withdrawal

from social contact, loss of sense of humor, lack of

spontaneity, passivity leading to moroseness, the

onset of multiple complaints of vague symptoms

that would hitherto have been ignored or even

hidden from the flight surgeon to avoid grounding,

and diminished energy and appetite. Later symptoms will almost certainly include irritability; increased use of cigarettes, coffee, and alcohol (which

obviously make things worse); digestive disturbances; weight loss; insomnia; and the disturbance

of sleep by bad dreams or nightmares. The flier may

develop tics, frank tremors, or an increased startle

reaction. Further symptoms of anxiety, depression,

and psychophysiological reactions will be superimposed on these symptoms if matters are not corrected.

The best early intervention is to talk things over

privately with the troubled flier. Whether the interview is initiated by the flier, flight surgeon, or

squadron commander, the flight surgeon should

take the role of a sympathetic and concerned counselor who wishes to help the flier regain composure

and return to the cockpit, once more fully effective.

Thus the flight surgeon supports that part of the

conflicted flier that wants to return to effective

duty. How long has the flier felt below par? Was it

due to a particular event, or to an accumulation of

things?

If an accident or a particular mission is on his

mind, allow him to ventilate. What was he doing?

Where? When? Then what happened? How did he

react? How did others react? How does he think he

should have reacted? What is he telling himself now

about the whole thing?

If it were cumulative stress, how has it affected

him? What is he afraid of? How does he see others
War Psychiatry

192

reacting to the situation? How do they react to him?

How much does he feel a part of the group and how

much ego support does he derive from them and

from the leaders? At times one may encounter

marked misperceptions about how others feel, how

they handle things, and how “I have let them down.”

In each case, the flight surgeon can reflect the

reality of the situations involved, correcting misapprehensions, clarifying the flier’s status in the squadron, and helping to strengthen the ways in which

the flier has dealt with the stress so far. An understanding, noncritical, tolerant acceptance and explanation of the flier’s anxieties (unrealistic) and

fears (realistic) is essential, so that the flight surgeon then assumes a warm but firm parental role

that allows for sympathy, affection, and protection

while expecting and demanding the utmost dedication to the mission, to the point of possible selfsacrifice.

By allowing the flier to talk about his anxiety,

especially if it is manifested through psychophysiological mechanisms, the flight surgeon may help

clarify that which the flier really fears: injury or

death. Verbalizing this fear allows the flier to examine it directly, rather than dealing through a smoke

screen of symptoms and vague apprehensions. It

also allows the flier to deal realistically with anxiety

about being seen as afraid, which may be perceived

as a strong taboo within a “macho” squadron: “Better to die than to look bad.”

When the flight surgeon accepts and defines this

fear as natural and universal, the flier’s tendency to

view it as an unnatural, exaggerated personal failing may be corrected. Thus he reassures himself

that he is normal and that if his squadron mates are

dealing with similar feelings and yet can continue

to function, so can he. Reassurance, accepting support, and firm encouragement to return to duty will

strengthen his ego and help him deal with the

doubts, self-criticisms, and guilt with which his

superego may be taxing him about his not being the

perfect flier. Remembering that the flier is conflicted (or else he would have quit long ago!) will

help the flight surgeon deal with personal uncertainties about such a therapeutic approach.

Gratification of the need for the flight surgeon’s

approval may do much to relieve anxiety, particularly in the more passive or dependent members of

the squadron. The amount of positive feedback

needed obviously varies from person to person.31,36

At a deeper level, an individualized psychotherapeutic technique must be used. This may be

performed by some particularly adept flight surgeons, or may require the services of more skilled

psychotherapists. Uncovering therapy will help

aircrew members express their honest fears; they

frequently lack insight into their own apprehensions. The insight gained may be only intellectual;

but, even expressing it verbally gives the emotion

legitimacy. Furthermore, the flier may be relieved

by no longer being afraid and unwilling to acknowledge emotions he regards as unworthy. The more

that the anxiety is expressed verbally, the less the

need to express it physiologically or psychosomatically; thus, the flier is relieved of the added fear of

bodily disease.

The ego, weakened and shaken by anxiety, needs

strong and repeated doses of reassurance, support

and encouragement....Many men despise and often condemn fear as unmanly and cowardly, and

therefore suppress or repress their own, out of guilt

or the hurt to self-esteem. These superego tensions

must be relieved by appropriate explanations.31(p82)

If fears are already conscious, uncovering is not

necessary; ventilation and reassurance may suffice.

Should such fliers be unwilling to tolerate their

fears or somatic concerns, they may respond to an

appeal to pride and conscience by pointing out the

obvious secondary gains. For example, being

grounded would remove them from danger, but

would transfer the risk to comrades. Use the transference relationship with the flight surgeon and

squadron for leverage: “We will think better of you

if you fly in spite of your feelings.” This may be

tempered by simultaneously gratifying dependency

needs through allowing extra time with the flight

surgeon, or a special system of appointments after

missions.

In the case of fliers who attempt to compensate

for these needs by denying them and rejecting proffered help, an especially sensitive and tactful approach may be necessary. The therapist may encounter displaced hostility, especially if morale in

the squadron is low. This symptom may need to be

interpreted to the flier: “I know things are bad in the

squadron, and I know you’re unhappy with them.

Still, we’ve got a mission, and you’re not really sick

and don’t need to be grounded. I know you can fly

and I’ll be willing to check you over after every

flight to be sure nothing else is going wrong with

you. This tension gets to everybody, but I know you

can gut it out for a while longer.”

Levy,31 whose approach has been paraphrased,

noted that no one had good statistics on what went

on within the squadrons. He felt that about 40% of

medical/operational failures were primarily psychological and that about half of these failures oc-
193

U.S. Air Force Combat Psychiatry

curred in the first 10 missions. He went on to point

out, as do all authorities, that all fliers would finally

break down if not eventually relieved from duty.

Captain Robert Rehm27 carried his interest in the

progression of responses to combat stress beyond

that of most flight surgeons. After a year as a flight

surgeon in Italy, he felt that he had merely scratched

the surface in dealing with his fliers’ psychological

problems; therefore, he began flying regularly with

the crews to better understand their experiences.

Although he does not specify, he was probably

assigned to a B-24 heavy bomber squadron. He

reports various common psychological factors occurring in three segments (the first 10 missions, the

subsequent 30, and the final 10) during his 50-

mission experience. He expresses the certainty that

anxiety was the greatest during the initial missions

over the target, especially when the new flier is

confronted with serious occurrences such as flak

wounds, aircraft damage, or witnessing the loss of

another aircraft.27(p5) Such a “mild catastrophic

event” [!] will shake the resolve of unaggressive aviators. Captain Rehm states that he found it necessary

to take a firm attitude and not to leave the decision to

continue flying up to the flier, but to explain—

repeatedly, if need be—that he had no medical

reason to ground the flier, who must continue to fly.

Such a firm stance was usually effective.

During his own “tour,” Captain Rehm describes

mostly short and rather easy missions at first, with

some exhilaration at actually being in combat and

taking some flak hits. However, a near crash on

takeoff laid the basis for a later phobia—he preferred to sit where he could not see the ground on

takeoffs. One such episode was not sufficient to

keep him anxious, but an accumulation of similar

phobias could become disabling.

After his first 10 missions, he found that the

excitement was subsiding as familiarity increased.

The many novel experiences were now accepted as

routine, given that no truly catastrophic event occurred. He felt less alone in the aircraft and more

homogeneous with the other aircrew members. The

war was no longer a personal matter between him

and the enemy, but the cooperative effort of a force

of which he was a part. He also felt a growing blind

faith in his pilot, something quite common in his

squadron. “All the dangers which have been safely

encountered and surmounted are epitomized in

that particular pilot. He stands as a tribute to

experience and a symbol of their safety.”27(p7) This

statement clearly delineates the identification with

the pilot and the magical powers attributed to him

by an ego defending itself against reality.

As the second period progressed, Captain Rehm

describes his emotional plateau as being able to

relax over friendly territory and more nervous in

the briefing for a bad target (Ploesti, for example)

than during the actual mission. After seeing one of

their planes shot down, he became somewhat anxious and was insomniac for a few nights. However,

his assurance reasserted itself when all went well

on subsequent flights.

He comments here on the importance of keeping

men flying regularly, “regardless of unusual or catastrophic episodes ... [I] returned a man to duty as soon

as physically able, following any injuries which he has

sustained. The longer he has to think about his injuries and how they occurred, the more the mental

‘gremlins’ play on his emotional stability.”27(p8) He

experienced the effects of a long stand down after his

35th mission, just after seeing a plane crash and

burn on takeoff, when bad weather grounded the

squadron for 10 days. This exacerbated his growing

fear of takeoffs, which was relieved only when a

trusted pilot had him sit on the flight deck during

takeoff and explained how little danger they were

in once takeoff speed was attained. (This explanation is, of course, somewhat irrational when one

considers that Captain Rehm had, in 35 rides, seen

two planes crash and burn on takeoff. One sees how

the weight of reassurance from a valued authority

transcends logic.) The flight surgeon must understand that a flier who is conflicted about continuing

to fly is just that, conflicted. That part of him that

wants to fly will seize on any information from a

valued figure, such as the flight surgeon, as an

excuse to return to what he knows he should be

doing anyway. Flight surgeons must never underestimate their power in such instances, even though

they understand the irrationality involved.

At about this point in a combat tour, Captain

Rehm comments upon the “benign hypochondria”

in many fliers who develop vague somatic symptoms, some real, such as head colds, some not. Wise

flight surgeons will not overemphasize the importance of such symptoms by initiating “junior medical student” workups for minor complaints, sometimes thereby attempting to exorcise their own

anxieties. In others, Captain Rehm observed overuse

of alcohol and tobacco, irritability, insomnia, nervousness, and temper outbursts. As he began his last

10 missions, he summarized his own situation:

I realized how all important the factor of physical

fatigue was. I became nervous and irritable and I

had a great deal of trouble controlling my emotions. I had little zest for the squadron activities.
War Psychiatry

194

My appetite decreased materially and I noted that

during the past two and one-half months my weight

had dropped from 178 to 156 pounds. I found that

I was smoking two packs of cigarettes daily instead

of one. The most noticeable factor was my inability

to sleep, especially before each mission. This was

most marked on the event of my fiftieth mission.

Missions to (various targets) were met and completed with much trepidation. The easier

missions...gave much relief but seemed much more

hazardous than formerly. However, throughout

this entire period, the interest and encouragement

of the men in the squadron and group spurred me

on to greater efforts than before.27(p10)

If a flier must be grounded for combat fatigue,

and local treatment is not sufficient, that flier must

be evacuated to a treatment facility where specialized psychiatric care is available. The author’s

experience in Vietnam was that the few fliers who

were evacuated for psychiatric care to the hospital

at Cam Ranh Bay 25 miles away were returned in a

week or two and were able to return to flying duties

without further difficulty. The author has heard

anecdotal reports from multiple sources about several fliers who were grounded for similar symptoms during the Persian Gulf War, and who were

evacuated to the United States for treatment. Upon

their hospital discharge, no administrative route

was available to return them to duty with their

squadrons; thus, they were returned to their Stateside bases. There they and their spouses were

shunned by other fliers’ families, and when their

squadrons returned from overseas, they were not

accepted back. In essence, their careers are ruined.

While these stories cannot be confirmed, their consistency among the sources rings true. If so, they

furnish a stark example of the loss of competent

fliers because of aeromedical evacuation beyond

the point of return to duty. This provides another

reason to give treatment as far forward as possible.

Medical authorities should also plan to provide an

administrative mechanism for return of such fliers

to their overseas squadrons.

As combat flying draws to a close, several changes

may be noted. Jones37 speaks of the “short-timer’s

syndrome” in soldiers, a mixture of mild anxiety

and phobic symptoms near the end of a fixed 1-year

tour. Some commanders kept men off tough patrols

and assignments during their last month, which

unfortunately tended to move the onset of the symptoms to the 11th month rather than the 12th. Thus,

the division psychiatrist discouraged this policy, in

order to maintain consistency in all units and to

avoid premature onset of symptoms.

The author saw two sorts of reactions in fliers

near the ends of their combat tours. The first was a

tendency to “beat up the sky” on the last mission, a

tendency that resulted in some unnecessary losses

from enemy fire or from crashes. One squadron

adopted the policy of suddenly announcing to a

flier, “That was your last mission—turn in your

gear,” about 10 days before the end of the tour.

The second reaction was to become progressively

cautious and super-safe, which at times resulted in

mission ineffectiveness. This reaction may represent the flying equivalent of “short-timer’s syndrome.” If so, this author agrees with Jones’ approach, which is to advise the commander not to

make special allowances for a flier near the end of

the tour, in order to avoid adding a secondary gain

to the natural tendency to let down right at the end.

Any person, flier or nonflier, needs a chance to

debrief and “decompress” at the end of a combat

experience. This process should be led in a sympathetic setting by a knowledgeable practitioner. Ideally, the squadron could undergo the process together, giving all a chance to achieve closure on

matters of self-esteem, of group validation of individuals’ performances, and of an agreed-upon remembrance of how things were. This process should

be formalized by such elements as a memorial service for lost comrades and a military parade, with

awards and decorations, and a casing of the colors.

Ratification of the worthiness of one’s service by a

valued authority is a powerful antidote for a stressful experience that may be used to balance the

doubts and emotional reactions yet to come.

Summary

Plans for dealing with combat fatigue in fliers

must be based on experiences of flight surgeons and

psychiatrists in past wars with the clear caveat that

conditions in future wars may be quite different.

Flight surgeons must understand the basic principles underlying the prevention, or at least the

delay, of combat fatigue; and they must use their

two major therapeutic modalities wisely: (1) the

judicious prescription of rest as a palliative and

restorative and (2) their own influence in sympathetic yet authoritative roles that offer understanding while expecting faithful service.

Psychiatrists to whom flight surgeons refer fliers

must also understand these principles and must

take care not to preempt the role of the flight surgeon, nor to belittle or ignore the need for coordination between the two disciplines in decisions regarding flying status.
195

U.S. Air Force Combat Psychiatry

SUPPORT OF NONFLYING PERSONNEL IN COMBAT

nerve gas or mustard. There is little precedent in

today’s U.S. Air Force for a line chief to tell his

armament troops, “You have to upload that F-16

right now! I know there’s persistent nerve gas

around, but all of you have your chemical assemblages on. We fixed up the rips the best we could

with plastic tape. If any of you get gas symptoms,

try to get back here. The rest of you will have to

keep uploading the plane, so don’t stop to help each

other. We have to get that plane off before they hit

us again!” Grinker and Spiegel1 describe similar

stress on ground maintenance troops in North Africa who came under attack by German fighters.

Especially in the early days of the Tunisian campaign, although the forward airfields were constantly patrolled by the fighter aircraft, these were

no match for enemy aircraft coming in considerable

numbers. The planes appear from nowhere, announcing their presence by the spatter of machine

gun bullets and the thump of explosive cannon

shells. They appear mysteriously, almost magically, flying out of the sun in the early morning, or

diving from behind a cloud to lay a string of bombs

throughout the dispersal area. One minute all is

peaceful, a scene of quiet, busy activity. There may

be a roar of motors in the air, but that is the normal

state over an airfield. The next minute enemy

fighter planes are buzzing the field, bullets kick up

dirt all about, and the tremendous crump [sic] of

exploding bombs deafens the ears. There is no time

to look for shelter, hardly time to put on a helmet—

nothing to do but lie flat on the ground and hope for

the best. The ack-ack batteries contribute to the

general noise and confusion—ineffectively in most

instances, because the planes usually come in too

low and too fast for effective anti-aircraft fire. In no

time at all, the enemy planes are gone, leaving

behind them a few twisted, burning planes, a few

injuries and deaths, and a number of incipient

anxiety states.

Because in this kind of attack the ego has actually

no time for defensive activity, its helplessness is

real and actual. There is nothing in the environment which can be used to anticipate the approach

of danger. Under such circumstances, any stimuli,

any loud noise, even the roar of aircraft motors,

may actually mean the beginning of an attack.

Inhibition of anxiety becomes increasingly difficult. When enemy attacks become incessant, almost everyone on the field develops some degree of

free-floating anxiety. The development of the symptoms of neurosis, aside from those of anxiety, in this

situation, is directly dependent on the capacity of the

individual ego to tolerate free anxiety.1(pp103,104)

U.S. Air Force doctrine currently calls for four

echelons of medical care in combat situations. The

first echelon (1-E) consists of care given before a

physician becomes involved: preventive measures,

first aid, buddy care, and the attention given by

enlisted medical personnel. The second echelon (2-

E) is the first care given by a physician’s assistant,

nurse practitioner, or physician, perhaps in a base

medical facility or in one located just off-base. Third

echelon (3-E) care is given in a larger medical facility (250 to 300 beds) located well off-base, either in

a presited hospital or in a transportable hospital

brought in by air or by truck. The fourth echelon (4-

E) facilities are larger still, and are located well

away from the primary battle zone. From these

hospitals, patients requiring long-term care will be

evacuated back to the United States.

By the nature of these facilities, psychiatric care

at the 3-E and 4-E level will be given by specialists.

Information in this chapter is primarily intended

for nonspecialists, and thus it will deal almost exclusively with the 1-E and 2-E care.

As mentioned in the Introduction, there is little

historical information on the effects of combat upon

the support troops who make up the majority of any

U.S. Air Force base population. In contrast to the

classical estimates of psychological casualties as

comprising about a one fourth to one half of all

battle-induced casualties in combat, during the Persian Gulf War psychiatric diagnoses among U.S. Air

Force troops averaged about 3/1,000/wk, about 5%

of the total morbidity. This may be compared to the

reported average for respiratory diseases of 21/

1,000/wk, or the nonbattle injuries rate of 12.3/

1,000/wk. Psychiatric diagnosis peaked at about

5.8/1,000/wk during the third week of the air combat campaign.38(p30)

These relatively low numbers would have undoubtedly been higher had the bases been under

concerted attack, and one might reasonably assume

that the particular vulnerability to stress found in

U.S. Army support troops under fire would apply

here also. Sir Winston Churchill once said, “Nothing in life is so exhilarating as to be shot at without

result,” but the more common experience seems to

be, “Few things in life are as stressful as being shot

at and not being able to shoot back.”

Consider the situation of an overseas U.S. Air

Force base under conditions of impending combat

on which troops might come under attack by enemy

air and land forces or by missiles that might bear
War Psychiatry

196

Marquez reports a similar scene 25 years later,

during the Tet attacks on Bien Hoa Air Base in South

Vietnam, 0200, 29 January 1968.

People were running around trying to find shelter

anywhere....The 120-mm rocket was an especially

frightening weapon because, in addition to doing

damage as a fragmentation weapon, it made a lot of

noise....Great fires were started, and the firefighters

were unable to put them out. People were standing

around staring and were too frightened to

act...Through it all, there was rampant confusion

and no one knew if another attack was imminent....It’s hard, but important, to keep busy in

the aftermath of one of these things. Some were

scared; some were totally out of their minds; others

were enjoying it!39(p22)

Marquez goes on to describe that someone issued

weapons to the U.S. Air Force troops on the base,

and suddenly there were

500 armed aircraft mechanics running around with

weapons, no enemy to shoot at, and no one in

charge....They were just firing at noises. It took me

four hours to retrieve those guns....My reasons were

clear—I was afraid my troops would kill each other

before dawn....Fear drives people to do very irrational things ... It takes a lot of discipline to get people

back together and working productively.39(p22)

What can be done today to prepare for such

stresses tomorrow? What should be done as the war

begins? General preparation should include attention to education, training, group cohesion, morale,

and sleep discipline, as well as to other elements

leading to improved or prolonged combat effectiveness. These preventive measures will be considered individually. They serve as prophylaxis and,

in a sense, as early treatment measures at the 1-E

level of medical care.

First-Echelon Measures

Education and Training

The medical officer on base who is most knowledgeable in such matters must be sure that all officers and senior NCOs understand the basic message

of this chapter, that they will have to deal with acute

stress reactions from the announcement of deployment through the first few days of combat, and that

more chronic combat fatigue will inevitably build

as time goes on. They must understand that they

should take preventive measures before and during

the conflict. Briefings should be given by mental

health professionals if possible, and, if not, by the

senior flight surgeon.

This information must be transmitted down

through the ranks to the working level. Leaders

should tell their troops ahead of time as much about

the combat conditions as possible. They may want

to say that it is almost certain that everyone, themselves included, will be afraid, and that it is normal

to experience the physical manifestations of that

fear. They must expect dry mouths, sweaty palms,

palpitations, rapid heartbeats, breathlessness, stomach flutters, and perhaps even nausea and vomiting, urinary frequency, or diarrhea. They will surely

be tremulous. All these symptoms are to be expected, as is a realization of their fear about what is

about to happen.

Leaders must also make it clear that they expect

all of their troops to do their jobs in spite of their

fears and to help each other out. In a phrase, “It is

all right to be afraid, and your body may let you

know that it feels the fear, but you must not let that

fear keep you from doing your duty.” This may be

compared to an athletic contest in which the players

know they are nervous and yet go into the game to

do the best they can, knowing that they will lose

much of the tension as soon as the first contact is

made. At that point, they will revert to the skills

that they have worked so long to acquire.

By discussing their feelings ahead of time, each

individual will know that he or she is not the only

one who is aware of being afraid, not the only

coward in a band of heroes. Each will know that it

is all right to feel fear, as long as each performs

assigned duties when the time comes for action. A

poll of infantry veterans has shown that, prior to

battle, 69% were aware of a racing, pounding pulse;

45% had sweaty palms; 15% had cold sweats; and a

lesser percentage felt faint, were nauseated or vomited, or had strong urinary or defecation urges.40(p11)

Most of these men were aware of the physical symptoms

of fear before they were aware of the emotion which

caused them!40(p24)

This poll also emphasized the importance of the

control of behavior in action. Of the infantrymen

surveyed, 94% said that seeing others act calmly under fire helped them to feel better and act better

themselves. Many found that concentrating on their

own duties helped, as did cracking jokes about the

situation. Some 97% said that knowing morale was

high in their unit made them better soldiers.40(p47)

All troops must understand the importance of

the unit mission and must know how their own

work helps the unit achieve its goals. They must

understand how they fit into the big picture and
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U.S. Air Force Combat Psychiatry

why that picture is important, or they will certainly

not risk their lives to do what must be done. More

concretely, they must understand exactly what they

are to do under attack, whether by land or air, by

conventional, chemical, or other means. Warnings

and all-clears must be crystal clear, to avoid unnecessary or panicky decisions. All concerned should

understand that people tend to regress in their

behavior when under acute stress, and a simple rote

performance of duty may see them through until

they become more accustomed to combat conditions. Actions to be taken under attack should be

rehearsed so as to be well-nigh automatic. As noted,

knowing that training is excellent and that readiness is high is a powerful antidote to fear in combat

and will help prevent acute combat stress reactions.

In a study of British unexploded ordnance disposal personnel, Rachman noted qualities of underlying resilience which he described as present in a

great many military individuals. When combined

with “adequate training, good and reliable equipment, high group morale and cohesion,” he found

that a sense of calmness, awareness of physical

fitness, and general psychological health nearly

completed the picture. The single factor that, he

felt, distinguished the “courageous” (decorated)

individuals was a singular lack of any hypochondriacal features at all. Most had “no bodily or

mental complaints whatsoever.”41(p102)

If one regards the desired outcome of a battle or

an attack as the transformation of a disciplined and

effective enemy military force into a disorganized

and powerless rabble [“Inside every army is a crowd

struggling to get out,”42(p175) then this issue of performance of duty under attack becomes the proper

focus of all military training. People on air bases

under attack must understand that failure to do

their work under the conditions of noise, smoke,

confusion, death, and destruction that have accompanied warfare since the invention of gunpowder,

will result in defeat. As different as battles and

warfare have become from those of the past, what

they retain is the human element:

the behavior of men struggling to reconcile their

instinct for self-preservation, their sense of honour

and the achievement of some aim over which other

men are ready to kill them. The study of battle is

therefore always a study of fear and usually of courage; always of leadership, usually of obedience; always of compulsion, sometimes of insubordination; always of anxiety, sometimes of elation or

catharsis; always of uncertainty and doubt, misinformation and misapprehension, usually also of

faith and sometimes of vision; always of violence,

sometimes also of cruelty, self-sacrifice, compassion;

above all, it is always a study of solidarity and usually also of disintegration—for it is toward disintegration of human groups that battle is directed.42(p303)

Understanding these elements of battle, the wise

physician, who has the commander’s ear, will assure that everyone within the command understands them also. It is a message seldom heard in

the peacetime U.S. Air Force, and then heard only

faintly. Much in battle is sociologic and psychologic,

and those who understand these factors and can

communicate them to the troops in a manner that is

understandable and memorable may have much to

do with winning.

With this background, the junior officers and

senior NCOs should get into the habit of having

small “how-goes-it” sessions to assure that everyone gets “the word” at the working level. Hocking43

comments that an excellent indicator of good morale among troops is the liberty felt by their officers

to tell the truth in times of difficulty or failure.

Tempering the truth is a sign of distrust of the

troops and an attempt to manipulate morale from

the outside. As such, it is immediately suspect.

Morale is a state of faith between the leaders and the

troops and must not be abused. If one does not

know what the situation is, one should say so and

do everything possible to discover what it is, rather

than lying about it. Faith, once betrayed, is almost

impossible to reestablish. Troops who know the

truth, and know that they know it, are much better

prepared to deal with it than those from whom it

has been concealed.

Group Cohesion and Morale

At the lowest unit level, a buddy system (the

British call it “battle friends”) should be established

whereby pairs of troops are specifically instructed

to look after each other. This system should reflect

natural friendships whenever possible, rather than

being imposed from above. Thus, each person is

aware that there is another person who will be

specifically looking out for his welfare when things

get rough, that no one will be forgotten or unaccounted for. As a corollary, each unit should maintain small group integrity so that individual bonds

and loyalties are not arbitrarily disrupted. Such

small groups should be together off-duty as well as

on in order to foster their interdependence. Working groups should live together in barracks or shelters, rather than being split up as sometimes occurs

in peacetime living.
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198

This point was emphasized by Manning and

Ingraham,44 who surveyed U.S. Army units to

establish some of the underpinnings of unit cohesion. One element, usually missing but of inestimable value when present, was the presence of

commanders or senior NCOs in after-duty, informal settings if they felt socially at ease doing so. By

doing so, they shared experiences other than those

of the workplace. “The more people interact, the

more varied the settings, and the more time the

group maintains stable membership, the more the

members have in common and the higher the resultant cohesion.”44(p65)

Skillful Leadership

The small unit leader must be familiar enough

with the troops to recognize when an individual’s

stress symptoms are getting out of hand. The leader

should be willing to give a little extra rest and time

off to those whose fears are beginning to get the best

of them. In his book Fighting Spirit, Major General

F.W. Richardson, a retired British Army physician,

discusses the here-and-now treatment of acute combat stress reactions.45 Two hundred yards behind

the battle line he had established

a sheltered rest station ... at the bottom of the hill ...

(S)omeone had given this place the name of ‘Tranquility House.’ Once its value had been clearly

recognized and the...medical officers instructed

about the early handling of cases of threatened

breakdown, it was enough for them to mark men’s

field medical cards ‘T.H.’ After 12 to 24 hours of

rest and hot meals at this post, many men, who

might otherwise have had to be sent to hospital,

were able to rejoin their units...without loss of

face.45(p106)

Such an arrangement may or may not involve a

medical professional, but the circumstances described certainly should not involve a formal admission in the medical sense, which would reinforce the “sick” role. The message should be “You’re

not sick and you’re certainly not a coward; you’re

just worn out and need a bit of rest before you go

back to duty.”

Obviously, medical advisors should assure that

officers and NCOs understand the early symptoms

of combat fatigue, those at the mild end of the

spectrum that might otherwise be ignored: insomnia, nightmares, restlessness, decreased appetite,

irritability, increased startle reflex, decreased efficiency, increased smoking or drinking, loss of sense

of humor, and changes in normal temperament

beyond those that are taking place in the unit as a

whole. Troops showing these symptoms should, if

possible, be given a little extra time off, or at least

the opportunity for a good night’s sleep (“three hots

and a cot”). A little consideration in these matters

may go a long way in prolonging the efficiency of

the unit, as well as its individual members’ ability to

function well.

Richardson went on to report that hundreds of

British soldiers were sent out of battle in World War

II by their officers because they were showing physical signs of fear. This practice not only was a waste

of manpower, but had the potential for a snowball

reaction among the troops not yet affected, to whom

the secondary gain for the symptoms was all too

clear. He points out the clear necessity for commanders to learn to

distinguish between men who are simply afraid

and those who are beginning to find fear uncontrollable. To distinguish between a man who needs to

be encouraged to carry on and one who should

quietly be got rid of, for the time being, lest his

fear become infectious, can test experienced leaders. During the trial by court martial of a soldier

for cowardice in Korea, a civilian counsel for the

accused was trying subtly to shift the blame onto

the shoulders of the platoon commander who,

he claimed, should have seen that the man was on

the verge of a breakdown. ‘Could you not see,’

he demanded aggressively, ‘that Fusilier L...

was trembling involuntarily?’ The young officer’s

splendid reply was ‘We were ALL trembling

involuntarily.’45(p111)

In the same vein, the leader should provide the

best amenities possible under the circumstances,

including food, shelter, and cleanliness. The troops

who know that their leaders are living up to this

valuable and venerable military tradition will understand the implicit message that underlies it: “As

I show that your physical comforts are important to

me, you can see that I consider each one of you

valuable, and you know that I will not waste your

lives needlessly in battle.” Loyalty in battle is, after

all, a two-way process.

Leaders should also be alert to undue confusion

or agitation in their troops while under fire, and

should set a firm, calm example. The timely joke is

of inestimable value in this respect. The leader

should help turn their minds outward, away from

their own troubles and toward their comrades, reinforcing each other’s efforts, doing the job at hand,

and supporting the base fighting mission. The

emphasis should be on teamwork and accomplishment (“We’re all counting on you”) to appeal to that
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part of each person’s ego that wants to perform

honorably under fire, to be thought well of by

comrades, and to be part of the best unit in the

winning force. By setting a calm example, not

minimizing the occasion but instead helping the

troops rise to its demands through pride and loyalty, by making them part of something bigger than

themselves, the U.S. Air Force leader is following

the example of the great leaders of history. Morale,

in this context, becomes a matter of concentration of

purpose, competence, honesty, selfless generosity,

dignity, and exemplary behavior.43

Sleep Discipline

Medical personnel must impress on commanders the importance of making sure that their troops

get adequate sleep, to the extent that the situation

allows. Studies have shown that 4 hours of uninterrupted sleep, especially if it includes the 3 hours

between 2 AM and 5 AM, are necessary to maintain

the efficiency of the troops over the long haul. In

these studies, the 4 hours of sleep consisted of the

total amount of Stage 4 sleep and of REM sleep that

the troops would have gotten under more normal

conditions; that is, their sleep became more condensed and efficient in refreshing them in the field

conditions of relative sleep deprivation. Less than

4 hours of sleep led to progressive fatigue and

inefficiency.46

This doctrine may be hardest to apply to the

commanders themselves, who may believe that they

are indefatigable. The military writings of

Wellington, of Napoleon (whose ability to nap was

legendary), and of Montgomery (in contrast with

Rommel, who exhausted himself) all bear witness

that “the high commander who, under the strain of

a prolonged campaign, can preserve an undisturbed

sleep pattern is the right man in the right

place!”45(pp76,77) This may be contrasted with the old

saw that “the military regard sleep as monks do sex:

the really competent ones get along without it!”45

Other Factors

Commanders should be aware that there are some

specific factors that may increase their troops’ susceptibility to fear: being alone, darkness, rumors,

lack of plans, and insidious silence punctuated by

loud or unexplained sounds. Knowing ahead of

time that such things increase apprehension may

help to reduce their effects, and the troops should

be warned about them. At best, the men may

recognize their own fears and joke about them. At

least, they will not be surprised that they feel afraid.

They will understand that there is no disgrace in

feeling fear, only in giving way to it.

Commanders must also be aware of the insidious

effects of prolonged inactivity or unstructured time

on morale, especially if accompanied by an undertone of anxiety about what might happen. Several

traditional antidotes are available, tailored to the

specific circumstances.

A good sports program is worth its weight in

gold. The one drawback is a tendency to cause

injuries, so be careful about activities involving

physical contact, and provide referees to keep things

in hand. Educational offerings will attract some:

lessons in the local language, history, and customs,

or even a formal course program if available. An

enlightened leave program may be possible, with

tourist-type day or overnight trips to local attractions. For prolonged campaigns, consider an R and

R policy.

Pay attention to work-alert-rest schedules. Avoid

switching personnel on and off night duty; it may

be possible to have reasonably stable day and night

sections, to avoid undue circadian disturbances.

Rotate tasks. Provide military training and upgrade. Cross-train if it is reasonable; this will also

benefit the organization in case of losses through

combat or illness.

As Hoffman47 points out, these factors, combined

with a sense of good leadership, fairness, competence, and caring, will demonstrate to the troops

that their commanders are looking out for their

welfare. Attention to details, alertness to signs of

stress in self and buddies, and open lines of communication up and down the chain of command during

lulls will help assure good performance when things

get rugged.

Medical personnel must assure that line officers

and NCOs understand that the best way to counter

the demoralizing and fearful effects of combat is to

foster good morale. The wise leader knows that

there are clear indicators of poor morale available,

such as an increase in abuse of alcohol and drugs,

venereal disease, fights, AWOLs (absent without

leave), and similar Article 15 offenses. One may

also see an increase in a constellation of medical

conditions, the prevention of which is a function of

personal discipline: sunburn, frostbite, immersion

foot, malaria (the troops are not using insect repellent, taking their prophylactic medications, or sleeping under their mosquito netting), food-borne diseases (improper hygiene), and other such maladies.

Further, a unit that is well-led, and knows it, will

identify itself with its leader and will begin to use
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200

his way of speaking, habits of behavior, and even

personal mannerisms.48 This magical identification

with a leader who is perceived as wise and powerful is a notable indicator that morale is high. Although a unit with good morale may not display its

discipline in the “snappy salute” sense, it will take

good care of itself. It will practice the essentials

necessary to preserve its own health and its operational readiness, and the troops will reinforce each

other in following the formal and informal rules

that maintain and increase their collective effectiveness.

Second-Echelon Measures

Almost all of the literature concerning the initial

care of combat fatigue victims has been written by

U.S. Army psychiatrists. One of the clearest descriptions of this care was given by W.C. Menninger49

in his classic monograph, Psychiatry in a Troubled

World, in which he discussed the treatment regimen

developed by the psychiatrists in the Mediterranean Theater in World War II.

By their plan the battalion aid station surgeons

were indoctrinated with “first aid” psychiatry. It

was they who had to decide whether a man should

be returned to duty, given a brief respite, or evacuated to the clearing station. It was fully appreciated

that many soldiers, if returned to the battalion

kitchen area and permitted a night of sound sleep

with the aid of a mild sedative and some warm

food, would be ready in 24 hours to return to

combat. No record was ever kept of the men so

handled, but it is known to be a sizable percentage

of the men seen at the battalion aid station.

The seriously upset soldiers were sent 2 to 5 miles

farther back to the division clearing station where

the division psychiatrist had his headquarters and

treatment center. This sometimes was in a tent or in

a commandeered building such as a schoolhouse,

factory, or whatever might be available. The soldier arrived here from his foxhole within 1 to 3

hours. Each one was seen initially by the psychiatrist and interviewed briefly. If he was recognized

to be too sick to benefit from brief rest and such

psychotherapeutic help as could be given in a short

time, he was immediately evacuated farther back.

The largest percentage of the soldiers who came to

the clearing station remained there for 48 hours.

These men were given sufficient sedation to insure

a good 12 to 24 hours of sleep, only interrupted

when awakened for food. On the second day, they

had an opportunity to shave and bathe. Approximately 40 per cent could return to combat on the

third day. Follow-up studies suggest that many of

these men carried on indefinitely. Perhaps 25 per

cent of this group had recurrence of symptoms and

became repeaters.”49(pp306–307)

Menninger goes on to describe the treatment of

those not handled at the clearing station (which, in

U.S. Air Force terminology, would be an off-base 2-

E facility). The worst casualties, or those not responding to brief intervention, were sent to “exhaustion centers” 16 to 24 km (10–15 mi) behind the

lines. These were staffed by 12 officers and 99

enlisted and were equipped to take care of 200 to

500 psychiatric casualties. Patients remained there

5 to 8 days and were treated with rest, recreation,

and narcosynthesis using sodium pentothal. These

centers developed training platoons, directed by

line officers, “which provided an additional 2 to 5

days of military activities at a graded tempo to

prepare the men for return to combat. Of the combat casualties, 20 per cent were returned to combat

from these centers.”49(p307)

Menninger notes specifically that, besides adhering to the classic treatment principles of proximityimmediacy-expectancy, the entire program assumed

that the chief preventive efforts were a function of

commanders, not of the medical personnel, and that

the active support of the line officers was required

in order to assure its success.

Thus the elements of care at the 2-E level include

the location of the unit, its staffing, its function, the

treatment setting, the principles of management,

the use of medications, and the options available for

disposition of those treated there.

Location and Staffing

Plans for locating the U.S. Air Force 2-E mental

health services change from time to time, but the

doctrine, configuration, and location will probably

not differ greatly from what will be described below, and will correspond in function, if not in location, to the system of which Menninger wrote.

Medical personnel remaining on a base under continuing attack or threat of attack will probably consist of a few flight surgeons, perhaps a surgical

specialist, some medical technicians and ambulance

drivers, and a mental health team consisting of a

psychiatrist, a psychologist, a clinical social worker,

and some mental health technicians. The remainder of the local medical and mental health personnel, perhaps augmented by others brought in under

mobilization plans, will work at one or more sites

located 5 to 10 km (3–6 mi) off-base; each site will be

independently capable of giving stabilizing medical care in support of approximately 4,000 troops. It
201

U.S. Air Force Combat Psychiatry

should be noted that distances given are rather

arbitrary. The important concept is “psychological

distance”: far enough from combat to be safe, near

enough to return to one’s own unit.

Although preliminary plans call for a psychiatrist, a psychologist or a clinical social worker, and

two mental health technicians to augment some 2-E

facilities as part of the 50-bed Air Transportable

Hospital, current U.S. Air Force manning levels

make it unlikely that more than one off-base 2-E

facility per base will be so staffed. Thus, each local

Director of Base Medical Services (DBMS) may well

have to decide how best to use the available mental

health staff, considering the on-base situation, the

off-base situation, the adequacy of communication

and transportation links, the combat/casualty situation, the nature of the threat, and other such variables. The disposition of local mental health resources may be changed as the situation dictates,

and such local flexibility should not be hampered

by excessive doctrinal rigidity. Common sense

should prevail, and all concerned should be aware

that their experience with the realities of the situation may quickly supersede set-piece planning.

Why be so insistent that early treatment be given

at the on-base 2-E facility rather than off-base? In

a lecture to U.S. Air Force mental health professionals in 1983, an Israeli psychologist pointed out

the value of having mental health professionals

use their knowledge and experience close to the

fighting:

• They can use their professional stature to

resist local unit commanders who want to

evacuate troops with symptoms of combat

fatigue. Less knowledgeable people might

give way to such pressure.

• They can respond realistically to any troops

who say “You don’t know what it’s like,”

because they live on the same base and under the same conditions. This corresponds

to the principle that flight surgeons should

fly in unit aircraft, both in peace and in war,

to meet the flier on equal footing in terms of

understanding the situation personally.

Although some 2-E facilities off-base may

also need a mental health capability, it is

crucial that patients with only mild or early

symptoms be kept on-base, along with a

contingent of mental health personnel.50

To his two reasons, a third may be added. Few

U.S. Air Force medical personnel today, officer or

enlisted, have personal combat experience. To leave

the triage decisions concerning patients with psychiatric symptoms in the hands of the flight surgeon

or DBMS, neither of whom is likely to have either

combat or psychiatric experience, is to put the troops

doubly at risk of the wrong decisions being made.

Mental health workers must be on-base, making

every effort toward rapid, effective interventions:

reassuring, explaining, exhorting, and above all,

returning troops to their units as rapidly as possible.

What, then, might be the function of a 2-E site offbase? The author sees this as an overflow facility,

used for patients who are truly mentally ill, or who

have not been able to return to duty as expected and

are awaiting evacuation. This facility may also

receive patients when the on-base 2-E facility is

overrun with troops. The realities of the situation

faced by the DBMS and the mental health staff

should quickly result in the available facilities being used in the most efficient manner possible, if the

tried-and-true principles outlined here are intelligently applied.

Function of the Second-Echelon Facility

Clearly, the burden of the initial management of

acute symptoms immediately after a base is first

attacked will fall upon whatever medical personnel

remain on that base, whether or not they have had

formal mental health training. Another Israeli Defense Force psychologist has emphasized that such

reactions may overwhelm unprepared medical personnel, especially if they themselves have also just

experienced their first attack.51 Human nature leads

one to look to any perceived authority for help in

crises, and the disaster literature leaves no doubt

that anyone who is seen as having special knowledge or skills in such a case will quickly be sought

out. When confronted with troops having combat

shock reactions, medical personnel will certainly

look to colleagues with mental health training—any

mental health training—to handle the unwounded

stress casualties.51

By now the reader must be aware that all military

mental health authorities agree on the necessity not

to overreact to such circumstances by evacuating

troops to the rear—not even a little bit to the rear—

because of the perceived secondary gain. “If they

ain’t hurt, don’t ship ‘em out!”

This inelegant slogan is easy to remember in a

crisis, and may be used by medics and line personnel alike. If the mental health troops on a base

overwhelmed with somatic casualties are pressed

into triage, litter-bearing, or treatment teams, they
War Psychiatry

202

may join in following the course of least resistance

and shipping the unhurt but stunned and sobbing

troops off-base to a less harassed 2-E facility. This

impulse must be resisted, or there will be an intolerable loss of unwounded troops to off-base locations from which it may prove very difficult to

reclaim them.

An on-base holding facility must be provided

to the DBMS by a wing commander who understands the principles involved, explains them to

the commanders of the various squadrons, and

supports the DBMS in their application. Reflecting

upon Richardson’s Tranquility House described

above,45 this author recommends that such an

on-base facility be established in a reasonably

secure location, away from primary targets, and run

by the available mental health personnel. Flexibility

in assigning mental health nurses and occupational

therapists to this facility may also prove useful.

In the personal communication previously

noted,51 Levy commented that the Israeli medical

service organizes its combat stress casualties along

military lines, with unit names rather than medical

names. Under this model, each U.S. Air Force

psychiatric technician might direct a “flight” of 10

or more casualties. Three or more flights would

comprise a “squadron,” with the squadron command element consisting of the psychiatric social

worker, an NCO-in-charge (NCOIC), and, if available, an occupational or physical therapist. This

latter function might even be filled by a knowledgeable physical training technician from the base gymnasium.

The structure of this local treatment team would

thus emphasize the military aspects of the situation

and minimize the medical aspects. At this level,

treatment essentially consists of acknowledging a

temporary inability to work, without falling into

the medical model (taking a history, writing up a

chart, making a formal diagnosis), that reinforces

the patient role. Such troops—do not call them

“patients”!—should not be formally admitted to

the facility. “You’re not a coward, you’re not sick,

you’re just worn out, and you’ll be all right in a day

or two” must be the constant theme. A chance to

rest, a hot meal (the U.S. Army’s “3 hots and a cot”),

a physical examination, however perfunctory, to

reassure that there is no physical problem, and an

appeal to honor, group loyalty, and the mission

may be all that is necessary. In fact, at his first

contact with the medics, all that a scared kid may

need is for someone in authority to tell him that he’s

all right, and that he must get back to work, do his

part, and not let his buddies down.

Principles of Treatment

The treatment of acute combat reactions or of

combat fatigue on-base may be summarized in the

acronym BICEPS (brevity, immediacy, centrality,

expectancy, proximity, and simplicity). The author

coined this acronym in 1980 for use in the U.S. Air

Force Surgeon General’s Medical Red Flag training

program. The principles of proximity, immediacy,

and expectancy, so named by Artiss, were articulated by Glass52 in World War II and were derived

from Salmon’s forward treatment during World

War I.53 The principles of brevity, centrality, and

simplicity were discussed by F. Jones, after the war

in Southeast Asia.37 Each principle might, of course,

be discussed at length, but, in the total context of

this discussion, they are identified as follows:

• Brevity. Treat briefly, from 12 to 72 hours,

with the explicit goal being a rapid return to

duty.

• Immediacy. Treat as soon as the person’s

behavior makes it clear that he or she can no

longer function as a productive squadron

member. Do not wait for full collapse of

function, especially if squadron authorities

or buddies indicate that this individual is

becoming nonfunctional. Do not wait for an

outside consultant, either. Begin treatment

now.

• Centrality. Treat combat fatigue cases who

are being considered for evacuation in a

single location, separate from somatic casualties and “sick” patients, preferably administered by a single individual. At this single

location skilled personnel may be able to

prevent further evacuation.34,37

• Expectancy. Treatment should be aimed at

getting the individual back to duty, and all

concerned must expect this to be the inevitable and only outcome. The therapists

should ally themselves with the patient’s

conscious will to remain and do the necessary duty, and should work together toward

that goal so the fatigued person can return to

friends, unit, and job. The therapeutic alliance must not allow any other goal to interfere with getting the person well, and the

functional definition of “getting well” is a

return to duty.

• Proximity. Treat close to the unit, so that

cohesion continues. This will be most concretely demonstrated by having the person’s

friends and commander visit, thus proving
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U.S. Air Force Combat Psychiatry

that they do not reject combat fatigue victims as cowardly or unworthy. Those who

repudiate their stricken comrades may be

unable to tolerate any such tendencies in themselves and thus reject those who symbolize

their own fears. Such people will contribute to

the problem by increasing the victim’s guilt;

and, if they are leaders themselves, may lose

troops unnecessarily because of this attitude.

Close liaison between therapists and the

parent unit will not only help the troops in

question, but will demystify the whole experience for the unit as well, and will show the

lack of secondary gain: becoming symptomatic is not an automatic ticket out of combat.

Here again, the value of keeping this 2-E

function on-base rather than several kilometers away is obvious.

• Simplicity. Treat in the here-and-now, aimed

at a return to duty. This is not the time for a

full-scale psychiatric evaluation and formulation, or a treatment contract extending into

the indefinite future.

Medications

Psychopharmacology, like other areas of drug

therapy, is a dynamic and rapidly changing field.

Each physician uses medications in a highly personal way, and psychiatrists are no exception. Some

are chemical nihilists, while others write a prescription for almost every patient they see. Thus, the

precedents for the use or nonuse of medications in

combat situations are by no means applicable to all

situations or to all therapists.

In World War II, psychiatrists frequently used

sodium pentothal or Sodium Amytal1(p52) to help

soldiers abreact their emotional turmoil. A review

of the use of medications in the Vietnam War by

some 40 U.S. psychiatrists revealed that a large

proportion of them used anxiolytic and neuroleptic

agents, even in early or mild cases of combat fatigue.54 These therapists reported the use of recuperation, social therapy (the milieu of expectancy),

and medications, in that order of frequency, in the

2-E environment.

They used anxiolytics in about 30% of their cases,

mainly for early symptoms, including apprehension (especially the “short-timer’s syndrome”), sleep

disturbances, tremors, and increased startle reactions. They used neuroleptics in about 20% for

threatened assaultive behavior, defects in judgment,

or other behavioral changes which concerned or

alarmed the unit. Neuroleptics were used with

increasing frequency in patients with increasingly

disturbed behavior, especially in those for whom

recuperative facilities seemed to be of little use.54

More recent practices contradict these findings.

The Israelis, as has been noted, are much more

interested in behavioral treatment. One source cites

the use of medications, and only tricyclic antidepressants at that, in only 8% of the 60 soldiers

referred for 3-E and 4-E treatment out of the 600

soldiers who were evacuated as combat fatigue

casualties in the 1982 Lebanon War. The treatment

program for the majority consisted of “walking and

talking,” abreactive individual and group psychotherapy, individual and group sports activities, and

combat-oriented military training.55 By contrast,

the British, in the Falkland Islands War, used shortacting benzodiazepines as a prophylaxis against

excessive fatigue due to insomnia, evidently with

good results.23

Two major cautions are offered against the early

use of medications. First, their use tends to reinforce the sick role, because the giving of medications is one of the hallmarks of the physician-patient relationship in American society. Second,

many psychotropic medications have a duration of

action longer than the 72 hours that a combat fatigue victim may spend in a 2-E facility, especially

if one takes into account the active metabolic products of some of the drugs. Sending a person back to

combat duty still under the influence of psychoactive

drugs may be dangerous. Even in peacetime, people

in the many combat support positions covered by

the Personnel Reliability Program would not be

allowed to take such medications and continue to

work in their sensitive, demanding jobs. The use of

such medications under combat conditions must

thus be thoughtfully weighed for the risk-to-benefit

ratio, both for the individual and for the mission.

In the end, the decision to use or not to use

psychotropic medications rests with the physician

on the scene. There is much information on this

subject elsewhere, and anyone potentially faced

with this situation would do well to know as much

as possible about a few psychotropic drugs before

the combat situation occurs, when there will be no

time to look them up. Use such drugs sparingly and

for specific target symptoms, with full consideration of the two negative factors noted above.

Treatment Setting

Although one may find it impossible to imagine

what a 2-E facility might look like, on- or off-base,

perhaps Enoch’s56 description of such a function in
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204

the Israeli campaign in Lebanon will be useful,

especially when compared and contrasted with

Menninger’s description of a similar function in

World War II, cited above.

Initially, (the) team would conduct an interview to

establish where the soldier had been, what he had

done, and what had happened to him. This interview was oriented objectively rather than toward

thoughts and feelings. The team confirmed two of

the observations made in previous wars. First,

thoughts and feelings inevitably followed the description of the objective events. Second, just describing what had happened clarified events and

reduced the emotional turmoil. The team would

allocate the next 6 to 8 hours of treatment to physical replenishment (water, food, and rest). Then the

soldier was given useful tasks to do and invited to

join in supportive individual and group psychotherapy. Next, the team arranged for comrades

from the soldier’s unit and for the unit commander

to visit the soldier. Then the soldier himself was

taken to visit the unit. In these ways, mutual

confidence between the soldier and his unit was

restored. When the soldier had recovered enough

to return to the unit, the team would arrange for

comrades from his unit to pick him up. This team

took advantage of its proximity to the front and the

soldier’s unit to maximize expectation that he would

return and to reinforce the soldier’s link to his

comrades and commander. The team observed

that units were happy to receive the soldier back,

confirming the finding from other sources that

under stress group members prefer someone they

know to someone they do not know, regardless of

presumed competence. With respect to themselves,

the members of the psychiatric team noted that,

because of their proximity to the front, they were

all afraid. However, sharing the dangers of combat

with the soldiers being treated reduced their reluctance to return a soldier to his unit. They noted that

their fear was diminished to the degree that the

(medical) commander was competent in ensuring

their supplies of gasoline and other essentials. When

this was not the case, they became more afraid,

hoarded supplies, and saw their clinical effectiveness decline. The team observed their tendency to

overidentify with the soldier they were treating; to

want to be the “good father,” and to protect their

new-found “son” from harm. This difficulty was

reduced through once-a-day staff meetings for the

purpose of discussing cases, providing mutual support, and working through emotional conflicts.

The Israelis observed that the psychiatric symptoms changed from the time the soldier broke down

at the front to the time he arrived at the (medical

station). At the front, soldiers suffering psychiatric

breakdown complained of an inability to perform—

termed by the Israelis “the ticket out” of combat,

while upon reaching the (medical station) they

complained of difficulties with thoughts and feelings—termed “the ticket in” to treatment. The

Israelis concluded that severity of initial symptoms

had little to do with prognosis for recovery; the

most important indicator of a good prognosis was

the soldier’s labeling himself as healthy, taking

initiative in his own care, helping others, and helping run the treatment team’s area.56(p14,15)

With the applications of the BICEPS principles

there is a deemphasis on medications and the “sick”

role. Troops in this ambiance must not be treated as

patients. They must spend the day in uniform, not

in pajamas, unless they are specifically supposed to

be in bed resting for the first 12 to 24 hours. Their

days should be structured and should be used purposefully to maintain the identity of each as a functional military person. Daily roll call, announcement of the day’s schedule, physical training, useful

activities such as digging trenches or bunkers, filling sandbags, improving the local area, playing

sports, and attending meetings should be the order

of the day. The value of occupational and physical

therapists in planning and carrying out such activities is clear.

In the 528th Medical Detachment, already mentioned, the role of occupational therapy personnel

as “environmental managers” both in the consultation role and the therapeutic role proved extremely

valuable during the Persian Gulf War. Presentation

as “work therapy” furthers the sick role, so the

presentation as “work assignment,” “work detail”

or “work activity,” may be more appropriate to the

“return to duty” ambiance of this modality.

Ellsworth and colleagues57 have presented a review

of this subject, together with a model schedule for

patient activities (Exhibit 8-1).

Group therapy sessions must be carefully monitored and one must be particularly careful not to let

them turn into “my experience was worse than your

experience” sessions. Such an ambiance may be

perceived as rewarding symptoms, and troops may

escalate each other into brief reactive psychoses if

not restrained.51 Thus, such sessions should be

goal-directed, here-and-now, and oriented toward

health rather than emphasizing symptoms and disability. Sports programs, which by their nature

reward healthy behavior, are of particular value.

Coaches urge one to perform in spite of symptoms.

The programs of Menninger49 and the Israelis56

were reflected in that of the U.S. Army in the Gulf

War. “PSYCH-FORCE 90” was the self-designation

of the 528th Medical Detachment, a psychiatric OM

(combat stress prevention and treatment) organiza-
205

U.S. Air Force Combat Psychiatry

EXHIBIT 8-1

SECOND-ECHELON TREATMENT

FACILITY: MODEL SCHEDULE FOR

PATIENT ACTIVITIES

tion of 15 officers and 33 enlisted troops deployed to

Saudi Arabia in October, 1990, to support the Persian Gulf War.58 This unit operated three consultation teams that made proactive visits to U.S. Army

units, and one base camp treatment team that furnished outpatient and inpatient therapy (20 beds).

Between November 3, 1990 and January 10, 1991,

the unit performed 600 unit consultations. Several

thousand soldiers were seen altogether. The units

performed 387 formal psychiatric evaluations, and

held 123 soldiers for treatment. Fifteen percent

were evacuated out of theater. (Of all the soldiers

evacuated to Europe, less than 6% had psychiatric

diagnoses.)59 This effective use of psychiatric treatment teams involved two facets. First, in consultations with commanders, they actively sought to

advise the field units about psychological stress,

work-sleep cycles, heat stress, buddy-aid, critical

event debriefings, and follow-up consultations

when necessary (as with training accidents or firing

weapons in anger).

Their second mission was to triage and treat

dysfunctional soldiers. After one interview, they

would make disposition: evacuate the truly mentally ill, hold a soldier for treatment if suicidal.

Otherwise, they attempted simple ventilation, focusing on solutions in the here-and-now. Problems

involving the family back home were referred to the

chain of command. (Their experience, and that of

the author 30 years earlier, was that evacuating

troops from a combat zone for family reasons was

folly, and would result in an epidemic of family

problems within the unit.)

Soldiers held for duty were kept in a military

environment—cots in tents. Therapeutic emphasis

was on healthy functioning through an intensive

work-therapy program, promoting adaptation

through psychological educational classes and small

group therapy. This involved only limited ventilation, restructuring problems into here-and-now resolvable issues, and acquiring adaptational skills.

Command consultation was obtained when warranted.

A common factor associated with developing

adjustment disorders was the soldier’s assignment

to a new unit within 90 days of deployment (ie, the

soldier was not yet strongly bonded to the unit).

Most soldiers presented for treatment within their

first month in theater, pointing up the need for

some stress training prior to deployment. Also,

problems reflecting troubles at home indicated the

usefulness of strong family support programs.

Other patient clusters centered around: (a) mothers leaving small children, losing their bonding; (b)

Reserve or Guard troops taking psychoactive medications prescribed by their civilian physicians, being cut off these medications through lack of availability, or contraindicated because they lowered

heat tolerance; (c) functional symptoms found to be

due to organic conditions; and (d) veterans of prior

wars undergoing exacerbations of traumatic stress

reactions. This latter situation frequently involved

medical troops, and was possibly associated with

their easy access to psychiatric care.

After the OM team arrived in theater, the evacuation of personnel because of personality disorders

fell by 50%; most evacuations after that were for

major psychiatric disorders.58 The success of this

unit should light the way for U.S. Air Force mental

health professionals.

Options for Disposition of Troops

Therapists working at on-base or off-base 2-E

facilities will have a number of choices for disposition

Adapted with permission from Ellsworth PD, Sinnott

MW, Laedtke ME, McPhee SD. Utilization of occupational therapy in combat stress control during the Persian Gulf War. Milit Med. 1993;58:383.

Exhibit 8-1 is not shown because the copyright

permission granted to the Borden Institute, TMM,

does not allow the Borden Institute to grant permission to other users and/or does not include

usage in electronic media. The current user must

apply to the publisher named in the figure legend

for permission to use this illustration in any type of

publication media.
War Psychiatry

206

EXHIBIT 8-2

OPTIONS FOR DISPOSITION OF TROOPS PRESENTING AT 2-E FACILITIES

1. Immediate return to duty.

2. Hold for a brief period, perhaps with a meal, rest, and return to duty without having been admitted.

3. Hold overnight, as in (2) without admission. Possible use of a single dose of short-acting benzodiazepine for sedation.

4. Relieve from duty (admit) and treat as indicated for 2–3 days. Use BICEPS principles. Return to duty.

5. Use of (4), with return to limited duty or to less hazardous or less demanding duty. This may be

especially useful in the “old sergeant’s syndrome.”

6. Use of (4), with unsatisfactory results and with subsequent evacuation to a 3-E facility.

7. Treatments (1–5), with subsequent return to commander for administrative action, in instances where

the problem is due to personality disorder rather than to medical or psychiatric problem.

8. Evaluation and immediate evacuation to the 3-E level when the diagnosis is a true and severe mental

disease. This procedure should occur only rarely.

9. Evaluation leads to a diagnosis of probable somatic disorder and the patient is transferred to the

appropriate treatment facility.

of troops who come under their care (Exhibit 8-2).

Precedent, imagination, and experience suggest

the outcomes delineated in the exhibit; others

may be developed as the exigencies of the situation

dictate.

In the section on care of fliers, the value of a

formal ending to a unit’s combat experience has

been mentioned. Current literature also underscores the value of a stress debriefing of the entire

unit. This is a formal process, and should be undertaken only by trained professionals, preferably not

assigned to the unit. It is modeled on the Critical

Incident Stress Debriefing,60 used by many civilian

fire and police departments, and similar organizations. This process has been termed the “AfterAction Stress Debriefing.”61

This process is too involved to be discussed here,

but is discussed extensively in Chapter 11, Debriefing Following Combat. Authors who served in the

Gulf War have attested to its value, and to the

consequences of not having such a program available.62,63 Medical personnel of many disciplines

know of the concept, and the absence of a chance to

process their combat experiences will be missed

and commented upon.

Summary

Future wars may replicate past wars in which air

crews carried out transportation, bombing, and

fighting missions from a relatively safe support

base. In this case, little change from prior practices

in the care of nonflying personnel is required. In a

large-scale engagement, however, modern tactics,

reflecting technological advances, call for pressing

the battle to support facilities, perhaps through

long-range missile or air assaults. In such a situation (eg, the Persian Gulf War) nonflying U.S. Air

Force personnel may become combat targets and

thus combat stress casualties. Currently, little provision is made for such casualties; however, there is

good reason to believe that the traditional principles of U.S. Army combat psychiatry, as described

by the “BICEPS” acronym, can be effective in treating and returning to duty the majority of these

casualties. Provision of this treatment will require

education and training of all personnel and medical

and mental health personnel assigned “forward” at

first- and second-echelon support installations. As

always, good leadership and cohesive units will

minimize combat stress casualties.

The author has studied this topic, lectured on it,

and discussed it with colleagues since 1979. He has

also read historical and current military biographies,

histories, aeromedical reports, and the literature of

military medicine and psychiatry. In a most introspective way, he has reexamined his service as a flight

CONCLUSION
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U.S. Air Force Combat Psychiatry

surgeon with the Air Commandos in Vietnam, and

would add the following remarks to this chapter.

To begin with, physicians and others thinking

about combat must understand that they will have

to deal with combat from three points of view. The

first of these has already been thoroughly discussed—the care of others. The second of these is

that they must also think about caring for themselves. The realities of combat will also reach those

trying to ameliorate its effects, often in a most intrusive and distressing way. Those feelings will have

to be dealt with. It is vital that mental health

providers take care of themselves and their colleagues. And the third point of view is that they

must care for their colleagues. This includes being

alert for the abuse of alcohol as a solvent for pressures and emotions, and be aware that medics, too,

need time off, especially those in the surgical arena,

confronted daily with carnage beyond comprehension. Patients, self, and fellow medics: one must be

aware of all three.

Commander Sandra Yerke’s graphic description

of the difficulties encountered in molding a group

of strangers into a competent staff on a hospital ship

during the Persian Gulf War64 should be required

reading for each medic on active duty. Anyone may

deploy at any time, if the circumstances are right,

and all must be prepared, always.

Wars tend to be come-as-you-are events, and

there will be little time to read up on them once

one starts. Field medical units usually do not include libraries, and thus mental health providers

most often deploy with only the knowledge they

carry in their baggage or in their heads. Base or post

libraries usually have very good military sections

and the author urges the reading of some books

written by medical personnel about their experiences. The thoughtful perusal of a few such books,

combined with constructive thinking about what

the role of the mental health provider might be in

such a situation, may help prepare such personnel

in ways that would not otherwise occur to them or

to those who train them.

In addition, medical officers and NCOs may well

have to exercise command of troops in the combat

ambiance, a fact that may never have occurred to

them until now. The responsibility for giving orders that may result in the loss of life or limb by

those carrying out the orders is not a subject taught

in medical school or emphasized in unit training

exercises. It is an awesome responsibility, and all

medical personnel would do well to learn a bit more

about combat leadership than the service usually

teaches medics. Military medical officers are accustomed to maintaining currency in their medical

literature. It is vital that they maintain currency in

the military literature as well. Through long experience, line officers will tend to believe that a medic

is a good medic unless proven wrong. They will

also tend to believe that a medical officer is not a

good officer until the medical officer proves that he

is. Medics must be as good at their job as those on

the line are at theirs.

Principles of conservation, training, planning, and

execution of war plans apply to the medical commander as surely as they do to the line commander.

(T)he physician-soldier must be able to make the

hard decisions that are required ... with little time

to reflect, depending instead on the education and

training that has led him [or her] to a leadership

position and the medical intelligence available....The troop commander must be prepared to

make decisions that place the lives of those that he

is responsible for at risk. So must the physician

who commands others in war.”65(p375)

Finally, and most personally, the author recalls

the well-known words of General Robert E. Lee as

he viewed the appalling battlefield at Fredericksburg

after his victory over General Burnside: “It is well that

war is so terrible, else we should become too fond of

it.” Having spent a year in Vietnam, and having been

immersed in the medical literature of war since 1979,

the author agrees. His wish and his prayer are that

none who read these words may ever have to put into

practice the principles of combat psychiatry.

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