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Combat Stress Control in Joint Operations

INTRODUCTION

INHERENT PROBLEMS IN JOINT OPERATIONS

COMMON COMBAT PSYCHIATRY PRINCIPLES AND POLICIES

Six Combat Stress Control Mission Functions

CSC Preventive Methods

Limitations of and Need for Joint CSC Operations

MILITARY BRANCHES IN JOINT OPERATIONS

U.S. Air Force MH/CSC Capability

U.S. Marine Corps and Navy MH/CSC Capability

U.S. Army MH/CSC

Situations for CSC Cooperation Between the U.S. Army and Air Force

Situations for CSC Cooperation Among the U.S. Army, Navy, and Marine Corps

JOINT OR COMBINED OPERATIONS OTHER THAN WAR

Overview

CSC Mission Priorities

CSC Staffing

Lessons Learned from Recent Experience

Joint Special Operations

Joint Prisoner of War or Hostage Repatriation

Civil Disaster Relief and Civil Disturbance Response

Mass Casualty Disasters

Recovery of Dead Human Bodies

RECOMMENDATIONS

CONCLUSION

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

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

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

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

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

COMBAT STRESS CONTROL IN JOINT

OPERATIONS

Chapter 10

JAMES STOKES, M.D.* AND FRANKLIN D. JONES, M.D., F.A.P.A.†
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244

Hans H. Helweg Patients Being Loaded on C-54, England 1944

Air-evacuation of the wounded, as depicted in this painting by Hans H. Helweg from World War II, is a

critical joint operation among the military services during combat. Of equal importance in a joint

operations arena is the providing of restorative services to soldiers, sailors, and airmen suffering combat

stress reactions.

Art: Courtesy of US Army Center of Military History, Washington, DC.
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Combat Stress Control in Joint Operations

As most recently seen in the Persian Gulf War

and the peacekeeping mission to Somalia, U.S. Army

combat operations in the post-Cold War will inevitably involve joint operations with the U.S. Air

Force, and often with the U.S. Navy and U.S. Marine Corps.1 Even peacetime power projections,

such as humanitarian and civil assistance, foreign

internal defense training missions, peacekeeping,

and narcotics interdiction will commonly include

members from several military services. Other

federal and civilian agencies, such as the Federal

Emergency Management Agency (FEMA), the State

Department, the Central Intelligence Agency (CIA),

the Federal Bureau of Investigation (FBI), Coast

Guard, Public Health Service, Merchant Marine,

Department of Veterans Affairs, Red Cross, and

others, may also play important roles. In joint

operations, U.S. Army Mental Health/Combat Stress

Control (MH/CSC) personnel and units may be in

a position to provide mental health support for

personnel from other U.S. services. Conversely,

U.S. Army personnel who are at risk to develop, or

who are developing, stress disorders may benefit

from assistance from another service.

INTRODUCTION

INHERENT PROBLEMS IN JOINT OPERATIONS

Joint operations have proved difficult and dangerous down through history. Recent U.S. experience in the aborted Iranian hostage rescue attempt

in 1980 and Operation Urgent Fury (Grenada) provided painful lessons learned when U.S. Army, U.S.

Air Force, and U.S. Navy teams who had not previously worked and drilled together had to cooperate

in complex, integrated operations. In part, the

difficulties arose from incompatibilities of materiel:

radios that could not communicate between the

different service components even when frequencies were known, “incompatible” computer systems, and lack of spare parts and trained mechanics

for each other’s equipment. Difficulties also arose

from the lack of shared standing operating procedures. To some extent, the services spoke different

“languages”—service-specific vocabularies and especially acronyms which the users found so familiar that they did not even realize that their words

were unintelligible to the other services or, worse,

might have quite different meanings to them. Lack

of a common training base raises doubts of the

other’s reliability and safety—these are not necessarily unrealistic when dealing with highly dangerous tasks requiring special skills such as landing

U.S. Army medevac helicopters on ships in the

dark. More subtle, and harder to counteract, are the

suspicion and mistrust that arise from different

nonverbal and verbal communication patterns, and

different culturally-encouraged styles of leadership

and comradeship. There is the natural human prejudice to favor one’s own tradition and fellow service

members. Even when leaders are trying to be impartial, subordinates may perceive favoritism. This

resentment can further interfere with open communication, morale, and cohesion.

The Department of Defense, the U.S. Congress,

and the civilian leadership have directed that serving in joint staff positions be an important criterion

for promotion to senior command positions in each

service, as well as to the joint major commands.

Increased familiarity and experience may go far to

resolve some of these inherent problems. Psychiatrists and other mental health professionals and

noncommissioned officers (NCOs) who provide

consultation to joint commands and staffs should

use their behavioral science and communications

skills to identify the problems and facilitate the

solutions. Ideally, some mental health experts will

become members of those joint staffs.

COMMON COMBAT PSYCHIATRY PRINCIPLES AND POLICIES

The medical support systems of all four services

share the basic principles for the prevention and

treatment of the dysfunctional combat stress reactions—”battle fatigue” and the disorders of frustration and loneliness, which are presented in greater

detail in Chapter 1, Psychiatric Lessons of War. In

all four services, control of stress and the prevention of stress casualties is a command and leadership responsibility. Psychiatric and other mental

health expertise in the services’ medical systems
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246

have the key role in supporting command with

prevention and in evaluating and treating cases.

The U.S. Army expresses the basic principles for

intervention for battle fatigue in the memory aid

“Treat with PIES” (Proximity, Immediacy, Expectancy, Simplicity).

• Proximity: treat in or close to the service

member’s unit.

• Immediacy: begin intervention immediately on recognition.

• Expectancy: give positive expectation of

rapid recovery and return to duty.

• Simplicity: use straight-forward, nonmysterious interventions.

The U.S. Air Force and U.S. Navy often teach the

same principles with the acronym “BICEPS” (Brevity, Immediacy, Centrality, Expectancy, Proximity,

Simplicity). The additional concepts, brevity and

centrality, are defined as:

• Brevity: everyone involved knows from the

beginning that treatment will be brief

(hours to days).

• Centrality: stress casualties are treated at a

central location separate from the sick and

wounded and they are not evacuated until

evaluated by skilled professionals to prevent inappropriate evacuations.

The U.S. Army also subscribes to brevity and to

the clear separation of stress cases. However, the

“central locations” (plural) will usually be dispersed,

as far forward as possible (in accordance with the

principles of proximity and immediacy), but under

“central control.” In addition, a central processing

facility will reevaluate those being evacuated to determine whether they can remain in the combat zone.

The simple (austere) intervention methods for treating battle fatigue are summarized by the “Five Rs”:

• Reassurance of normalcy.

• Rest from extreme stress.

• Replenishment of physiologic well-being.

• Restoration of confidence by treating the

person as a service member, not a “patient”; by debriefing (retelling the stressful events); and by work activities.

• Return to duty, if possible, in the service

member’s own unit.

All cases of serious misconduct, including those

that are attributable to combat stress (for example,

substance abuse, insubordination, atrocities, absence

without leave, and malingering) must be returned

to the line units for administrative and disciplinary

action in the theater of operations. They are evacuated according to “BICEPS” (brevity, immediacy,

centrality, expectancy, proximity, simplicity) only

if they have other medical, surgical, or psychiatric

conditions that require medical treatment prior to

administrative disposition.

True neuropsychiatric (NP) cases, for example

major depression and persistent schizophrenic-type

psychotic disorders, who have a poor chance for

rapid return to duty should be evacuated as soon as

they can be stabilized and reliably distinguished

from battle fatigue. Post-traumatic stress disorder

(PTSD) should be prevented by routine unit (team)

debriefings. The debriefings should be accomplished as soon after trauma as is tactically feasible,

and again during homecoming. Deployed service

members can tolerate high stress best when they

know that the unit, the service, and the government

are assuring that their families are well cared for

and informed.

Six Combat Stress Control Mission Functions

Six combat stress control (CSC) functions are

defined by U.S. Army doctrine.2,3 The relative requirement for each function varies depending on

the scenario and mission, and especially on the type

and intensity of conflict involved. The six functions,

listed in usual order of priority, are as follows:

1. Consultation-Liaison: preventive advice,

education, and interventions to unit leaders, staffs, medical personnel, chaplains,

and troops.

2. Reorganization/Reconstitution Support to

attrited units at field locations.

3. Proximate Neuropsychiatric Triage: sorting

of stress and NP cases based on where they

are best treated to maximize return to duty

according to the PIES principles, where the

“S” stands for safety—that of the soldier,

the unit, and mission accomplishment.

4. Stabilization of seriously disturbed cases,

for patient and unit safety and to evaluate

return to duty potential;

5. Restoration: 1 to 3 days of holding treatment

in forward, austere medical facilities.

6. Reconditioning/Retraining: additional 1 to 2

weeks of treatment at more secure (usually

rearward) combat stress control facilities

as needed by some cases.
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Combat Stress Control in Joint Operations

All six combat stress control functions could call

for joint operations, in somewhat the same order of

priority as listed. Reconditioning is the least likely

or desirable for joint sharing. Neuropsychiatric

triage and stabilization may be especially important in some joint situations.

CSC Preventive Methods

The primary focus of combat stress control and

mental health in a theater of operations (whether in

combat or in operations other than war) is preventive. The mental health/combat stress control (MH/

CSC) personnel must be proactive. They must diplomatically demonstrate their preventive value to

line unit leaders. Specific methods include (but are

not limited to) the following:

• Attending and providing input at staff meetings and planning sessions.

• Conducting frequent (routine) unit survey

interviews.

• Keeping command informed of stress, morale, and leadership issues that concern the

troops; advising and teaching stress control

measures.

• Training and encouraging routine after-action debriefing by leaders of small units.

• Conducting critical event debriefings following any especially traumatic events.

• Training chaplains, medical personnel,

and line personnel to do critical event

debriefings, too.

• Coordinating and participating in endof-deployment debriefings, memorial and

closure ceremonies, and reunion preparation.

Limitations of and Need for Joint CSC

Operations

Each service must have its own MH/CSC personnel, organic to its own structure (active and

reserve) for the following reasons. MH/CSC personnel must have mutual positive identification

and cohesion with the unit leaders and service

members they support. More than any other medical specialty (except flight surgeons), they must

know the mental and physical demands and stressors of the service members’ mission duties in order

to judge them psychologically able to return to

duty. They must understand the organizational

structure, individual and group dynamics, and

leadership issues involved. Assuming equal training and experience within their own services,

the MH/CSC person who is working within his

familiar service can be expected to be significantly more effective than the one who is working with service members and organizations of a

different service.

However, in joint operations, there will surely be

times and places where each service will not have

its own MH/CSC personnel on the spot when combat stress control support is needed. Immediacy

and proximity are basic principles in combat stress

control interventions. Another service may have

combat stress control resources nearby. One service may also have a highly experienced combat

stress control expert in the area of operation, while

the other services may have only novices locally

available. It is therefore important that there be

contingency plans and, when feasible, standing

operating procedures to permit efficient sharing of

combat stress control resources. The cross-fertilization of ideas and techniques, as well as the professional moral support, will make all the participants

more effective.

All stress casualties who are evacuated to another service’s facility should receive the same treatment as that service’s own cases: provide immediate reassurance, and initiate rest, replenishment,

and activities to restore confidence. Successful 1- to

3-day restoration can probably be accomplished

with mixed service groups. Care may need to be

taken to assure that any interservice rivalry is used

constructively, not destructively, in the program.

The treatment is provided until the casualties can

return to duty to their original units or be transferred to their own service’s backup combat stress

control facility.

In theory, longer-term reconditioning is best

done by the casualties’ own service, where it can

maximize the common identity, traditions, and culture of that service. If limited resources require a

single, joint reconditioning center, it would be

best to have both (or all) services represented on

the treatment staff. If the number of cases were

sufficient, the cases could be organized into singleservice working groups (squads). Here, especially,

interservice rivalry and competition could be

therapeutic, but would require careful modulation to keep it constructive. Joint reconditioning

could also be applied to alcohol and drug rehabilitation in theater for cases with potential for useful

return to duty.

This chapter will review the MH/CSC assets that

the services may deploy to the theater. It will also

suggest ways of using them jointly.
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248

MILITARY BRANCHES IN JOINT OPERATIONS

Each of the four military services has its own

applicable rules and regulations for the delivery

of mental health care to its service members.

These rules and regulations are “living” documents

in the sense that they are modified through the

course of time and experience. The following discussion of the structure and delivery of mental

health care in the various services provides a snapshot view from the period immediately after the

Persian Gulf War. The emphasis is not on the

specific structure, although these structures are

detailed for the reader, but rather on how the delivery of this vital care is coordinated between the

various military services. It is expected that these

configurations will change according to mission

and available staff.

U.S. Air Force MH/CSC Capability

Overview

In World War II, U.S. Army Air Corps psychiatry

was primarily concerned with “operational fatigue”

in flight crews (especially bomber crews) who flew

many high-casualty combat missions. The mental

health of flight crews was (and is) the responsibility

of the unit’s flight surgeon.

In more recent wars, the flight crews have become increasingly “professional”—that is, highly

selected, trained, and motivated officers and senior

NCOs flying in highly sophisticated aircraft. Their

living facilities (when they are not flying) and crew

rest policies have usually been sufficient to minimize cumulative sleep loss and physiologic deprivation. Such factors have made these “elite” personnel relatively resistant to battle fatigue, even

when flying high-risk missions over prolonged periods. However, they may still be subject to battle

fatigue during surge conditions, or when there are

serious problems at home, or as a “short-timer syndrome.”

Recently, stress control concern in the U.S. Air

Force has focused more on the ground personnel.

These are potentially at high risk for stress casualties because they may work extremely long hours at

complex, dangerous tasks. They may come under

attack, including nuclear, biological, or chemical

(NBC) attacks, unable to move from the center of

the “bull’s eye.” They may receive little training in

self-protection and have no way to strike back. The

U.S. Air Force perspective on combat stress is described in U.S. Air Force Combat Psychiatry4 and

Chapter 8 of this volume, U.S. Air Force Combat

Psychiatry.

U.S. Air Force Echelon II CSC

The U.S. Air Force Echelon II level of care is

roughly equivalent to the U.S. Army’s Echelon II

(field medical treatment companies—with a surgical team added), but is less mobile on the ground.

The Air Combat Command may deploy a 50-bed air

transportable hospital (ATH) to provide Echelon II

medical capability (or to reinforce existing air base

dispensary medical personnel) at forward tactical

air fields or air bases. The ATHs are each designated a numbered “Tactical Hospital.”

Each 50-bed ATH includes a Combat Stress Unit

(CSU) with one psychiatrist (or pediatrician with

combat stress training, or clinical psychologist);

one clinical psychologist or social work officer;

and two mental health specialists (914s, equivalent to the Army’s MOS 91G [social work technician]). This CSU is therefore similar to the U.S.

Army CSC prevention teams in the CSC medical

detachment and CSC medical company (previously

described), except that it may not have its own

vehicle.

The Combat Stress Unit is expected to provide

consultation-liaison in the hospital and to nearby

units. It may form a Disaster Response Team. It

should be able to conduct outpatient treatment and

a 1- to 3-day restoration holding treatment program. This program may be in tents collocated with

the air transportable hospital’s medical and surgical capability, in the hospital staff’s quartering area,

or perhaps separate from the hospital but still within

the air base perimeter. This latter location would

usually be in an available “building of opportunity.” If there is an NBC threat, the building could

be given some degree of collective protection. Cases

who cannot be held at this echelon, or who fail to

return to duty within 3 to 7 days (depending on the

likelihood of return to duty and available space and

personnel), would be transferred by air to Echelon

III or IV.

U.S. Air Force Echelon III CSC

The U.S. Air Force Echelon III care is roughly

equivalent to the U.S. Army’s Echelon III (Combat

Support Hospital) hospital care, but further to the

rear, in the theater or communications zone

(COMMZ). This care may be provided by a contin-
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Combat Stress Control in Joint Operations

gency hospital. This is a deployable medical systems (DEPMEDS) facility that, in some cases, may

be in storage in the COMMZ prior to mobilization.

Contingency hospitals can have over 250 beds and

a neuropsychiatry section, staffed by psychiatrists,

clinical psychologists, social work officers, and enlisted specialists (914s). The numbers of the specific

professionals will vary according to the mission,

the availability of staff, and evolving CSC doctrine.

This staff can provide consultation within and

around the hospital, and deploy a disaster response

team. It can supervise care of neuropsychiatric

patients and medical/surgical patients who have

psychiatric complications on the medical wards. If

augmented with psychiatrically trained nursing

personnel, it can staff a 16-bed neuropsychiatry

ward. It could also establish a 1- to 3-day restoration program or a longer duration reconditioning

program separate from the medical and surgical

facilities. In a preestablished theater, Echelon III

care might also be provided by a preexisting small

base hospital; this might not have the combat stress

control restoration/reconditioning capability unless augmented with MH/CSC personnel.

U.S. Air Force Echelon IV CSC

The U.S. Air Force Echelon IV is roughly equivalent to U.S. Army Echelon IV, general and field

hospitals in the communications zone. For the U.S.

Air Force, this care would be provided by large,

fixed hospitals near major air bases. Approximately

one in four such hospitals would have inpatient

psychiatric capability. These might also have other

mental health (psychology, social work, and occupational therapy) personnel. The other hospitals

without the neuropsychiatric wards might still have

some neuropsychiatric/mental health staff to provide consultation and triage. The neuropsychiatricstaffed facility should be configured to be able to

conduct a reconditioning program which maintains

a nonpatient care atmosphere.

U.S. Marine Corps and Navy MH/CSC Capability

Overview

Each U.S. Marine Corps Division is part of a taskorganized Marine Expeditionary Force (MEF),

whose medical planning is the responsibility of the

MEF surgeon. All medical support in U.S. Marine

Corps units is provided by U.S. Navy personnel.

Each U.S. Marine Corps division has a U.S. Navy

psychiatrist as division psychiatrist/assistant division surgeon, and a petty officer psychiatric technician. The psychiatrist is usually at the division’s

home base at Camp Lejeune, North Carolina; Camp

Pendleton, California; or in Okinawa. On full deployment, he would deploy to the theater of operations. He might be augmented with a second U.S.

Navy psychiatrist.

The U.S. Marine Corps can task organize into a

Marine Expeditionary Force (MEF) which has an

infantry division, a Marine Expeditionary Brigade

(MEB) which has an infantry brigade, or a Marine

Expeditionary Unit (MEU) which has an infantry

battalion. The U.S. Marines deploy by way of ships

at sea with a U.S. Naval task force, usually on a 6-

month rotation; ships sailing directly from their

base to the theater; and air transportation as reinforcements to the theater of operations where they

rendezvous with units that deployed by ship to

meet pre-positioned ships loaded with the equipment.

Each U.S. Marine Corps battalion has a battalion

aid station (BAS) roughly similar to those of U.S.

Army battalions. Within the MEF, additional medical support is task organized in the Force Service

Support Group (FSSG) which includes the medical

battalion.

U.S. Marine Echelon II Medical Battalion Assets

Each Marine medical battalion in a Marine Expeditionary Force has four surgical companies. The

headquarters platoon of each company includes a

combat stress platoon, each of which includes a U.S.

Navy psychiatrist, two psychologists, and three

psychiatric technicians.

These U.S. Navy mental health professionals only

join the medical battalion on mobilization. As with

the U.S. Army professional officer filler system

(PROFIS) or Individual Ready Reserve fillers, such

a late-arriving officer will take days to weeks to

become a fully effective CSC consultant or treatment team leader.

If a MEF is at sea, the organic U.S. Marine Corps

medical resources are controlled by the U.S. Navy’s

Commander, Amphibious Task Force (CATF) and

function to some extent while aboard transport

ships, caring for U.S. Marines. Once the amphibious force has established a beachhead, the CATF

surgeon and the U.S. Marine Corps’ Commander

Landing Forces (CLF) surgeon meet to plan the

landing of the beach evacuation station.

The troop transport ships have medical and surgical capability varying with size and type. Some

ships (especially the helicopter assault ships or
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250

hover craft mother ships), would become emergency surgical or medical care sites (primary casualty receiving and treatment ships) in the first

hours of an opposed landing. Any other transport

or landing ship whose troops and cargo have disembarked could be used as a restoration site for

stress casualties. It is recognized, however, that

return to duty from a ship would be much more

difficult than from a shore facility, both logistically

and psychologically.

As the beachhead expands, additional medical

assets are landed. A U.S. Marine brigade would

usually be followed by one of the medical collecting

and clearing companies as it moves further from the

beach. The beach evacuation station might be expanded by landing the surgical support company.

There is currently no formal mental health doctrine as to whether U.S. Marine Corps battle fatigue

casualties should be held/restored at the medical

collection and clearing companies, the surgical support companies, or on the troop transport ships

offshore. The U.S. Marine Corps division psychiatrist and the medical battalion’s combat stress centers must train physicians, corpsmen, and other

medical or line personnel to provide this treatment.

The U.S. Marine Corps line units’ Drug and Alcohol

NCOs can be a valuable resource for cross-training.

Combat Stress Centers

When high-intensity conflict is expected and leadtime is sufficient, the combat stress platoon will

implement a combat stress center. Four such combat stress center teams were improvised and fielded

during the Persian Gulf War. Each such center was

staffed by one or two psychiatrists, from one to

three clinical psychologists, up to three psychiatric

technicians, and corpsmen or nursing personnel

who received on-the-job training. These teams were

supplied with tents and cots at the surgical support

centers to provide restoration, as well as providing

preventive consultation and neuropsychiatric triage. In the Persian Gulf War, they did not deploy

forward to augment the collecting and clearing

companies.

U.S. Navy Echelon III/IV Afloat—Hospital Ship

A major U.S. Marine Corps or joint operation will

be supported by a 1,000-bed hospital ship. Each

hospital ship may have a neuropsychiatry ward

and staff, including a psychiatrist, a clinical psychologist, two or more psychiatric nurses plus onthe-job-trained medical/surgical nurses, a social

work officer, and petty officer psychiatric technicians plus on-the-job-trained corpsmen. The mental health/neuropsychiatric staff can staff a mixed

medical/psychiatric ward on one of the ship’s light

care bays. They may establish a separate section of

the ship for restoration of stress casualties who

reach the ship. This section carefully avoids any

patient care atmosphere. The hospital staff may

also deploy task-organized teams, including special psychiatric rapid intervention teams (SPRINTs)

to provide reconstitution support to ships which

suffer heavy casualties from accidents or enemy

action. The USS Comfort deployed such a team to

the helicopter amphibious assault ship Iwo Jima

following a boiler explosion with fatalities during

the Persian Gulf War.

U.S. Navy Echelon III/IV Ashore—Fleet Hospital

The Combat Zone Fleet Hospital comes in two

sizes—it can be a 250-bed or a 500-bed deployable

medical systems (DEPMEDS) facility, roughly

equivalent to the U.S. Air Force 250-bed Contingency Hospital and U.S. Army 500-bed General

Hospital. These receive patients from U.S. Navy

ships and U.S. Marine Corps units in the combat

zone. The COMMZ Fleet Hospital (500-bed) has a

convalescent mission which makes it roughly similar to the U.S. Army’s 500-bed Field Hospital.

All fleet hospital staffs include a neuropsychiatry

mental health team, consisting of one psychiatrist

with the 250-bed facility and two psychiatrists with

the 500-bed facility. No psychiatric nurses are specifically assigned, but a charge nurse and several

ward nurses may be provided, and some could be

psychiatric nurses. In addition there are three psychiatric technicians with the 250-bed facility and six

with the 500-bed facility. There is also one clinical

psychologist with the 500-bed facility only. This

team staffs a neuropsychiatric ward. It can also

establish a restoration or reconditioning program

which maintains a nonpatient atmosphere, if provided with general purpose tents. Such a facility

was established at two fleet hospitals during the

Persian Gulf War, one in Saudi Arabia, and one in

Bahrain.

U.S. Navy CSC Capability in Peacetime Disasters

For peacetime training accidents, airplane

crashes, ship collisions, disasters, and other brief

traumatic contingencies short of war, the U.S. Navy

deploys SPRINTs, which are discussed in further

detail in Chapter 9, U.S. Naval Combat Psychiatry.
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Combat Stress Control in Joint Operations

Special psychiatric rapid intervention teams are

task organized from a multidisciplinary pool of

mental health personnel at large U.S. Navy hospitals. These personnel maintain a rotation in order to

be available for deployment on 24-hour notice.

Teams usually are led by a psychiatrist and may

include a social work officer, psychologist, psychiatric nurse, chaplain, and enlisted technicians.

The SPRINT members provide on-site consultation to command. They assist local shipboard, port,

or air station medical, mental health, and chaplain

personnel with critical incident stress debriefing. The SPRINT concept is based on brief, immediate, proximate, positively expectant intervention

following a critical incident. The teams have not

been trained or equipped to provide restoration

or reconditioning support to an ongoing combat

operation.

U.S. Army MH/CSC Capability

U.S. Army Echelon II MH Sections

All divisions, brigades, and area support battalions have mental health sections. Each combat

division’s main support medical company or medical battalion has a mental health section consisting

of a psychiatrist, a clinical psychologist, a social

worker, and six or seven behavioral science specialists (9lGs). The Table of Organization and Equipment (TO&E) authorizes the mental health section

three 11⁄4 ton vehicles. By doctrine, the section

should deploy an NCO or an officer/NCO team to

work consistently with each deployed maneuver

brigade. The separate brigade’s medical company

has one NCO and two junior 91Gs (social work

technicians) for a heavy (armor or mechanized infantry) brigade, and one NCO 91G for a light infantry brigade. Armored Cavalry and Ranger Regiments currently have no organic mental health

personnel. Future U.S. Army plans will make a

mental health officer/NCO team organic to all maneuver brigade and armored cavalry regiment medical companies, while keeping the division psychiatrist at division level to supervise all combat stress

control operations. Each area support medical battalion in the corps has a psychiatrist, a social work

officer, and eight 9IGs (E-3 to E-7) The section has

one 21⁄2 ton and three 3⁄4 ton trucks. It should routinely assign a 91G NCO to each of the three area

support medical companies. These are supervised

and, when needed, reinforced by the officers from

the area support medical battalion’s headquarters

and medical support company.

U.S. Army Echelon II/III CSC

The medical CSC detachments and companies

provide U.S. Army Echelon II/III care. The medical

detachment CSC has 9 officers, 14 enlisted, one 2 1⁄2

ton and six 11⁄4 ton trucks with trailers. Basis of

allocation is one per division or one per two or three

separate brigades. It is composed of three CSC

prevention teams (each with a psychiatrist, social

work officer, two 9lGs); and one CSC restoration

team (each with a psychiatric nurse and two psychiatric technicians, an occupational therapist and two

occupational therapy technicians, a clinical psychologist and three 9lGs, plus a patient administration specialist).

The CSC prevention teams usually reinforce the

brigade support areas to prevent stress casualties

and unnecessary evacuation, and to assist the return to duty of recovered cases and unit reorganization efforts. The CSC restoration team usually provides neuropsychiatric triage, stabilization, and 1-

to 3-day restoration at a medical company in the

division rear or forward corps. This team also

provides consultation and reorganization support

there, and reinforces forward as needed. These

multidisciplinary teams are not unbreakable atoms.

Their specialist personnel should be combined or

cross attached flexibly to make mission-specific

“task-organized CSC elements.” In operations other

than war, the CSC detachment may be only partially deployed, and support the echelon-abovedivision units as well as reinforcing the division

MH assets.

The Medical Company, CSC has 27 officers, 58

enlisted, one 1⁄4 ton, six 21⁄2 ton, and ten 11⁄4 ton

trucks. Basis of allocation is one per two or three

divisions for high-intensity war, or one per corps or

theater for prolonged low-intensity conflict. The

CSC company has a company headquarters; six

CSC prevention teams (psychiatrists, social work

officers, 9lGs); four CSC restoration teams (psychiatric nurses, psychologists, occupational therapists,

technicians). Personnel from these teams should be

switched flexibly across the CSC prevention and

CSC restoration teams to tailor for specific missions.

The company headquarters (HQ) assists medical

brigade or medical group HQ with CSC planning

and with command/control and administrative/

logistic support of its dispersed teams and the CSC

detachments. The cook and vehicle mechanics are

usually divvied out to the dispersed CSC working

elements. The CSC HQ has a staff chaplain to

provide the religious/spiritual perspective to the
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MH/CSC team and to help coordinate with the

chaplain network of unit ministry teams, HQ staff

chaplains, and hospital chaplains.

The company’s six CSC prevention and four CSC

restoration teams are task organized into larger

elements to provide comprehensive CSC support

behind each division. The CSC elements can staff

reconditioning centers (usually collocated with combat support hospitals); deploy teams to reinforce

the area support medical battalion mental health

section in corps; detail teams to provide direct CSC

support to the corps’ brigades or to units undergoing reconstitution; deploy its personnel or teams

forward by air ambulance or ground vehicle to

rapidly reinforce or reconstitute the CSC detachments at the divisions and brigades as needed.

U.S. Army Echelon III Corps-Level Hospitals

Each 300-bed combat support hospital (MedForce 2000 model) in the corps is a DEPMEDS facility which has a neuropsychiatry ward and consultation service. This service has a social work officer,

three psychiatric nurses and one medical/surgical

nurse, seven psychiatric ward aids (MOS 91F),

one behavioral science specialist (MOS 91G), and an

occupational therapy specialist (MOS 91L). The

section provides consultation throughout the hospital and to nearby units. They staff a 20-bed intermediate care ward module which may also treat

medical cases.

The current 60-bed (and the future 30-bed

MedForce 2000) Mobile Army Surgical Hospitals

and the current 200-bed combat support hospitals

(CSHs) have no MH/CSC staff, although a psychiatric nurse could be filling a vacant medical/surgical nurse slot. The current 400-bed evacuation

hospital has a psychiatrist, a psychiatric nurse, and

two psychiatric technicians (MOS 9lFs). It will be

replaced by the MedForce 2000 CSH.

U.S. Army Echelon IV General and Field Hospitals

The 500-bed general hospital and 500-bed field

hospital (MedForce 2000 models) are DEPMEDS

facilities which will usually be established in the

communications zone. Each has the same

neuropsychiatry ward and consultation service as

the MedForce 2000 model CSH described above.

The field hospital also has a clinical psychologist

with two 9lGs, and an occupational therapist with

two 9lLs. The mission of the MedForce 2000 field

hospital is to be a convalescent facility which

returns soldiers to duty in the theater within

30 days. It should have a reconditioning facility,

kept separate from the “patient care” area. It may

also provide a drug and alcohol rehabilitation program for soldiers with good return to duty potential

(the current field hospital has no neuropsychiatry

staff). The mission of the MedForce 2000 general

hospital is primarily to prepare soldiers for safe

evacuation to the continental United States (CONUS), including the severe neuropsychiatric disorders who cannot return to duty in theater.

U.S. Army CSC in Medical Command/Control

Headquarters

The MedForce 2000 organizational structure provides for mental health staff sections in the theater

and corps-level medical headquarters units. The

medical command and the medical brigade each

will have a psychiatrist, a social work officer or

psychologist, an occupational therapy officer, and a

91G NCO. The subordinate medical groups each

will have a psychologist, a social work officer, and

a 91G NCO.

These MedForce 2000 positions will not be officially implemented until 1995. However, the precedent has been established for having some

neuropsychiatry staff at headquarters level. In the

Persian Gulf War, the U.S. Army Central Command

Surgeon requested and received a staff neuropsychiatry consultant from the Office of The Surgeon

General as an interim measure. Seventh Corps also

requested and deployed to the Persian Gulf with a

staff corps psychiatrist. The medical brigade at Fort

Bragg, North Carolina, requested and received a

psychiatrist (rank of colonel) for their relief mission

in South Florida following Hurricane Andrew, and

now has PROFIS staff on post. The Medical Group

headquarters at Fort Lewis, Washington, took its

authorized social work officer, psychologist, and

91G NCO to Somalia, then sent them home early.

The Medical Group in Europe has directed its

PROFIS social worker to plan contingency CSC

support for Bosnia peace enforcement.

Situations for CSC Cooperation Between the

U.S. Army and Air Force

A number of situations have occurred or will

occur in which U.S. Army and U.S. Air Force personnel must cooperate in the treatment of stress

psychiatric casualties, as well as in preventive stress

control activities.
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Combat Stress Control in Joint Operations

U.S. Air Force Liaison Personnel in U.S. Army Units

U.S. Air Force personnel routinely work as air

liaison officers in U.S. Army headquarters units

down to the brigade level. Under special circumstances, they might function further forward as

observers calling in air strikes.

These personnel should receive preventive consultation support along with their U.S. Army headquarters. If these personnel develop battle fatigue,

they should be treated in the same way and in the

same facilities close to their units as their U.S. Army

coworkers, with positive expectation of return to

their same duty in 1 to 3 days. If they fail to respond

to treatment, they should be transferred to U.S. Air

Force facilities.

Downed U.S. Air Force Pilots

U.S. Air Force forward air controllers (FACs) fly

small aircraft above the battlefield and guide high

performance attack aircraft against ground targets

close to U.S. units. Other U.S. aircrews attack targets far behind enemy lines. Both FACs and attack

aircrews may be forced to crash-land or bail out,

and may subsequently show symptoms of battle

fatigue which could harden into post-traumatic

stress disorder (PTSD). Transport aircraft crews

could crash or be disabled while making air drops

or flying into forward U.S. Army air strips. Some

U.S. aircrews may be shot down behind enemy lines

and reach U.S. lines only after extended periods of

escape and evasion under conditions of extreme

physical and mental stress. Other downed airmen

may be extracted from behind enemy lines by U.S.

Army helicopters or Special Operations. Some may

be brought to U.S. Army medical facilities after

being rescued or exchanged as prisoners of war.

The line unit leaders and medical personnel who

encounter U.S. Air Force aircrews first should automatically apply all of the principles and methods of

treating battle fatigue: reassurance; rehydration;

nutrition; sleep; restoring hygiene; opportunity to

talk about and ventilate the experience; and appropriate self-care duties that restore confidence. It is

important not to predict psychopathology, and to

instead convey the quiet expectation of return-toduty. The airman should be transported (not “evacuated”) back as soon as possible to their unit’s air

base or to the U.S. Air Force medical facilities (described earlier) which support that base.

If more serious signs of battle fatigue develop or

persist while the airman is awaiting transportation,

combat stress control personnel talk with the airman to reinforce the initial crisis intervention. They

emphasize the normality of the symptoms and the

likelihood of their rapid improvement.

U.S. Army Units Stationed near U.S. Air Force

Bases

U.S. Army units, especially combat-support/service-support units, may be located on or close to

U.S. Air Force bases. These may lack organic mental

health support and be distant from U.S. Army combat stress control unit elements. The combat stress

unit of the U.S. Air Force’s tactical hospital should

provide proactive consultation and mental health

support to the U.S. Army units. For example, in the

Persian Gulf War one combat stress unit provided

such outreach support to an U.S. Army transportation battalion whose drivers drove very long, dangerous convoys on the Tapline Road and a Patriot

air defense artillery battalion under heavy stress

defending against the Scud missiles.5

Forward U.S. Air Force Bases under Attack

U.S. Air Force bases will be located in the corps

and communication zone, and perhaps even in division areas as the battle progresses or in unconventional counterinsurgency conflict. The air bases’

ability to function may be severely degraded in

high-intensity conflicts. Air bases are natural targets for air and long-range missile attack, including

time bombs, cluster bomblets, persistent chemical

and/or nuclear weapons. Even in low-intensity

conflicts, they are targets of mortar, short-range

rocket and sapper attacks. Because of their stockpiles of munitions and fuel, even small attacks on

air bases can produce catastrophic disasters. Even

in peacetime, air crashes can also produce sudden

mass casualties and widespread devastation.

U.S. Army units will be located next to air bases,

both in the corps areas and communications zone,

and may be detailed to reinforce their organic ground

defense (air police) and antiair/antimissile defense

capability. Forward air bases, especially those that

do not have an area theater hospital, will have very

limited medical/surgical resources, and may need

routine support from nearby U.S. Army medical

units. This could include combat stress control

consultation and neuropsychiatric triage/stabilization from the MH/CSC personnel of the area support medical battalion; CSC company; or CSH, field,

or general hospital. Only after careful coordination
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254

might U.S. Army combat stress control units provide restoration or reconditioning for air base personnel, in preference to evacuation to rear echelon

U.S. Air Force facilities.

In the event of mass casualties at the air base, U.S.

Army combat stress control teams, along with other

medical units, could provide emergency triage and

reconstitution support. As soon as possible, these

teams would be joined by (and continue to work

with) additional U.S. Air Force combat stress unit

(CSU) disaster response teams sent to the site. As

suggested above, mass casualties or traumatic

crashes can occur in peacetime. The following case

history illustrates support by U.S. Army Combat

Stress Control teams to a U.S. Air Force base.

Case Study 1: Mass Murders at a U.S. Air Force Base

A disgruntled ex-airman who had been discharged

from the U.S. Air Force on psychiatric grounds entered the

hospital of Fairchild Air Force Base (Spokane, Washington) with an automatic weapon. He killed the psychiatrist

while the doctor was providing therapy to a patient, killed

the psychologist, then stalked through the hospital, randomly shooting patients and staff in the corridors and

waiting rooms. He was finally shot and killed in the

parking lot by U.S. Air Force security police. On hearing

the news, the psychiatrist commander of the U.S. Army’s

98th combat stress control detachment (Fort Lewis, Washington) contacted the surviving members of the Fairchild

mental health section and offered to send a team to assist.

The hospital commander concurred, but the initial reaction at a higher U.S. Air Force echelon was that the U.S.

Air Force was sending its own teams and a U.S. Army

team would be superfluous. The Fairchild and Fort Lewis

mental health personnel mobilized general officer support

to reemphasize the potential mutual value of the U.S.

Army team’s participation, and approval was quickly

granted. A four-person CSC preventive team (a psychiatrist, social worker, and two enlisted personnel) deployed

by commercial air within 2 days. Their orders had been

pushed through the system by their higher TO&E headquarters over a weekend, and their travel funding provided by the medical activity.

At Fairchild Air Force Base, the U.S. Army team interfaced well with, and provided debriefing support to, the

surviving U.S. Air Force social work officer and behavioral

science technicians. While reinforcing U.S. Air Force stress

teams worked in consultation and debriefing with other

hospital staff, patient, and community groups, the U.S.

Army team was given responsibility for assisting the U.S.

Air Force Security Police who had been involved in the

incident. They also assisted the mental health section in

scheduled and special psychotherapy for their outpatients,

who were deeply distressed by the deaths of their therapists. Those sessions were conducted in a temporary clinic

away from the hospital, which was closed for forensic

evidence collection and necessary cleanup and repairs.

While these activities were still ongoing, a B-52 bomber

crashed on base while practicing low-altitude stunt maneuvers. All the crew were killed. A second four-person

team of the 98th CSC detachment was hastily deployed

from Fort Lewis, Washington. It assisted with debriefings

of the emergency crews and others who rushed to the

crash site and recovered the bodies. Upon completion of

their work, both teams returned to Fort Lewis.

Comment: The nature of the horrible mass murder was

such as to impact on the entire Fairchild Air Force Base

community and the surrounding retiree outpatient population. While the U.S. Air Force could have mobilized

sufficient stress and mental health teams from other

bases and medical centers, that would have put a greater

strain on quality of care elsewhere in the U.S. Air Force

system. It made tactical and economic sense to include

in this relief effort the teams from a relatively nearby U.S.

Army unit that had been trained in the mission of quick

deployment to deal with critical events. The tragic opportunity provided excellent clinical experience for the U.S.

Army teams. It also provided administrative experience in

coordinating a rapid joint operation in the peacetime,

garrison force. When the B-52 crash compounded the

trauma for the Fairchild Air Force Base community, it was

simple to reinforce the effort.

Initial Rapid Deployment Contingency Operations

In rapid deployment contingency operations,

such as Operation Just Cause (Panama, 1989), medical care at the airhead may at first be provided only

by the U.S. Air Force personnel of the Aeromedical

Evacuation Squadron (operating a mobile aeromedical staging facility). These may be augmented

by U.S. Army surgical squads (forward surgical

teams). None of these units have organic MH/CSC

personnel, although psychiatric nurses may have

been assigned to fill surgical nurse vacancies. Battle

fatigue and neuropsychiatry cases for all services

will probably be brought to this facility along with

the seriously wounded, ill, and injured. Many cases

may have had no prior MH/CSC evaluation.

The ability of this facility to prevent the overevacuation of simple stress casualties (including

battle fatigue, minor heat exhaustion, mild concussion, and other conditions) is severely limited by its

preoccupation with the seriously injured. However, training the triage officers and other patient

care providers in combat stress control principles

can enable them to hold and return to duty stress

casualties. This is normally accomplished after the

initial rush of surgical cases has been treated. In

Operation Just Cause, the U.S. Air Force nursing

personnel did hold and return to duty a U.S. Army

battle fatigue casualty on the third to fourth day of

the operation. The following case is taken from the

Persian Gulf War.
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Combat Stress Control in Joint Operations

Case Study 2: Chaplain’s Assistant

In the Persian Gulf War, the medical company of the

U.S. Army armored brigade had moved into Kuwait close

behind the armored battalions. Battles against Iraqi armor

and infantry were still going on. Several kilometers away,

U.S. air power attacked Iraqi forces that had dug in around

a mosque. In the aftermath, it was discovered that Kuwaiti

civilians had taken refuge in that mosque, and some had

been killed or wounded by the “collateral damage.” The

medical company hastily sent a mass casualty response

team, which included the brigade’s U.S. Army psychiatrist, the forward support battalion chaplain, and the

chaplain’s assistant. The psychiatrist remembers vividly

the image of the chaplain’s assistant coming out of the

wreckage carrying two very young girls, one dead and the

other seriously injured. Over the next several hours as the

surviving casualties were transported to the medical company and given emergency care, there was no time to

conduct an immediate debriefing. The chaplain’s assistant

became silent and preoccupied, withdrew from the group,

and finally began to shake uncontrollably, barely able to

communicate. The psychiatrist would have preferred to

treat him on site, but armored battles were still occurring

nearby and there was the possibility of another mass

casualty or emergency move. He could neither devote full

attention to this one stress casualty nor trust that casualty

to respond appropriately and safely in an emergency.

Reluctantly, he sent him with the other casualties on a

truck going back to the U.S. Marine surgical support

company (and combat stress center) in Saudi Arabia.

Several days later, the chaplain’s assistant was returned to duty in the forward support battalion. By this

time, the ground campaign had concluded, but the unit

was still occupied with the dangerous and often gruesome

process of securing the battlefield. The chaplain’s assistant was able to participate in the unit’s new missions in

his original role, and demobilize and return home with it.

Comment: This case illustrates the constraints that the

tactical situation can impose on preventive and treatment

intervention at far-forward medical facilities. The U.S.

Marine Corps/U.S. Navy backup system was able to

function and return the soldier to duty quickly. This

reduced (if not eliminated) the risk of PTSD developing

from what was a highly traumatic event for all the medical

personnel, and arguably an even higher psychological

trauma for a young man in the chaplain corps.

The capability to return stress casualties to duty

at a forward deployed aeromedical evacuation

squadron and U.S. Army surgical team task force

could be greatly improved at little cost. This could

be accomplished by providing one or two NCO or

officer personnel (preferably with MH/CSC training), plus some very spartan “sheltering” (not formal “patient holding”) and supplies. Local buildings, hangers, or improvised shelter may be

sufficient. The supervisory personnel could be either from a U.S. Army unit mental health section,

from a U.S. Army medical combat stress control

detachment or company, or from a U.S. Air Force

unit. To be fully effective, this augmentation must

be present at the outset of the operation. If it arrives

later, the majority of stress casualties who arrived

with the first, second, or third rush of badly wounded

cases will already have been evacuated.

In addition to preventing the loss of “pure” battle

fatigue cases, this austere restoration capability

could also permit holding and return to duty of

some minor disease nonbattle injuries whose overevacuation could result in psychological harm. Such

cases include members of elite units (such as U.S.

Army Airborne, Ranger, and Special Operations

Forces, and U.S. Navy SEALs [“SEa Air Land”],

descendants of the World War II Underwater Demolition Teams) who tend to regard evacuation for

minor orthopedic jump injuries, heat exhaustion,

dehydration, or mild concussion as dishonoring.

Such patients may often volunteer to be allowed to

remain at the mobile aeromedical staging facility

(MASF) for one to three days, eating meals-readyto-eat (MREs), sleeping on ground pads, providing

local security, and helping out within the limits set

by their minor disability, rather than be evacuated

far from their comrades. This could be medically

permissible, provided the delay does not increase

the risk of death or permanent disability from an

inadequately diagnosed condition. If such selected

cases are held, and later evaluation indicates that

they can still not return to limited or full duty in

their units, they could then be evacuated without

feeling shame or guilt. The MH/CSC personnel

who supervise such cases would also initiate stress

debriefing for those wounded in action (WIA) who

were awaiting evacuation and for the medical staff.

Ongoing Combat Operations

As the theater stabilizes, the aeromedical evacuation squadrons will continue the primary role of

staffing mobile air staging facilities. These facilities, located at air bases and simple landing strips,

receive patients from the combat zone hospitals.

They hold the patients for several hours, providing

continuity of care until the patients can be loaded

onto aircraft for air evacuation to the communications zone or the continental United States (CONUS). Some of the airframes may be dedicated

medical aircraft; however, most aircraft that depart

from the combat zone will be general purpose cargo

aircraft (C130s, C141s, a few C5As, the future C17)

hastily reconfigured with litter sets. The MASF also
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serves as the rest and staging area for the in-flight

nursing personnel.

The MASFs will deal with three types of patients

who pose stress or psychiatric issues:

1. True, severe neuropsychiatric patients. By

doctrine, these will arrive and be transported on litters, in restraints, well medicated and sedated. Only if departure is

delayed by weather or other mishap will

these patients pose problems.

2. Wounded or injury cases with significant psychological distress or organic mental disorder.

These may create a considerable strain on

the MASF staff and the in-flight nursing

crews. Both the patients and the staff

could benefit from special MH/CSC advice regarding their psychological and

pharmacologic management.

3. Battle fatigue cases who have not responded to

restoration or reconditioning and who are being evacuated to COMMZ or CONUS for

further reconditioning or treatment for PTSD.

These soldiers should be ambulatory, but

may have been given long-acting antianxiety medication (such as diazepam) for the

flight. It is important that the MASF and

in-flight personnel maintain the sense of

positive expectation of full and rapid recovery. They, too, should treat these cases

as service members being transferred temporarily to the rear, not as sick or “mental”

patients. However, unless the flight personnel have been thoroughly briefed and

reassured by the neuropsychiatry or MH/

CSC consultants, they may insist that these

battle fatigue cases be restrained on litters,

causing some psychological harm. (If that

must be done, it should be explained as

giving the service member better opportunity to sleep on a long and possibly bumpy

flight.)

Personnel from the combat support hospital’s

neuropsychiatry ward and consultation service, the area support medical battalion mental

health section, and/or the medical combat stress

control detachment or company should maintain

regular contact with the MASF personnel. This is

important both to assure the correct management of

the stress and neuropsychiatric evacuations and

also to assist the MASF and in-flight U.S. Air Force

nursing staffs with processing their own, high-stress

experiences.

During a Major Buildup

In the buildup phase of a rapidly developing

contingency theater, one or more airfields will be

major points of entry for U.S. Army (and perhaps

Marine) forces into the country. The U.S. Air Force

50-bed air transportable hospitals at the airfields

are likely to be the first U.S. Echelon II/III hospitals

set up in the country. U.S. Army clearing companies and mobile army surgical hospitals, if they

arrive by air, will probably move quickly off the

airfields to support the maneuver units. U.S. Army

unit medical and CSC personnel should determine

what U.S. Air Force medical facility is supporting

the airfield and its vicinity. If possible, this information should be provided before the units leave

CONUS. As U.S. Army units continue to pour into

the points of air debarkation, any soldiers who

develop serious stress, physical, or neuropsychiatric

symptoms in flight or soon after landing could be

brought to the U.S. Air Force facilities for evaluation and care.

If feasible after landing, the U.S. Army medical

and combat stress control personnel should visit

the U.S. Air Force facility to review basic doctrine

for the triage and treatment of stress casualties.

They should coordinate the procedures for returning duty battle fatigue cases to their units immediately (prior to the unit’s departure from the airfield

or temporary assembly area). They should coordinate where restoration battle fatigue (rest battle

fatigue) cases can be sent for 1 to 2 days’ light duty

with the soldier’s unit’s own combat service support elements. Depending on staffing and workload,

it may be possible for the area theater hospital’s

combat stress unit to provide 1- to 2-day observation and restoration for any hold battle fatigue cases.

Here, too, coordination for how to return recovered

cases to their units (which are themselves in transit)

will be critical.

In the unlikely event that many stress casualties

developed in flight or soon after arrival, it may be

useful for the U.S. Army division mental health

section, area support medical battalion mental health

section, or combat stress control detachment or

company to temporarily reinforce the U.S. Air Force

combat stress unit at the area theater hospital while

many units are flowing through the airhead.

Every reasonable effort should be made to

apply the principles of PIES and the method of the

Five Rs to prevent the unnecessary evacuation of

stress, fatigue, jet lag, and minor somatic and

orthopedic overuse syndromes from the theater

soon after their arrival. Most of these cases will
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Combat Stress Control in Joint Operations

present with physical, not emotional, complaints.

Over-evacuation may cause permanent psychological harm to the patients. It may also grow into an

“evacuation syndrome” (see Chapter 1) as other

new arrivals under stress consciously or unconsciously develop the same symptoms. Malingerers,

who are deliberately faking or self-inflicting symptoms, should be returned to their units in the theater

for disciplinary action.

During Redeployment Home

To a lesser extent, U.S. Army units may also need

to rely on U.S. Air Force area theater hospitals

or contingency hospitals at the airheads during

some phases of redeployment to CONUS after the

conflict is over. In this case, the stress issue will

not be apprehension over impending battle but

rather impatience to get home, perhaps mixed with

apprehension in some soldiers over what they will

find there.

U.S. Air Force and U.S. Army medical/combat

stress control personnel should coordinate their

preventive consultation and triage practices to discourage the tendency for some soldiers and airmen

to develop stress syndromes in the unconscious or

conscious wish to get home before the rest of their

unit. The MH/CSC personnel may also provide or

facilitate prereunion briefings and discussion groups

to defuse potential homecoming stress. Coordination with the chaplains of both services is essential

to this effort.

Post-traumatic stress symptoms may also be

present, but are more likely to be mentally suppressed by the focus on putting the unpleasant

experiences behind one and going home. U.S. Army

and U.S. Air Force MH/CSC personnel may be able

to cooperate and pool dwindling resources (along

with the chaplains) to provide preventive afteraction stress briefings or critical event debriefings

to individuals, groups, or units at special risk.

Situations for CSC Cooperation Among the U.S.

Army, Navy, and Marine Corps

As with the U.S. Air Force, a number of situations

will require cooperation between U.S. Army, U.S.

Navy, and U.S. Marine Corps personnel.

U.S. Navy/Marine Corps Liaison Personnel in

Army Units

In combat actions close to the ocean, where U.S.

Army units can receive close air support or gunfire

support from U.S. Navy ships offshore, the U.S.

Army headquarters units may be augmented by

U.S. Navy or U.S. Marine Corps air liaison teams

and naval gunfire liaison teams. If these personnel

develop battle fatigue, they should be treated in the

same way as the U.S. Army and U.S. Air Force

personnel and in the same facilities close to the U.S.

Army unit.

Downed Pilots

If U.S. Navy or U.S. Marine Corps aviators are

shot down over U.S. Army territory or are recovered from behind enemy lines, they should be treated

as indicated above while they are being returned to

their units or to U.S. Navy/U.S. Marine Corps medical facilities. Conversely, U.S. Army aviators who

are recovered or rescued by U.S. Marine Corps or

U.S. Navy units should receive similar treatment

from their rescuers and, if necessary, from U.S.

Marine Corps/U.S. Navy MH/CSC personnel until

returned to the U.S. Army.

Neighboring Units

If U.S. Marine Corps and U.S. Army units are

fighting alongside each other, as happened in the

World War II Pacific Theater, Korea, Vietnam, and

Southwest Asia, they may use each other’s medical/surgical facilities. This would most likely occur

as a result or side effect of the air evacuation of

serious surgical wounded cases.

The U.S. Marine Corps/U.S. Navy medical battalion does not have dedicated medical evacuation

vehicles. Evacuation of any casualties by air must

use general purpose helicopters or request U.S.

Army “dustoff” medevac. In the latter case, they

may be brought to U.S. Army medical treatment

facilities. Ground evacuation must be coordinated

using ground vehicles in backhaul. This latter is the

U.S. Army’s doctrinally preferred way to transport

all battle fatigue cases. Stress casualties traveling

by truck will naturally be brought to their own

service’s medical clearing facilities. However, in

the confusion of real operations, doctrine restricting the air evacuation of stress casualties may be set

aside. In crisis situations, line commanders and

forward medical personnel will seek to clear the

battlefield of all noneffective casualties.

Those stress cases who show symptoms of amnesia, loss of motor or sensory functions or agitation

(in particular), may be sent immediately by air or

ground to a hospital to rule out serious physical

causes. This could be the hospital of the other
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service. It will be necessary to extract any such

stress cases from the evacuation chain and return

them to suitable battle fatigue restoration facilities.

In this situation, it is important to get the service

member back to his own service as soon as possible.

In a large-scale operation near the ocean, a U.S.

Navy hospital ship is quite likely to reach the theater before U.S. Army combat surgical hospitals

have arrived and been set up. On one hospital ship

in the Persian Gulf during Operation Desert Shield/

Storm, 9% of psychiatric admissions were U.S. Army

personnel and 5% were U.S. Air Force personnel.6

While the hospital ship’s neuropsychiatric ward

provides a suitable place to stabilize true neuropsychiatric cases for further evacuation, it is not well

suited to restoring U.S. Army battle fatigue casualties to duty. The shipboard environment, even of

the non–patient-care combat stress control bay,

would be both unfamiliar and seemingly remote

from the soldiers’ units. Extra effort would be

necessary to maintain positive expectation and the

sense of proximity. The potentially recoverable

U.S. Army soldier should be transferred to a restoration and reconditioning center ashore as soon as

possible. The same concerns are probably relevant

to U.S. Air Force stress casualties evacuated to a

hospital ship.

The shipboard setting may be less significant for

U.S. Marines treated for stress on the hospital ship’s

combat stress center, as they are accustomed to

going directly from ships to ground combat. It may

be even less a problem for U.S. Navy shipboard

sailors who are recovering from battle fatigue incurred in ship disasters or combat. Prompt return

to the service member’s original unit or ship remains crucial to maximizing recovery.

Cross-Attached Units

U.S. Army battalions or brigades may be crossattached to U.S. Marine Corps task forces or divisions,

and U.S. Marine Corps elements may be cross-attached to U.S. Army units. For Operation Desert

Storm, a U.S. Army armored brigade was attached to

a U.S. Marine Corps division to give it M1A1 (Abrams)

tank capability. The U.S. Army Operations and Sea

Force concepts for the post-Cold War world make

such cross-attachment increasingly likely.

U.S. Army personnel who are evacuated to a U.S.

Marine Corps/U.S. Navy/U.S. Air Force facility,

such as to the psychiatric or combat stress center at

an MH/CSC should receive the correct treatment

for battle fatigue there. In the Persian Gulf War, a

U.S. Army combat stress control officer/NCO team

(from the division mental health section) with the

U.S. Army armored brigade had to refer four combat stress casualties back through U.S. Marine

Corps/U.S. Navy channels. One, who proved to

have additional neuropsychiatric problems, was

evacuated to a U.S. Air Force hospital in England.

Three returned to duty with their U.S. Army unit in

days, proving that joint combat stress control interventions can work.

Case Study 3: Light Battle Fatigue

During the Persian Gulf War, a soldier arrived at night

by helicopter, along with several wounded soldiers. He

had the 1,000 yard stare, sat passively, and responded

slowly to questions in one or two words only with firm

prompting. He knew his name, rank, serial number, and

unit, but was unable to describe what had happened. The

medical/surgical nurses who triaged him knew the principles of BICEPS, and it was feasible to hold him for the

night because the initial surge of surgical mass casualties

had slowed and a holding tent with cots had finally arrived.

The orthopedic surgeon they consulted trusted their triage judgment. The soldier was given verbal reassurance

and taken to lie down and sleep. The next morning the

nurses found the soldier at the mess line, wolfing down

breakfast. He said he was “fine,” and had to get back to

his unit. He was still unclear about what had happened

when the unit had “taken heavy flak,” and only vaguely

remembered being brought by helicopter and talking with

someone in the night. He was assigned to performing

work details around the MASF while waiting for his unit to

pick him up. Indeed, he complained so much about the

menial duties that the U.S. Air Force nurse reminded him

that she was the officer and he the enlisted soldier, that

one of them had to do these duties, and she said it was to

be he. Both were happy when his unit’s truck arrived to

take him back to duty.

Comment: Had this soldier been evacuated to San

Antonio, Texas and home base, it is quite likely that he

would have become a true psychiatric casualty, left the

U.S. Army, and perhaps developed long-term disability.

Battle fatigue casualties in U.S. Marine Corps

combat units that are working under U.S. Army

command/control should be transported to their

own medical units if such units have been included

in the task force from the Force Service Support

Group. These medical units could be augmented by

combat stress control personnel or teams from the

U.S. Army division mental health section, combat

stress control detachment, or combat stress control

company. If no U.S. Marine Corps medical battalion companies are included, U.S. Marine Corps

stress casualties should be sent to the nearest U.S.

Army brigade, division, or area support clearing

company with combat stress control capability.
259

Combat Stress Control in Joint Operations

During a Major Buildup

The U.S. Army now has cargo ships with

preconfigured unit sets of equipment pre-positioned

strategically around the world. These are a seagoing version of the European theater’s “POMCUS”

(pre-positioned overseas material configured unit

sets) sites. The ships can sail to a suitable port at the

threatened host nation, to which the soldiers can be

flown from their units in CONUS. Other U.S. Army

units will load their heavy equipment onto fast

cargo ships at ports of embarkation in CONUS (or

Europe, as in the Persian Gulf War). The ships sail

to the theater, while the troops finish predeployment

preparation at home station and fly to the theater in

time to meet the ships at the port of debarkation.

U.S. Army transportation units have the mission

and equipment to unload these ships at the port. If

hostilities have begun, the port is likely to be the

target of a long-range missile, air, or terrorist attack,

adding to the stress of very long, hard working

hours in crowded spaces.

Initial U.S. Army units assembling at a seaport of

entry could utilize the combat stress unit of a U.S.

Air Force air-transportable hospital at the airfield.

Alternatively, they might utilize the medical collection and clearing company or surgical support company of a U.S. Marine Expeditionary Force if any of

those have been landed. Those facilities could have

the U.S. Navy psychologist and/or psychiatric

corpsmen. The U.S. Army contingent in the port

could eventually receive echelon II medical support

from a U.S. Army area support medical company,

which should have a 91G NCO and perhaps the

social worker or psychiatrist of the area support

medical battalion. These could also support the

U.S. Navy, U.S. Marine Corps, and U.S. Air Force

units.

Later in the buildup, U.S. Army troop units that

are landing from ships at a port of embarkation or

awaiting the arrival of their equipment by ship

could receive MH/CSC consultation and treatment

support from a nearby Fleet hospital if no U.S.

Army MH/CSC or combat support hospital

neuropsychiatric assets are available. In the Persian Gulf War, the fleet hospital in Bahrain did

provide the neuropsychiatric ward capability for a

nearby U.S. Army combat support hospital which

(having the pre-MedForce 2000 TO&E) had no organic mental health/neuropsychiatry personnel.

Conversely, a U.S. Army combat support hospital’s

neuropsychiatric ward and consult service could

care for U.S. Navy and U.S. Marines (and U.S. Air

Force) cases if no fleet hospital had arrived.

During Redeployment Home

Some U.S. Army combat service support units

may have to remain longer in the theater than other

units to load equipment on ships for transport home.

These units should be supported by U.S. Army

combat stress control teams, but could also be supported by personnel from the U.S. Navy fleet hospital if it has not already been redeployed. This will

work best if the fleet hospital neuropsychiatry personnel practice preventive outreach consultation.

Conversely, the U.S. Army combat stress control

teams could provide proactive prevention and treatment as needed by U.S. Navy dockside or shipboard personnel in the port, if the fleet hospital or

other U.S. Navy combat stress control is not available or needs reinforcement.

Joint SPRINT Operations

In peacetime or military operations short of war,

joint special psychiatric rapid intervention teams

may be hastily task-organized to support a major

U.S. Navy, U.S. Marine Corps, or U.S. Army reorganization/reconstitution support mission. For example, following the Iraqi Exocet missile attack on

the USS Stark, a joint U.S. Navy-U.S. Army team

was deployed to debrief surviving crew members.

Crew members were debriefed as they worked on

the damaged ship next to a tender at Bahrain. The

team consisted of U.S. Navy SPRINT personnel out

of Spain, plus members of a U.S. Army stress management team from 7th Medical Command, Europe. The U.S. Army team had had extensive experience in responding to terrorist and hostage

incidents. The activities of that joint team have been

published.7

JOINT OR COMBINED OPERATIONS OTHER THAN WAR

ing, humanitarian civil assistance (international

disaster relief), and nation assistance (public health,

engineering, and other projects) in which no combat is anticipated. Alternatively, the unstable situOverviewThe post-Cold War world will continue to call

upon the U.S. armed forces to conduct peacekeep-
War Psychiatry

260

ation may call for peace enforcement (“peacemaking”), noncombatant evacuation operations, or foreign internal defense training missions to countries

that are experiencing terrorism or insurgency warfare. In these situations, U.S. forces are at higher

risk of having to fire in self-defense, but with very

restrictive rules of engagement. While some of

these operations may be of brief duration and clear

objective, others may be greatly prolonged, with no

clear endpoint. Most such operations will be joint

operations, and many may be coalition operations

under multinational or United Nations auspices.

CSC Mission Priorities

The combat stress control mission in stressful

operations other than war (in usual order of priority

because of relevance) is to:

1. Prevent post-traumatic stress disorder

(PTSD). This is a risk for the service members who must encounter extreme human

suffering, victims of injustice or atrocity,

and perhaps confused combat under ambiguous, restricting rules of engagement.

Preventive activities are indicated routinely, because stress or PTSD symptoms

may not be evident at the time.

2. Prevent misconduct stress behaviors. Stressinduced misconduct can be due to tension,

high ambiguity of friend vs foe, reaction to

atrocities seen or casualties sustained, cultural friction, frustration, boredom, tedium, and let-down. There may be special

temptations for alcohol or drug abuse,

because of local availability, lack of routine urine screening as a deterrent, and

casual use of substances by coalition allies

or the local population. Unless prevented,

weakening discipline could escalate to use

of excessive force and even commission of

atrocities. Such misconduct would invalidate the humanitarian mission in the eyes

of the local population, the media, and

U.S. and world opinion. Because criminal

violation of the Uniform Code of Military

Justice and international law must be publicly investigated and punished, combat

stress control preventive advice to leaders

in how to recognize and defuse early signs

of stress is critical to success.

3. Prevent and treat (return to duty) battle fatigue or contingency fatigue. This is done in

the usual ways. In static operations other

than war, it is expected that most such

cases can be helped in their own units

while still on duty, or be rested for a day or

two in a nonmedical support element. Few

will normally need medical holding, and

very few should be evacuated.

4. Prevent, diagnose, stabilize, and evacuate or

return to duty any neuropsychiatric disorders

(environmental or substance-induced organic

ones, and the endemic functional disorders).

These may include cases with psychiatric

disorders who were on medication from

civilian sources without wanting it on their

military records. They may relapse when

supply runs out, or have medication side

effects aggravated by the local climate. If

feasible, they should be tapered off medication or shifted to drugs that can be continued safely in theater. In some soldiers,

the situations observed in the operation

may activate PTSD from prior combat,

childhood, or inner city experiences. If

PTSD is reactivated from prior traumatic

exposure it would be best to treat in the

theater, working through past and current

trauma simultaneously, if that is feasible.

CSC Staffing

The CSC support for an operation other than war

should be tailored to the specific mission, the expected stressors and the size and mix of forces

deployed. This will have to be determined by

experience and perhaps at first by trial and error.

For instance:

Vignette 1: Sinai peacekeeping missions involve about

1,000 U.S. troops in a multinational coalition on 6-month

rotations in desert observation. Conditions are stable,

with no combat, but occasional accidental injury or deaths

occur. While no mental health support is required, having

a mental health/combat stress control NCO, an officer or

an officer/NCO team on site significantly reduces problems in the unit. These personnel are frequently requested by command. Social workers, psychologists,

psychiatrists, occupational therapists and 91G behavioral

science NCOs have filled these assignments.

Vignette 2: Medical support for U.N. peacekeeping

troops in Croatia involved a U.S. mobile army surgical

hospital (MASH) augmented with a social worker/91G

team, located in Zagreb. These provide MH/CSC services to sick, injured, or wounded peacekeepers from

many countries, often working through translators. They

also support the hospital staff and cooperate with allied

(British, Dutch) mental health personnel. A 50-bed U.S.
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Combat Stress Control in Joint Operations

Air Force air-transportable hospital staff replaced the U.S.

Army MASH in the rotation plan. Six months later, staff

from a U.S. Navy fleet hospital took over the facility,

including a psychiatrist, psychiatric nurse, and psychiatry

technicians.

Vignette 3: Operation Restore Hope in Somalia was

initially “front-end loaded” to support about 28,000 troops

with a U.S. Army light infantry division’s mental health

section of a psychiatrist, social worker, psychologist and

several 9lGs supporting one brigade (plus) at several

locations; a U.S. Army medical group headquarters with a

social worker, psychologist, and 91G; a U.S. Marine

Corps medical battalion (minus) with a filler U.S. Navy

psychiatrist, psychologist, and corpsman. No shipboard

mental health neuropsychiatric personnel were involved.

A U.S. Army medical combat stress control detachment’s

preventive section with three psychiatrists, three social

workers, and six 9lGs (social work technicians), was

deployed. A U.S. Army combat support hospital (minus)

with a psychiatrist, psychiatric nurse, and two 9lFs (psychiatric ward aids) was also deployed. No U.S. Air Force

mental health personnel were deployed to Somalia with

the U.S. Air Force’s MASF team. A 50-bed air-transportable hospital with a social worker supported the staging

facility at Cairo West, Egypt.

The various elements coordinated activities to provide

mental health outpatient and brief inpatient therapy, mobile preventive consultation and education, and critical

event debriefing (CED). The CEDs followed deaths of unit

members, deaths of Somali civilians under stressful circumstances, and other highly traumatic events. The U.S.

Army CSC teams debriefed U.S. Marine Corps companies following two combat deaths and a suicide. (They

also debriefed an Australian unit following a death by

accidental weapons discharge.) They provided consultation to the U.S. Air Force AeroMedical Evacuation Squadron.

As the situation in Somalia became clearer, the U.S.

Navy/U.S. Marine Corps and the U.S. Army Medical

Group quickly sent their mental health personnel home.

The U.S. Army division mental health section and combat

stress control detachment sent their personnel home later

by increments, each replacing them eventually with one

social work officer each and one 91G each as the force in

country sank below 4,000. The U.S. Army combat support

hospital neuropsychiatric section rotated home with the

hospital, being replaced by a field hospital with no mental

health/neuropsychiatric personnel.

Vignette 4: Operation Continue Hope (in Mogadishu,

Somalia under United Nations auspices) began with the

two U.S. Army social workers and two 9lGs as above,

supporting 4,000 U.S. Army troops plus a few U.S. Marines, U.S. Air Force, and U.S. Navy personnel in the U.N.

headquarters. The division social worker was then recalled home on compassionate grounds.

The combat stress control detachment social worker

and 91G worked out of the field hospital, providing case

evaluation and treatment plus active preventive education and critical event debriefing to units. Workload

increased as ambushes caused mass casualties among

the coalition allies and sporadic injuries and eventually

deaths to U.S. service members. Nocturnal mortar and

rocket attacks also harassed the five United Nation’s

cantonment areas in the city. The combat stress control

officer also assisted with debriefings and prebriefings of

the Swedish hospital’s personnel, and of coalition wounded

at the U.S. Army CSH.

Efforts to reinforce the combat stress control detachment officer and NCO rapidly with an occupational therapist and NCO were frustrated. Eventually, after 3 months,

the combat stress control detachment team rotated, replaced by two social workers and two 9lGs, while fighting

and U.S. casualties continued to escalate. The 10th

Mountain Division replaced its one 91G with two. The new

U.S. Army combat stress control team later provided

training and debriefing supervision to the U.S. Navy corpsmen supporting a 50-man U.S. Marine Corps detachment

at the United Nations headquarters after three U.S. Marines were wounded and a Somali interpreter was killed by

a command-detonated mine. There were still only the two

U.S. Army mental health social work officers and three

9lGs in Somalia when U.S. casualties escalated markedly

in early October 1993, followed by a rapid U.S. Army troop

buildup. These worked as best they could to provide

mobile, preventive consultation and debriefings until rotating home late in the withdrawal of U.S. troops.

Lessons Learned from Recent Experience

1. Joint coordination in planning total combat stress control staffing capability in theater can be improved.

2. It is relatively easy to “front end load”

MH/CSC personnel into operations other

than war, when the combat arms aren’t

dictating that their personnel and warfighting logistical needs require all the

transport capability.

3. It is relatively easy to send people or increments home early.

4. It may be almost impossible to reinforce

the theater rapidly with more CSC assets

(at least by the U.S. Army). Therefore

don’t send too much home too soon.

5. U.S. Army CSC detachments can be deployed in increments and maintain a rotation schedule. There is still resistance

(prejudice) against sending occupational

therapy and psychiatric nursing expertise

on CSC missions, which must be overcome.

6. Preventive workload estimate is that there

should be no less than two MH/CSC officers and two NCOs for a brigade-sized

(joint) force; and sufficient officer/NCO
War Psychiatry

262

teams to visit each company-sized unit

(approximately 100 men) for 1 hour weekly,

and more often and longer when critical

event or end-of-tour debriefings are

needed.

Joint Special Operations

Overview

Special Operations Forces prepare for and support battle in all levels of open conflict. They also

play a major role in military operations other than

war, including nation assistance (“building”) and

humanitarian civil assistance, disaster or refugee

relief, counternarcotics, counterterrorism, intelligence gathering, peacekeeping/peacemaking,

search and rescue (open and covert), strikes and

raids, and noncombatant evacuation operations.

While some of these operations may be well-publicized after the fact, most of them (and especially the

Special Operations aspects of them) generally keep

a low profile and avoid attention. Some are covert,

and some are deeply covert.

Special Operations Forces

The U.S. Army has Special Operations Forces

ranging from the well-known Airborne Ranger Battalions and the Special Forces (“Green Berets” of the

1960s) to the secretive but highly publicized Delta

Force (counterterrorist team), the Psychological

Operations (PSYOPS) units which provide printing

and broadcasting capability, the Civil Affairs units,

Long Range Surveillance Companies, and a special

helicopter aviation unit. The U.S. Navy has the

SEALs, and the U.S. Marines have Force Recon. The

U.S. Air Force has Special Operations Forces aviation units. There may be other military and government intelligence and covert operations units whose

very existence is a secret.

Mental Health Capability in Special Operations

Forces

Because of the strict requirement for secrecy,

Special Operations Forces (SOF) units have their

own psychologists and perhaps other mental health

personnel, who also avoid publicity. The psychologists have an important role in screening applicants

for suitability for special operations, monitoring

the high stress training and selection process,

and providing ongoing personnel reliability and

readiness-for-duty evaluations. They may debrief

SOF teams after critical events. Many of these tasks

cannot be done by regular MH/CSC personnel

who lack the necessary organizational trust and

security clearances. The SOF MH personnel presumably also provide or arrange mental health psychiatric treatment for whatever neuropsychiatric disorders arise among their highly selected

but highly stressed and somewhat atypical populations. The families of the SOF personnel (and SOF

personnel in nonsensitive positions) are presumably cared for by the routine mental health/medical

system.

Contact Between Special Operations and Conventional MH/CSC

In deployments and combat, Special Operations

Forces personnel can develop disabling battle (conflict) fatigue, misconduct stress behaviors, posttraumatic stress disorders, and stress-induced

functional or organic neuropsychiatric disorders.

They may then be brought to conventional MH/

CSC personnel or facilities because they need urgent management or care, and the few Special Operations MH/CSC personnel are not immediately

on hand. Wounded or sick Special Operations Forces

personnel will usually be evacuated through

conventional channels. This can create a problem

for those in highly covert units because they

and their organizations go to great lengths to maintain secrecy (even to the extent of deleting the

cases from the medical record and patient flow

statistics).

The conventional MH/CSC clinician (U.S. Army,

U.S. Navy, or U.S. Air Force) could find himself

trying to diagnose whether the service member

who refuses to tell him anything about himself or

his unit (or who is rambling deliriously about his

“secret mission”) has a paranoid or grandiose delusion, is deliberately faking for personal reasons or

to get over on the system (malingering), or really

does belong to the Special Operations Forces. The

answer may not be easy to get quickly.

If the latter case is true, it would be best to get the

service member back under the care of Special Operations Forces specialists. Like the downed U.S.

Air Force, U.S. Navy, or U.S. Army pilots who are

best returned to their own roots, the return to the

Special Operations Forces environment may be more

therapeutic than keeping the case further forward

among strangers. This may be a situation where

SOF-trained MH/CSC personnel of a different service could be more effective than non-SOF personnel of the same service.
263

Combat Stress Control in Joint Operations

For less dramatic SOF cases that qualify as routine battle (conflict) fatigue, the Five Rs should still

work to get the service member back to his own

forward-deployed unit in 1 to 3 days. The primary

modification would be not to push the debriefing

phase to the point of describing a secret mission

in great detail. The main effort is to restore and

build on the SOF ethic of resilience and elite reputation. Because of that SOF elite identity, SOF personnel may be more likely to present with the loss

of physical abilities forms (somatoform disorders)

of battle fatigue than with the overtly emotional

forms. This adds to the problems of differential

diagnoses.

Joint Prisoner of War or Hostage Repatriation

Prisoner or hostage repatriation is often a joint

operation. The prisoners of war (POWs) may come

from two or more services. The U.S. Air Force is likely

to fly the survivors from their release point to one of

the service’s hospitals for a thorough physical examination and treatment of any injuries or illnesses.

There, they will be subjected to intensive intelligence debriefings whose primary purpose is to document facts about their captors and captivity. They

will also be the subject of intensive media interest

and perhaps interviews. Their families may also be

involved in the nationwide or worldwide attention

and may be flown to the medical facility.

U.S. Army stress management teams have had

extensive experience in hostage release scenarios,

such as:

• A cruise ship and airliners briefly seized by

terrorists (with loss of life).

• Military and civilian embassy personnel held

by Islamic fundamentalists for over a year.

• Individual hostages held for years under

extreme hardship and deprivation.

• POWs repatriated at the end of the Persian

Gulf War.

The stress control challenge in this hectic process

is to provide therapeutic critical incident stress

debriefing (CISD) and reunion assistance in the

midst of conflicting demands while minimizing

secondary trauma from the repatriation process

itself. The principles of PIES apply. Contact with an

MH/CSC team should begin as far forward as possible. Ideally, the same MH individuals will travel

back with the victims to complete the process. If

that is not possible, the “hand off” to a second team

should be clear and positive to the victims. Joint

coordination and participation in this process is

essential.

This chapter has thus far discussed various administrative structures and programs to prevent

and treat psychiatric casualties. A main theme has

been that unit troop morale and cooperative coordinate interservice efforts are critical in both prevention and treatment of combat stress reactions. Chapter 16 provides additional information regarding

interventions with POWs.

Civil Disaster Relief and Civil Disturbance

Response

Similar cooperation between military and civilian agencies is seen in disaster relief efforts. National Guard units (U.S. Army, U.S. Navy, U.S.

Marine Corps, and U.S. Air Force) have often been

called up by their state governors to maintain law

and order and provide emergency medical and engineer support following natural disasters. Experience after Hurricanes Hugo and Andrew suggests

that the active component of military services will

also be increasingly called upon to provide quick

and massive response following major disasters in

the United States.

Case Study 4: Hurricane Andrew

After Hurricane Andrew (1992), a joint task force (JTF)

was given extensive responsibility for coordinating and

implementing emergency relief and cleanup activities. It

included active component U.S. Army divisional and corps

assets, U.S. Marine Corps units, U.S. Navy ships, U.S. Air

Force aircraft, and ground personnel. The mission included setting up and running tent cities to house and feed

homeless victims, and clearing wreckage to restore essential infrastructure, providing medical and preventive

medical support. All of this was in complicated relationship to state, local, volunteer, and other federal agencies,

the media, and the victims themselves.

The U.S. Army medical brigade commanded the medical task force. It requested and received an experienced

neuropsychiatry consultant. U.S. Army division mental

health section personnel from three divisions deployed

with their division units to the disaster area with the

following functions:

• To provide stress control support to the corps-level

units along with those of their divisions.

• To train U.S. Army personnel who were canvassing

areas block-by-block to identify potential mental

health problems and cases.

• To relay this information every evening from the

medical brigade to the state mental health authorities who directed civilian mental health teams to fill

the need.
War Psychiatry

264

A U.S. Navy SPRINT team was initially requested by

the U.S. Coast Guard to provide critical incident stress

debriefing to U.S. Coast Guard families, and later it

became a joint task force resource. U.S. Air Force stress

teams deployed to assist at Homestead Air Force Base

which was heavily damaged by the storm, but did not later

join the JTF. U.S. Army combat stress control personnel

from a corps-level detachment were standing by to deploy

but were not required as civilian mental health assets

became available. U.S. Army Reserve combat stress

control units were also preparing to send volunteer teams

on temporary tour active duty if called upon. (A U.S. Army

Reserve combat stress control company did activate 12

persons to assist the Red Cross at refugee shelters

following the January 1994 Los Angeles, California earthquake. The organizational, cross-cultural, and language

skills of the U.S. Army reservists proved especially helpful.)

Comment: The JTF that responded to Hurricane Andrew provided a coordinated response, in conjunction

with the efforts of the civilian community, to alleviate the

various hardships that survivors were experiencing. These

responses lessened long-term problems for these communities.

Mass Casualty Disasters

In a disaster that kills and injures thousands, as

well as devastating property, additional military

mental health/combat stress control would be

needed as follows:

• To provide or supervise stress debriefing

and follow-up of the service members who

are pulling the bodies of living and dead

from the ruins and providing emergency

care.

• To provide combat stress control support to

mobilized service members (especially those

in the local National Guard units) whose

own families are in the disaster area, and

whose fates may be unknown for some time.

• To assure stress control support to those

service families, once located.

• To coordinate the military effort with the

many other agencies and resources.

Effective coordination under high stress conditions is the key to success. U.S. Army corps-level

combat stress control detachments and companies

(both active and reserve components) should have

this as a contingency mission with written standard

operating procedures.

In a major mass casualty disaster that devastated

all medical facilities over a large area, U.S. Air Force

area theater hospitals and contingency hospitals,

U.S. Army medical companies and CSHs, U.S. Marine Corps surgical support companies (SSCs), and

perhaps U.S. Navy Hospital ships might also be

deployed, bringing their additional neuropsychiatric/mental health personnel.

While physical trauma cases may have to be

evacuated some distance for definitive surgery, any

civilian stress cases (and secondary military ones)

should be kept close to their homes or displaced

families (or their units). As with battle fatigue,

these cases need to be treated according to PIES and

the Five Rs in a non–patient-care atmosphere.

Recovery of Dead Human Bodies

One mission that is common across the services,

in war and in many operations other than war, is the

requirement to recover and process dead human

bodies. These may be the bodies of fellow service

members, perhaps even personal friends. They

may be the bodies of enemies killed in combat,

either by oneself or by other combat forces. They

may be civilians, including children, adult men and

women, and elderly people with whom one naturally identifies and empathizes. The number of

bodies may range from intimately few to appallingly

many. Depending on the cause of death, time

elapsed, and weather, the state of the bodies may be

grossly mutilated and decomposed (as in the

Jonestown massacre) or unnervingly intact and

seemingly unharmed (“as if only asleep”). The

sights and smells (and perhaps touch) in the work of

processing human bodies invoke an arguably innate horror and revulsion, especially on first exposure. Prolonged exposure may produce cumulative

horrors or a numbing of all feeling. The intense

sensory experiences, often combined with emotionprovoking thoughts, can form extremely vivid, painful memories that become the seeds of post-traumatic stress disorder.

Extensive studies have been conducted on military and civilian units that were unexpectedly required to recover human remains, and on mortuary

affairs personnel and other specialists who process

human remains on a routine basis.8,9 Even the latter

can be adversely impacted by special individual

bodies or by mass casualties. The research has

focused on what specific aspects of the task cause

the greatest distress. It has recorded the ways that

those recovering and processing the bodies have

found to protect themselves. Exhibit 10-1 summarizes and condenses recommendations from a number of sources, most notably McCarroll et al8 and

Ursano and McCarroll.9 This was prepared in pocket
265

Combat Stress Control in Joint Operations

EXHIBIT 10-1

WHEN THE MISSION REQUIRES RECOVERING DEAD HUMAN BODIES

HOW TO PREPARE YOURSELF, YOUR BUDDIES, AND THE UNIT

THE MISSION

One consequence of many humanitarian and peace support missions, as well as of war, is coming in contact with bodies which have died under

tragic or horrible circumstances. All soldiers, in all types of units, may be assigned the mission of recovering, processing and perhaps burying

human remains.

– We may collect the bodies of fellow service members so that the Mortuary Affairs specialists can return them to the United States for

identification and burial.

– We may gather and perhaps bury the bodies of enemy or civilian dead, to safeguard public health.

– The numbers of dead may be small and very personal, or they may be very, very large.

– The victims may include service members much like ourselves, or young men and women, elderly people, small children and infants

for whom we feel an innate empathy.

– Being exposed to children who have died can be especially distressing, particularly for individuals who have children of their own.

Extensive experience has been gained during such missions, and in working with the body recovery teams afterwards to help them cope with

the memories. This experience can help you, your buddies and your unit take such a difficult mission in stride. You can complete the mission

proud of what you have done, and return to your usual duties, career and family life without being unduly troubled by the memories, even

when those memories include some very sad, unpleasant or distressing details.

WHAT TO EXPECT

Some body recovery missions involve situations where there are no living survivors. Other situations are in concert with ongoing rescue,

emergency medical care, and survivor assistance activities. In the latter case, the reactions of the living victims may include grief, anger,

shock, gratitude or ingratitude, numbness or indifference. Such reactions may seem appropriate or inappropriate to you, and may interact

with your own reactions to the dead.

In some situations, the bodies may be distorted or mutilated. Seeing mutilated bodies invokes an innate horror in most human beings,

although most of us quickly form a kind of tough mental “shell,” so that we won’t feel so badly. To some extent, we come to see the remains

simply as objects, without reflecting that they were once people.

– The dead bodies may be wasted by starvation, dehydration, and disease (eg, Rwanda refugees or some POW and concentration

camp victims).

– They may have been crushed and dug out from under rubble, (eg, the Beirut barracks bombing or earthquake victims).

– They may be badly mutilated by fire, impact, blast or projectiles (eg, the victims of the air crashes at Gander, Newfoundland, and

Sioux City, Iowa; the civilians killed by collateral damage and fire near the Commandancia in Panama City, or the Iraqi army

dead north of Kuwait).

– They may be victims of deliberate atrocity (eg, the Shiites of south Iraq, or any side in Bosnia).

Sometimes, however, the cause of death leaves few signs on the bodies (eg, the mass suicide with cyanide at Jonestown, Guiana [South

America], or victims drowned in floods). The caregivers often say this is harder to adapt to, because it is harder to form that “shell.”

Of course, the degree of decomposition of the bodies will be determined by the temperature and climate, and by how long it has been before

you can reach them and begin collection.

In addition to seeing mutilated or nonmutilated bodies, you will often have to smell the bodies and other associated strong odors. You may

have to touch the remains, move them, and perhaps hear the sounds of autopsies being performed, or other burial activities. These sensations

may place a strain on your capacity to do the work, and may trouble you in memories. We will list below things you can do to help this.

Being exposed to large numbers of dead bodies is not a normal part of human experience. Therefore, when you are exposed to bodies, you

should not be surprised to be feeling things you are not used to.

• When you are exposed to bodies, you may experience sorrow, regret, repulsion, disgust, anger, and futility. REMEMBER, THESE ARE

NORMAL EXPERIENCES GIVEN THE SITUATION IN WHICH YOU HAVE BEEN PLACED.

In fact, it would be surprising if you did not have at least some of these emotions.

• You may start to see similarities between yourself (or others you love) and those who have died. This could lead to feelings of guilt

(“Why wasn’t it me?” or “Why can’t I do more to stop it?”) or anxiety (“It could have been me”). Again, these feelings are NORMAL

given the situation.

• Humor is a normal human reaction or “safety valve” for very uncomfortable feelings. In body handling situations, it naturally tends

toward what is aptly called “graveyard humor.” Don’t be surprised at finding this in yourself or others.

GUIDELINES FOR HOW TO WORK WITH HUMAN REMAINS

Prepare yourself, as much as time and access to information allows, for what you will be seeing and doing. It is better to be prepared for the

worst and not have to face it than to be underprepared.

• Learn as much as you can about the history, cultural background, and circumstances of the disaster or tragedy. How did it come to

happen? Try to understand it the way a historian or neutral investigating commission would.

• Look at videos and photographs of the area of operation and of the victims. The television news networks and news magazines may

be sources. If pictures of the current situation are not available, look up ones from previous similar tragedies in the library archives.

Share them as a team, and talk about them.

Understand the importance and value of what you are doing.

• Remember that you are helping the deceased to receive a respectful burial (even if in some cases, it must be a hasty and mass burial).

You are saving their remains the indignity of simply being left on the ground to decay.

• In some cases, you are helping survivors know their loved ones have died, rather than remain for years in uncertainty. Those relatives

or friends can then take the bodies for private burial, or at least know where they are buried.

• By collecting or burying the bodies of those who have already died, you are providing a safer, healthier environment for those

individuals still living.
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When you are seeing or working with the bodies, think about the larger purpose you are serving, without attempting to relate to each

individual who has died. By not focusing on each individual, you will be able to do your important job more effectively.

• Remember that the body is not the person, but only the remains.

• Some people who have done this important work have found it helpful to think of the remains as wax models or mannequins (as if in

a training exercise), or as memorial models to which they were showing the respect due to the original person who was no longer there.

• If your job requires you to collect personal effects from the bodies for identification, intelligence or other official purposes, do not let

yourself look closely at or read those personal effects. (The people who need to examine those effects are advised to do so remote from,

and preferably without having seen, the body.)

• Needless to say, do not desecrate or take souvenirs from the bodies. Those are criminal acts.

• Humor, even graveyard humor, is helpful if it remains on a witty and relatively abstract level. It is unhelpful when it becomes too gross,

too personal (eg, comments or practical jokes which pick on members of the team who need support, not ridicule), or too disrespectful

of the individual dead. Some members of the team may become upset at excessive graveyard humor, and even the joker may remember

it with guilt years later.

• Each of you can say prayers for the dead, and conduct whatever personal ceremonies your own beliefs and background recommend.

The unit chaplain and/or local clergy may also conduct rites or ceremonies. Even very brief rites at the time can help, perhaps to be

followed by larger, formal ceremonies later.

Take steps to limit exposure to the stimuli from the bodies.

• Have screens, partitions, covers, body bags or barriers so that people don’t see the bodies unless it is necessary to their mission.

• Wear gloves if the job calls for touching the bodies.

• It may help to mask the odor with disinfectants, air-fresheners, or deodorants in some locations. Using other scents such as perfume

or aftershave lotions is of limited value in the presence of the bodies, and is perhaps better saved for when taking breaks away from

the work area. Don’t be surprised if the scents bring back memories of the experience for a while thereafter.

Take care of yourself and each other.

• When the mission allows, schedule frequent short breaks away from working with or around bodies.

• Drink plenty of fluids, continue to eat well, and especially maintain good hygiene. To the extent possible, Command should assure

facilities for washing hands, clothing, and taking hot showers after each shift. (If water must be rationed, Command should make clear

what can be provided and how it should be used and conserved.)

• Hold team after-action debriefings frequently to talk out the worst and the best things about what has occurred, sharing thoughts,

feelings and reactions with your teammates.

• A mental health/stress control team or chaplain may be able to lead a Critical Event Debriefing after a particularly bad event or at the

end of the operation.

• Plan team as well as individual activities to relax and get your mind off the tragedy you are helping to correct. Do not let yourself feel

guilty about this, or about not being able to fix all the tragedy immediately. YOU MUST PACE YOURSELVES FOR THE TASK, AND

DO WHAT CAN BE DONE WITH THE RESOURCES AVAILABLE, ONE STEP AT A TIME.

• Stay physically fit.

• Keep your Unit Family Support Group fully informed about what is happening, and make sure your family members and significant

others are included in and supported by it.

• Take special care of new unit members, and those with recent changes or special problems back home.

If the stress caused by working with the dead bodies begins to interfere with your performance or your ability to relax, or if you feel that you

are becoming overwhelmed, TAKE ACTION. Do not ignore the stress.

• Seek out someone to talk with about how you are feeling. This might be a buddy or someone else. Other people are likely to be feeling

the same things you are. The important thing is not to withdraw from others and become isolated.

• The unit chaplain, medic, or a combat stress control/mental health team member can often help.

Likewise, it is important to help your buddy, coworker, subordinate or superior if he or she shows signs of distress.

• Give support and encouragement, and try to get the other person to talk through the problems or feelings that they are having. By

working with each other, you both will be better able to cope with the situation in which you must work.

After you have completed your mission and are no longer working around the bodies, you may experience a variety of feelings. These may

include feeling bad about not treating each body as an individual, and needing to express the emotions that were pent up while you

were doing the work of body recovery. DO NOT KEEP THESE EMOTIONS INSIDE. They are normal, and are best worked through

by talking with your fellow unit members.

• Take an active part in an end-of-tour debriefing and pre-homecoming information briefing within your unit prior to leaving the

operational area.

• Follow through with Family Support Group activities which recognize and honor what the unit has done and shares the experience

(and the praise for a hard job well done) with the families.

• Don’t be surprised if being at home brings back upsetting memories from the operation. You may find it hard to talk about the

memories with family or friends who weren’t there. This is very common. Try to talk about them anyway. Also stay in touch with

your teammates from the operation.

• If you still find yourself upset, don’t hesitate to talk with a chaplain or with the community mental health or stress control team in your

area. This is just wise preventive maintenance.

Reprinted from Combat Stress Actions Office; HSHA-PO, Department of Preventive Health Services, AMEDD Center and

School, Fort Sam Houston, Texas 78234-6142.

EXHIBIT 10-1 (continued)
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Combat Stress Control in Joint Operations

card format for the Rwanda refugee relief mission.

The card was subsequently used by the commander

of the second of two National Guard medical companies activated and deployed to conduct body

recovery and processing at a civil airline crash site

and nearby armory. In initial follow-up, the company reported that the recommendations had proved

very helpful. The first National Guard medical

company deployed to the same site had not had the

card, and within a month of demobilization it had

made seven referrals for treatment of PTSD. Follow-up of both companies is continuing.

for U.S. Army mental health staff sections of

major command or medical command headquarters, medical brigade (combat zone and

communications zone), and medical group.

• Coordination must be actively considered

and, when feasible, be accomplished by the

mental health section or neuropsychiatric

ward/section of U.S. Army divisions (mental health section of main support medical

company or medical battalion); U.S. Marine

Corps divisions (psychiatrist of division HQ,

psychologist of surgical support company);

U.S. Air Force tactical (air-transportable)

hospital (combat stress unit); area support

medical battalion (MH Section); U.S. Army

medical CSC companies and detachments;

U.S. Army combat support, field, and general hospitals; U.S. Air Force contingency

hospitals; U.S. Navy field hospitals; and

U.S. Navy hospital ships.

Initiative at the Operator Level. In the spirit of

joint operations, direct coordination between junior MH/CSC officers and NCOs in the theater of

operations should be actively encouraged by all

higher headquarters. The MH/CSC personnel at

the operator level should take the initiative to make

such contacts even in the absence of coordination

from higher echelons. They should, of course, inform their higher HQ of all such contacts as soon as

possible.

Conferences and Symposia. When the tactical

situation allows, formal conferences or symposia

should be scheduled to bring together representative MH/CSC personnel from all the services in the

theater of operations (plus allies and the host nation) to share their experiences. Joint participation

should also be actively sought in peacetime conferences and continuing health education courses.

Doctrine Development. In preparation for joint

contingencies, doctrinal material on joint CSC operations should be drafted, staffed through all necessary channels, and incorporated into the relevant

The U.S. Army, U.S. Air Force, U.S. Marine Corps,

and U.S. Navy are all working to improve their

capability to prevent stress casualties across the

continuum of operations. Their efforts are directed

toward providing immediate intervention close to

the battle or high-stress activity and the service

members’ units. The organizational and written

doctrine are still evolving, but all recognize and

adhere to the basic time-proven principles. Because

cooperation and coordination are the guiding principles of combat stress control, the following actions should be taken to achieve an effective Joint

Operations CSC capability.

Joint Coordination. For any joint operation,

combat stress control (neuropsychiatric, mental

health) personnel from each service should seek out

and coordinate with their counterparts in the other

services. The following actions should occur:

• Coordination should be initiated by the joint

command staff early in the contingency

planning and operations. Each joint command surgeon should have triservice

(multidisciplinary) CSC consultants. These

should be on staff or available by telecommunication or temporary duty, even in operational security (OPSEC) situations.

• Each service should be encouraged to deploy sufficient MH/CSC personnel to support its own major contingent.

• Arrangements should be made for MH/

CSC backup from other services to support

small elements that do not bring their own

CSC assets.

• All headquarters and MH/CSC personnel

being deployed should be informed about

all the other CSC personnel on the way as

quickly as possible (consistent with operational security).

• Coordination should be continued and fostered by the joint headquarters during mobilization and deployment.

• Coordination must be an important mission

RECOMMENDATIONS
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manuals and training programs of all services. Joint

CSC involvement should be practiced whenever

possible in field exercises and training deployments.

The lessons learned in these, and in true contingency deployments, should be systematically staffed

and incorporated into the evolving doctrine.

Periodically, the lessons learned from recent conflicts are reviewed to facilitate doctrine development and more productive operations in the future.

Such reviews commonly consider the substantial

logistical assets, including medical services, in a

combat zone. The usual rationale for the establishment of medical assets (aside from moral and morale considerations) has been that returning medically noneffective service members to duty is the

most efficient way to mitigate losses due to attrition, that is, to conserve the fighting strength.

Conventional medical support in the theater of

operations, however, is a substantial undertaking—

the hospitals are heavy, require huge spaces, and are

difficult to move; they are staffed by a large number of

personnel; and they have extensive requirements for

food, fuel, and unique equipment and supplies not

usable by any other component of the deployed force.

Thus their setup occupies significant quantities of

personnel, space, time, and “lift.”

The most likely future war-fighting scenarios for

the U.S. military describe discrete combat actions of

strictly limited duration fought by small elite forces.

Only a small portion of the full spectrum of medical

support is likely to be available at the onset of an

unexpected war, or an operation other than war,

that is likely to be of short duration. Furthermore,

in these future scenarios, few service members who

become medically noneffective for more than 1 to 3

days are likely to return to duty before the fighting

ends and the unit withdraws. Thus, there is little

need, from the viewpoint of many in the line, to

establish extensive medical support in the combat

zone for the purposes of returning medically noneffective service members to duty.

A possible medical operational scenario following from these scenarios would be to immediately

evacuate all service members who become medically noneffective to existing bases outside of CONUS or to CONUS where they would be treated.

The only service members who would receive medical treatment in the combat zone would be those

with critical injuries who would not survive evacuation. Small, rapidly deployable surgical hospitals

would be available to provide resuscitative surgery. What little additional medical support present

in the combat zone would be at the unit level and

except for treating the most minor medical and

surgical problems, would be used for triage and

preparation for evacuation. Almost all of the conventional third echelon medical support would be

absent.

These review processes periodically suggest that

mental health personnel not be deployed for supposedly brief combat scenarios and that any combat

stress casualties and lightly injured casualties be

rapidly evacuated from the combat zone, perhaps

as far as CONUS. In such scenarios, service members manifesting combat stress reaction would not

be kept at the unit level as required by existing

doctrine but would be evacuated. The proponents

of such scenarios maintain that although less than

optimal from the standpoint of the current tenets of

military psychiatry, the number of such service

members expected would be minimal; first, because

only elite units, the members of which seem to have

a greater tolerance to combat stress, will be deployed, and second, because the expected duration

of combat will be short.

There are substantial fallacies in this argument.

First, the mental health personnel who are organic

or attached to the critical combat and combat support units can be crucial in their primary mission of

helping leadership sustain and enhance combat

performance. They will exercise primary prevention by reducing the negative impact of stressors

and by prophylactic debriefings to minimize PTSD

and other post-deployment difficulties. These delayed problems can occur in service members who

show no dysfunction during the operation. Avoidable attrition of combat-experienced service members, due in part to post-traumatic stress, was observed following the successful 1983 Grenada and

1989 Panama operations (see Chapter 1, Psychiatric

Lessons of War). The mental health personnel in

theater will also exercise secondary prevention by

enabling temporarily overstressed service members to regain optimal effectiveness without leaving

their tactical teams or their organic combat service

support elements. There the overstressed service

member is aided by his own buddy, immediate

leader, medic, chaplain, or a general medical professional. These helpers must receive technical

supervision and mentoring from a mental health

officer or NCO. Mental health expertise is required

to triage and make initial interventions in some

cases. In a pinch, the battalion surgeon, if already

well-mentored and knowledgeable, can subsume

the mentoring role. The service members who are

restored to effectiveness in this manner within their

own units never become medical casualties because

they are not absent from duty.
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Combat Stress Control in Joint Operations

Secondly, some overstressed service members

will require 1 to 3 days of restoration activities

before return to their units. It must be emphasized

that these combat stress cases, although casualties

because they are temporarily absent from their units,

are not medical patients. The forward-deployed

mental health personnel will perform neuropsychiatric triage to identify and stabilize the small

number of true neuropsychiatric patients for prompt

evacuation. Of major significance to the issue of

deployment of assets in a theater of operations, the

support for combat stress casualties is minimal: a

sleeping bag, MREs, and a trained helper. These

stress casualties can be temporarily assigned to a

combat service support unit, if no level II medical

company is suitable. At the combat service support

unit, these stress casualties remain under the technical supervision of mental health personnel or the

CSC team. This practice is in accordance with the

doctrine of some North Atlantic Treaty Organization (NATO) countries. Years of hard experience

have confirmed the importance of not evacuating

overstressed (or minimally injured) service members from the theater without a brief (1- to 3- day)

period of restoration. The restoration program poses

minimal logistical burden beyond the subsistence

of the participants who pay for their keep by performing necessary labor. The entire program is

deliberately not medical, and has no necessary relationship with large hospitals.

Finally, and most importantly, any behavior that

allows an honorable exit from combat can become

an evacuation syndrome, no matter how elite the

troops. In addition, combat stress casualties would

likely occur in greater numbers in combat support

troops, which are necessary to any deployment, as

was seen in the 1973 Yom Kippur War, the 1982

Lebanon War, and the 1989 invasion of Panama.

Lightly wounded casualties react much the same as

combat stress casualties when evacuated. The point

most often overlooked by the line, and by many in

the medical profession, is that nonevacuation of

combat stress casualties is the treatment. An evacuated combat stress casualty may become a chronic

mental cripple. His best chance for recovery is in

the early proper management of the syndrome.

Any proposed deletion of psychiatric support

brings to mind the World War II psychiatrically

disastrous early North African campaign. A few

brief battles resulted in large numbers of psychiatric casualties, many of whom were evacuated to

CONUS to fill VA hospitals for years after the war

ended. Such a policy, seemingly compassionate, is

medically inhumane.

CONCLUSION

The U.S. Army, U.S. Air Force, U.S. Marine Corps,

and U.S. Navy are all working to improve their

capability to prevent stress casualties. Their efforts

are directed toward providing immediate intervention close to the battle and the service members’

units. The organizational and written doctrine are

still evolving, but all recognize and adhere to the

basic time-proven principles.

REFERENCES

1. US Department of the Army. Operations. Washington, DC: DA; 1993. Field Manual 100-5.

2. US Department of the Army. Health Service Support in the Theater of Operations. Washington, DC: DA; 1 March

1991. Field Manual 8-10.

3. US Department of the Army. Combat Stress Control in a Theater of Operations. Washington, DC: DA; 29 September

1994. Field Manual 8-51.

4. US Department of the Air Force. U.S. Air Force Combat Psychiatry. Washington, DC: USAFSAM-TR-85-83;

January 1986.

5. Pierce MI. Personal Communication, 1992.

6. Dinneen M. Interventions aboard the Iwo Jima following a fatal boiler explosion. In: Belenky GL, Martin JM,

Sparacino LR, eds. The Shield in the Storm: Mental Health Operations During the Persian Gulf War. Westport, Conn:

Greenwood Press; in preparation.
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7. Sokol RJ. Early mental health intervention in combat situations: The USS Stark. Mil Med. 1989;154(8):407–409.

8. McCarroll JE, Ursano RJ, Wright KM, Fullerton CS. Handling of bodies after violent death: Strategies for coping.

Am J Orthopsychiatry. 1993;63:209–214.

9. Ursano RJ, McCarroll JE. Exposure to traumatic death: The nature of the stressor. In: Ursano R, McCaughey B,

Fullerton C, eds. Individual and Community Responses to Trauma and Disaster. New York: Cambridge University

Press; 1994: 46–71.