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U.S. Naval Combat Psychiatry

Chapter 9

U.S. NAVAL COMBAT PSYCHIATRY

INTRODUCTION

Naval Mission

Naval Organization

Naval Medicine

Naval Psychiatry

HISTORY OF MARITIME PSYCHIATRY

NAVAL COMBAT ENVIRONMENTS

Submarine Warriors

Merchant Mariners

Surface Warriors

Naval Air Warriors and Carrier Battle Groups

Marines: Amphibious Warriors

CARE OF CASUALTIES

History of Hospital Ship Operations

Psychiatric Care of the Combat Injured

SPECIAL PSYCHIATRIC RAPID INTERVENTION TEAM

History

Organization and Mission

Intervention Techniques

SUMMARY AND CONCLUSION

JOHN MATECZUN, M.D., M.P.H., J.D.*

*Captain, Medical Corps, U.S. Navy; Chief of Staff, DoD TRICARE Managed Care Program, Region 1 Staff Office, Washington, D.C.; formerly

Force Surgeon and Assistant Chief of Staff, Health Services Support, Headquarters, U.S. Marine Corps Forces Pacific, Camp H.M. Smith, Hawaii
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Paul Sample Crew’s Quarters Aboard U.S. Submarine, Pacific 1943

Paul Sample was a war correspondent and artist for Life Magazine during World War II and spent time with

a submarine crew on routine patrol in the Pacific. His painting depicts leisure time activity in the very

cramped quarters of a submarine. Naval combat is extremely diversified due to the varying fighting

components and missions of the U.S. Navy, however, all naval combat is similar in that most of it is

characterized by periods of intense activity, followed by lulls, such as shown in this painting.

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

INTRODUCTION

Naval Mission

Since its inception, the United States has been a typical maritime power looking to the oceans for trade,

ideas, and culture; colonized from overseas; and threatened only by potential adversaries across the seas.

The United States reached the zenith of maritime

power in the period immediately following World

War II at which time it had the strongest armada of

naval and merchant vessels ever assembled by any

one nation. At that time, the U.S. Navy had complete superiority at sea with no opponent left capable of contesting use of the seas. Such sea control

(the capability to assert one’s own use of the seas

and to deny that use to others) has been the fundamental role of the U.S. Navy.

During the period of the Cold War, the U.S. Navy’s

force structure and capabilities were oriented towards

sea control and three other missions: (1) strategic

deterrence, (2) naval presence, and (3) projection of

power ashore. Deterrence was carried out by ballisticmissile submarines, a crucial part of the deterrent

“triad” (Strategic Air Command [SAC] bombers and

intercontinental ballistic missiles [ICBMs] were the

other two). Presence was carried out by the use of

naval forces below the level of hostility and ranged

from informal ship visits to patrols just outside a

nation’s waters. The method for projecting power

ashore was an outgrowth of U.S. expertise developed

in the amphibious assaults of the island campaign in

the Pacific during World War II and consisted of

operations putting U.S. Marines on a beach or the use

of naval air or surface forces to destroy targets ashore.

In September 1992 a new direction for U.S. Naval

forces, called “... From the Sea,” emerged. The

national security strategy shifted from a focus on

global threat to a focus on “regional” challenges.

There was a concurrent emphasis on joint and combined operations. This resulted in a fundamental

shift away from open-ocean war fighting on the sea

towards joint operations conducted from the sea.

The mission of the U.S. Navy during a regional

conflict became controlling the ocean adjacent to

the littoral battlefield, the ground from the shore to

objectives, and the skies above both.

Naval Organization

Even before the United States had a Constitution,

it had an organized navy. In 1775, the Continental

Congress created a congressional oversight committee for the Continental Navy. On 10 November

1775, the Continental Marines were established. They

celebrate their birthday annually on 10 November

even though the present U.S. Marine Corps was established by an Act of Congress on 11 July 1798.

The Department of the Navy (DON) was formalized in 1798 and has been in evolution since that

time. The Secretary of the Navy (SECNAV), a civilian,

is in charge of DON. The Chief of Naval Operations

(CNO) is the senior military officer of DON and commands the operating forces and shore establishments

of the U.S. Navy. The Commandant of the Marine

Corps (CMC) is responsible to SECNAV for Marine

Corps matters. Both the CNO and the CMC are

members of the Joint Chiefs of Staff. CMC is not part

of the command structure of the CNO; there is, however, close cooperation between the two military

heads who report to SECNAV. Both U.S. Navy

officers and U.S. Marine Corps officers are considered U.S. Naval officers, although the two services

have unique cultures and traditions.

The operating forces of the U.S. Navy are included in the fleets; Pacific Fleet includes the Third

and Seventh Fleets, Atlantic Fleet the Second Fleet,

and U.S. Naval Forces, Europe, the Sixth Fleet. The

operating forces of the U.S. Marine Corps include

the U.S. Marine Corps Forces Pacific which includes

the I Marine Expeditionary Force (I MEF), and the

III Marine Expeditionary Force (III MEF), and the

U.S. Marine Corps Forces Atlantic, which includes

the II Marine Expeditionary Force (II MEF).

There is a dual chain of command to the operating forces. There is an operational chain from the

President through the Secretary of Defense to a

Commander of a unified or specified command. In

this chain of command the unified commanders

pass orders to naval service component commanders such as the Commander in Chief, U.S. Pacific

Fleet (CINCPACFLT) or the Commander in Chief,

U.S. Atlantic Fleet (CINCLANTFLT). In August of

1992 Marine Corps service component commands

were established and U.S. Marine Corps Forces

Pacific (MARFORPAC) and U.S. Marine Corps

Forces Atlantic (MARFORLANT) became Echelon

II commands within their unified commands.

There is also an administrative chain of command through SECNAV and CNO or CMC to the

operating forces. Within this dual chain the administrative chain of command is permanent while the

operational chain of command is task oriented and

can be restructured as necessary.
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The U.S. Navy and U.S. Marine Corps together

are responsible for developing and maintaining an

effective amphibious warfare capability. This team

is unique with mobility and versatility enabling it to

fight multidimensionally on land and at sea as well

as under the sea and in the air.

The naval environment is unique as well. Because of the historical isolation during long, harsh

sea voyages command at sea has been filled with

great responsibility. Perhaps in no other military

organization is the effect of a commanding officer

on morale so keenly felt.

Naval medical officers noted variations in the incidence of neurosis in different ships in which they

served. There was a great depth of meaning in the

old naval term ‘a happy ship,’ implying a unit in

which there was mutual trust and respect between

officers and men, and dependent to a great extent

on officers and senior raters who not only knew

their jobs but who also had a sympathetic understanding of the men under them and could get the

best out of them.1(p647)

Ships themselves are known to take on a personality and a life of their own to the crew.

She was to become the ruler of my life, and the most

beautiful and responsive creature I had ever known;

a hard, exacting mistress, but loyal, generous, and

courageous. All ships have souls, and all sailors

know it, but it takes a while to learn to commune

with one. It took me a long time for Trigger had to

find her own soul too.2(p11)

Naval Medicine

Physician services for the Continental Navy were

often contracted for by the ship’s master and attached to the ship for a specific cruise. Most were

surgeon’s mates who had some medical training

but who were relatively inexperienced. Some held

medical degrees. In 1811 Congress established U.S.

Navy hospitals and a U.S. Navy hospital fund. The

fund was to be collected from U.S. Naval personnel,

a small portion of whose pay would provide for the

service. The first U.S. Naval hospital was built in

Washington, D.C., about 1821. The oldest hospital

building in service in the U.S. Navy is Building One

at the Naval Hospital in Portsmouth, Virginia, which

still houses the inpatient psychiatry services.

The Bureau of Medicine and Surgery (BUMED)

was established in 1842. Dr. William P. Barton

became the first Chief of the Bureau of Medicine

and Surgery with a staff of four. In 1871 the Medical

Corps was first mentioned in an Act of Congress

which established it as a separate entity and as a

staff corps of the U.S. Navy. U.S. Navy medical

department personnel provide services to both the

U.S. Navy and U.S. Marine Corps. The U.S. Marine

Corps has no medical branch but does have U.S.

Navy medical personnel assigned to U.S. Marine

Corps units and under U.S. Marine Corps operational command.

Naval Psychiatry

There were few psychiatrists in the U.S. Navy, or

for that matter in the country, until World War II. In

1940, the U.S. Navy had 10 Regular Navy psychiatrists doing clinical work and 7 in training; a total of

about 25 medical officers performed neurology and

psychiatry duties.

The neuropsychiatric branch at BUMED was established in 1942. Dr. Francis Braceland took charge

of U.S. Navy Psychiatry in World War II, initially as

a special assistant to the Surgeon General, and subsequently as the Head of the Neuropsychiatric Branch.

The number of psychiatrists reached a maximum of

693 at the end of World War II. Out of the wartime

training programs grew the current U.S. Navy psychiatry residency programs. By 1948 the number of

psychiatrists on active duty had declined to 74 with 32

in training. That year the Surgeon General reported

“personnel needs in Psychiatry are still critical

and an active procurement program has been

initiated.”3(p412) (“Ce plus le change....”)

The Neuropsychiatry Branch at BUMED lasted

some 35 years through several name and mission

changes until 1977. A few years later a system of

specialty advisors to the Surgeon General was put

in place and the Specialty Advisor for Psychiatry

(SAP) has been a focal point for U.S. Navy psychiatry since that time.

HISTORY OF MARITIME PSYCHIATRY

Ship differs from shore and the challenges of

shipboard life make life different for sailors. Much

of the following was adapted from the excellent

review by Captain Rolf Steyn.3
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U.S. Naval Combat Psychiatry

The Vikings of the early middle ages were sea

warriors who bequeathed the term ‘berserk’ for a

peculiar battle frenzy by which they were seized

(probably enhanced by mead—beer fermented from

honey). In the early Renaissance, communities

loaded their maladaptors, for a fee, on ships (the

ship of fools) for transport to unknown destinations. Some modern parallels are occasionally carried out by judges who encourage maladaptors to

go to sea instead of jail. “It is a popular delusion

that the ne’er-do-well, the black sheep of the family,

will be picked up and made a man of by the discipline of the military life.”4(p408)

Sailors in the 16th through 19th centuries manned

great fleets which conquered the world. Their crews

are suspected of spreading syphilis that was a major

cause of mental illness and other diseases which

proved devastating to previously unexposed populations. Many showed the weakness, irritability,

and depression associated with scurvy. Crews had

general ill health so mental troubles alone did not

stand out. The annual death rate in the British Navy

was 1 in 8 in 1779.3

Sailors were known to consume large amounts of

alcohol. Admiral Edward Vernon, known in the

English fleet as “old grog” directed in 1770 the issue

of a daily half-pint of rum mixed with a quart of

water to sailors of the West Indies fleet. This was

designed as a temperance measure to remedy abuses

stemming from straight rum drinking. The mixture, which was also called “grog,” won general

acceptance in the British Navy as well as the American Navy which was patterned after it. Congress

incorporated the rum ration in legislation in March

of 1794. In 1806 whiskey was substituted as cheaper

and more wholesome.3

In the 19th century about 80% of floggings in the

U.S. Navy were administered for drunkenness and

alcohol-related offenses. Flogging was abolished in

1850, possibly related to Dana’s publication of Two

Years Before the Mast. President Lincoln abolished

the grog ration on 1 September 1862. In the 20th

Century improvements in nutritional knowledge

and food handling greatly improved the physical

health of naval forces with concomitant mental

health improvement.

During World War II psychiatric diagnoses in the

U.S. Navy and U.S. Marine Corps were common

with some 150,000 patients being admitted for psychiatric illness. Over 100,000 sailors and marines

were separated for psychiatric disorders, constituting 34% of total medical separations. Not included

in these numbers are 90,000 recruits who were discharged for mental reasons.3

Group therapy first became an accepted treatment modality during World War II, largely because of the large numbers of patients and paucity

of therapists.

Group therapy, born of necessity, was soon found

to have other things to commend it. The individual

undergoing treatment lost the feeling of uniqueness and of shame when he saw that other persons

were suffering the same emotional distress as he

himself was undergoing. There is no reason to

believe that this type of therapy cannot be carried

on in civilian life.5

Variability in diagnosis during World War II led

to work towards a definite nosology with Captain

George Raines contributing with Brigadier General

William Menninger to a joint Armed Forces nomenclature and method of recording psychiatric conditions in 1949 which later led to the first American

Psychiatric Association nomenclature, the Diagnostic and Statistical Manual (DSM).6

Literature on the subject of psychiatric casualties

at sea is almost completely nonexistent. This is in

part a problem with the collection of medical statistics in an environment where there may be few

medical personnel, such as on a small ship. The loss

of a ship may mean the loss of an entire crew so

combat stress casualties cannot be ascertained. As

a ship continues to function after a battle, it may be

that many sailors who would otherwise have been

identified as casualties are able to stay with their

division until acute reactions have subsided. This

may be particularly true if they were in close contact

with shipmates and working within their division

in which case only the most dysfunctional casualties would ever have been evacuated.

Ursano and Holloway7 note that psychiatric combat casualties are a unique class of conditions defined by etiology (eg, combat), rather than by symptomatology and that the behavior and

psychophysiological manifestations of the combat

casualty are protean.

This author would argue that there is a “plasticity” in the presentation of psychiatric symptoms

related to cultural or subcultural environments that

exist in the military and the expectations that such

cultures engender which determines a large part of

the protean nature of such casualties. In the following sections some of the subcultures which make up

the U.S. Naval culture will be explored.
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NAVAL COMBAT ENVIRONMENTS

Submarine Warriors

History of Submariners

Submarines were born in 1620 when Cornelius

van Drebbel, a Dutch physician, launched a wood

vessel covered with greased leather in the River

Thames. This ship was really little more than an

oar-driven diving bell which was not capable of

submersion and probably ran awash during its trip.

Although a submarine first saw action during the

U.S. Civil War, submarine warfare came of age in

World War I. The U-boat arm of the German Navy

demonstrated what could be achieved in the interdiction of trade routes. They sank almost 6,000

ships, mostly defenseless, merchant vessels grossing a little over 11,000,000 tons and in so doing

rendered it almost impossible for the Allies to continue the war. There were 13,333 noncombatant

merchant seamen and passengers who died during

these attacks.8(p7) U-boats also sank nine British and

French battleships and 14 cruisers. A single German submarine U-9, in a brief engagement, destroyed three British cruisers, an event which had a

profound effect on maritime strategy during the

war.8(p7)

World War II saw submarine warfare continue in

the same strategic role that had begun in the previous war. The tactical introduction of the wolf pack

and the night surface attack decimated Allied convoys attempting to cross the North Atlantic. The

Axis Powers sank almost 3,000 merchant ships with

a tonnage approaching 15,000,000. German U-boats

also sank two battleships, eight aircraft carriers and

some 50 destroyers.8(p228) Only the development of

the convoy system and depth charges allowed the

United States to continue supporting the allies.

The Submarine Service of the U.S. Navy adopted

U-boat tactics to the Pacific and sank more enemy

warships than had the U-boats. They were also able

to sink more than 1,100 Japanese merchant ships

with a tonnage of almost 5,000,000.8(p228) The size of

the Submarine Service was only 1.6% of the U.S.

Navy’s total strength yet they suffered a heavier

proportion of casualties than any other branch of

the U.S. Navy. In the Pacific theater, more than

3,500 submariners were killed8(p154) and there were

many examples of extraordinary heroism. The trials of the submariner have been brought to popular

attention through novelizations and motion pictures such as Run Silent, Run Deep 9 and Das Boot.10

Psychiatric Casualties

The hazards encountered by submariners can be

seen as unique and extremely stressful.11 During

patrol allied submarines were “lone wolves” and

subject to intense attack when sighted by enemy air

and surface antisubmarine units. The depth charge

was the primary antisubmarine weapon and the men

could not help but wonder when the next bomb or

depth charge would make a direct hit. All knew that

submarines were being lost to enemy counterattacks.

While being hunted, they were unable to fight

back and “ran silent” with all, except those necessary to control the ship, in their bunks. Those who

were up and about removed their shoes. Talking

and unnecessary noise was kept at a minimum for

everyone. The interior became excessively hot and

humid because of secured ventilation, air conditioning and refrigeration units. All of this resulted

in enforced inactivity and helplessness during the

trauma of exploding depth charges. Even when not

being attacked there were the stressors of mines,

shallow water operations, air-sea rescue operations,

reconnaissance operations, and days of patrolling

without enemy contacts.

During World War II there were no studies of

U.S. psychiatric casualties occurring aboard submarines while on war patrols. A review after the

war11 noted that there were approximately 1,520

war patrols completed by U.S. submarines, of which

1,489 patrol reports were available for study. An

attempt was made to extract from those reports

instances of “psychiatric casualties.” These were

essentially those men who were unable to continue

with their duties secondary to what was thought to

be some psychiatric-related problem. The total

number of cases so identified by the authors was 56.

This would have been a rate of .00044 casualties per

man-patrol. Estimating another way this would

have equalled an “admission rate” of 2.2 per thousand men in the Submarine Service. These figures

also suggest that the role of an evacuation syndrome was essentially unavailable in the submarine setting.

Case Study 1: Depth Psychiatry

That there were frequent stress reactions short of

“breakdown” is illustrated in extracts from the reports.

General manifestations of responses to the conditions

were described as “excessive physical weariness with
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U.S. Naval Combat Psychiatry

headaches, lethargy and sometimes heat exhaustion.”

Also noted were frequent somatic symptoms.11(p608)

For the first two hours we were in a mighty tough

spot....The predicament of the ship was a fact fully recognized by the older and more experienced men. As the

youngsters folded up, the others took over....The most

startling effect was the apathy engendered by the combination of heat, pressure, physical effort and mental stress....

[W]ithin a period of 24 hours following the depth charge

attack, several cases of mild gastric disturbance consisting of light nausea and cramp-like feeling developed;

rapid recovery without treatment followed...[A]pproximately one-half the crew complained of headaches, slight

diarrhea and acidosis for three or four days following the

depth charge attack.11(p608)

Comment: The World War II casualty figures may be

incomplete and underestimated but still present an enviable record. The authors believed the low casualty rate

could be ascribed to factors of selection (every man was

a volunteer), training, morale, pre- and post-patrol physical examinations to detect men in need of rest and

rehabilitation, rest camps and rotation (after two consecutive patrols), and confidence in submarines, officers, and

shipmates.

Behnke12 relates the comments of a former sub

commander on this unique environment:

To operate a complicated mechanism like a submarine, each individual must be free to volunteer

information, to discuss when discussion is profitable, to exercise initiative and discretion in carrying out his duties; yet in other situations he must

obey instantly, without question and without

thought as to his safety. The recognition of the

subtle changes in a situation that determine where

and when and in what circumstances these two

widely different attitudes are demanded is what

makes a good submarine man.12(p724)

The British Submarine Service during the war

reported a 40/1,000/y rate of psychiatric casualties.13(p343) Disparities between countries in reported rates have been hypothesized to be a tendency of commanding officers of U.S. submarines

to transfer or separate a crewman for other than

psychiatric reasons.14 Other labels such as chronic

maladapter, upper respiratory disease, or environmentally unadaptable may have diluted U.S. psychiatric attrition statistics. This same author relates

a “resistance to psychiatry in the submarine service” and exemplifies the resistance with a quotation from Admiral Rickover in speaking before a

Subcommittee of the Committee on Appropriations:

I view with horror the day the Navy is induced to

place psychiatrists on board our nuclear submarines. We are doing very well without them because the men don’t know they have problems. But

once a psychiatrist is assigned, they will learn that

they have lots of problems.14(p583)

The advent of the nuclear submarine ushered in

a new gamut of missions and stressors for submariners. Submerged missions increased dramatically

in length from 3 days during World War II to 60 to

90 days.

There have been few published reports of the

incidence of psychiatric attrition during submerged

missions. During 360 Fleet Ballistic Missile Submarine missions in the period from 1963 to 1967 there

were some 192 psychiatric cases. This would be an

incidence of about 4/1,000/y.15(p1) The proportion

of crew members referred for psychiatric evaluation has been reported variously as 20/1,000/y in

1963,14(p579) 42/1,000/y in 1967,16(p548) and 50/1,000/

y in 1968.17(p26)

One important problem is how many psychiatric

cases require a medical evacuation at sea. Such

evacuation may cause an entire mission to abort at

relatively high strategic or tactical cost. Biersner18

reported that from 1963 to 1967 there were no cases

of mental disorders severe enough among submariners to require a medical evacuation at sea. From

1968 to 1973 there were only three cases severe

enough to require evacuation at sea.18

U.S. submarine psychiatry began late in World

War II with the assignment of a psychiatrist to the

Submarine Base, New London, Connecticut. The

psychiatrist was called upon to (a) decide whether

volunteers with marginal aptitude test scores possessed compensatory traits predictive of later success and (b) apply therapeutic techniques to the few

submariners who had met aptitudinal requirements

but showed acutely maladjustive behavior during

protracted war patrols.14

The Bureau of Medicine and Surgery made a

decision shortly after the war to focus upon the

selection of men with maximum adjustment potential rather than “salvaging” maladjustive crew members.14 The use of empirically validated aptitude

measures coupled with personality tests came into

use. Those whose tests showed marginal aptitude

or personality patterns were interviewed by the

psychiatrist.

Insights gained from this process as to the dynamics underlying the decision to volunteer for the

submarine service have shown that apart from increased pay for hazardous duty the most important

motives are social in nature, that is, a person values

highly the status coincident with the acquisition of
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the “dolphin” showing submarine qualification and

acceptance in the “submariner culture.” Also strong

affiliative motives to establish highly affective-toned

friendship relationships within the submarine crews

are important aspects of the motivation.

Pathological motives such as counterphobic behavior demonstrated by volunteering in reaction to

claustrophobic or other phobic impulses were postulated to be operating in some volunteers. Phobics

who were not screened out initially were presumably eliminated during the training by failure to

withstand 50 pounds per square inch pressure while

in a recompression chamber and by failure to make

an unassisted buoyant ascent to the surface of the

training tank from an escape hatch in 50 feet of

water.

Some volunteers appeared primarily interested

in the possibility of fleeing domestic responsibilities. Obviously eliminated were those with “incipient psychotic trends.” A “fair number” of antisocial

characters were noted to slip through the intake

“selection sieve” and later turn up as disciplinary

problems usually resulting in elimination early in

their submariner careers.

Medical Support for Submariners

Navy medical officers who volunteer are usually

trained in undersea/diving medicine at the Naval

Undersea Medical Institute (NUMI). The curriculum there contains a psychiatric syllabus. They are

often assigned to a submarine squadron after training. The medical department aboard an individual

ship is usually staffed by an independent duty

corpsman.

Chapter 15 of the U.S. Navy Manual of the Medical

Department19 lists physical standards for selection

for various duties. There is a specific section on

screening volunteers for submarine service.

One current initiative in aiding the medical department aboard the submarine is a computerbased

patient management system for isolated environments, called MEDIC. Four diagnostic modules are

under development including abdominal pain, chest

pain, psychiatric disorders, and dental problems.20

The psychiatric module consists of a brief structured

interview, with verbatim questions developed for use

by medical corpsmen. Specific diagnosis and treatment suggestions were developed for each interview

profile which make suggestions that are within the

corpsman’s trained skill levels. A computer-aided

instruction component was also developed to provide the corpsman with initial training in some

general emergency treatment principles.21

There is currently no psychiatrist assigned to

the operational assets of the submarine service

nor are there any assigned to the Naval Undersea Medical Research Laboratory. Psychiatric support to the operational forces is most often obtained

through the psychiatrist assigned to the Naval Hospital near the home port. This contact is usually

initiated by the independent duty corpsman or

squadron doctor.

Merchant Mariners

Mission and Stressors

Although the Merchant Marine is not one of the

uniformed services, it has great importance to any

war effort. As any medical planner knows, “lift” is

crucial to success and there is never enough “lift.”

Merchant ships have been called upon to deliver

goods to invasion harbors and beachheads in the

past and will be in the future.

The stressors imposed on crews of these shipping

vessels during World War II by submarine warfare

and bombing attacks were extreme. Sailors of the

Merchant Marine were subjected to torpedo attack,

bombs, mines, machine gun and shell fire, severe

body wounds, long blacked-out voyages through

submarine infested waters, and occasionally being

cast adrift as a survivor of a ship sinking on the open

sea with resultant exposure to cold, hunger, thirst,

and exhaustion.22

Psychiatric Casualties

During the first year of American participation in

World War II, more fatal casualties were recorded

among American merchant seamen than among

men in the combined armed services. The incidence

of combat or “convoy” fatigue among survivors of

torpedoed and bombed merchant ships was not

clearly studied, for several reasons including

seamen’s unions, but it created such a serious drain

on marine manpower that in January, 1943, the

Surgeon General of the U.S. Public Health Service

called a conference of leading military and civilian

psychiatrists to discuss ways and means of preventing and treating this condition among merchant

mariners.23

A program was formulated to be operated jointly

by the U.S. Public Health Service, the War Shipping

Administration, and the United Seamen’s Service.

The program centered on the need for convalescent

homes set up at or near convenient ports of call

along the Atlantic, Pacific, and Gulf coasts.
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U.S. Naval Combat Psychiatry

In attempting to evaluate statistics regarding

Merchant Marine psychiatric casualties, as in attempting to evaluate all maritime psychiatric casualty statistics, there is one group of seamen with

psychiatric disturbances who can never be studied

or effectively counted—those whose acute reactions were so incapacitating as to prevent their

making any effective effort to escape catastrophe.

Many of these men were surely acute psychiatric

casualties and just as surely buried at sea with their

ships.

[M]en showed blind confusion and panic, childlike

states of terror, self dramatization, rage or stuporlike trance states. Some men clung to a red hot rail

or buried their heads between their arms. Some

leaped blindly into a blazing sea when there was no

burning oil in some other direction or ran about

with dangerous implements in their hands, striking blindly.22(p401)

The personality characteristics of Merchant Mariners have not been studied in any systematic way.

Some impressions of the personalities of the survivors of torpedoing were that a majority had gone to

sea early in life before age 18, and many of these had

run away from home or gone in spite of parental

objections. The sea as a vocation had only rarely

been a tradition in the family.

Motivation for becoming Merchant Mariners

seemed to derive from a strong, inarticulate need to

get away from home and to get away from the

disciplined social authority and regimentation of

life on land. Several such sailors contrasted the

regimentation and discipline of previous U.S. Army

or U.S. Navy service with the freedom and informality of their life in the Merchant Marines. A large

percentage had severed all contact with members of

their families. Few were married.22 Typical of the

ships was the Troubador, a 5,808-ton tramp,

a rusting steamer that had been scuttled by her

truculent crew at Jacksonville when America entered the war, and now boasted a seventeen-nation

crew of ex-convicts and the rakings of the U.S.

deportation camps. While at anchor in New York

harbour...the ship’s ammunition magazine had

been deliberately flooded ‘by a person or persons

unknown’. Eight Colt automatic pistols had been

issued to the naval Armed Guard officers shortly

before sailing: ‘This was considered necessary in

view of the conduct of the ship’s crew.’...[I]n Iceland on 20 June, twenty members of Troubador’s

crew mutinied, having been told their ship was

now bound for Russia. They sent a deputation up

to their Master, the Norwegian Captain George

Salvesen, and told him they refused to take the ship

any farther. The Reykjavik port director ordered

Salvesen to use his ship’s Armed Guard to quell the

mutiny. The American naval gunners rounded up

the seamen and barred a dozen of them into a

stinking hold in the forepeak area, in ‘very crowded,

foul conditions.’ The seamen held out in there

under armed guard for fifty hours and then surrendered. ‘We didn’t have any more appreciable

trouble until the convoy reached Russia,’ reported

the Armed Guard officer, Ensign Howard E.

Carraway, to his superiors.24(p100)

These sailors had an extraordinarily large pay,

($500 per month plus danger money) in defense of

which it was pointed out that they were not maintained by a shipping company while on shore, did not

receive a pension and had a high rate of casualties.22

Psychiatric casualties were not limited to unlicensed seamen. An increasing number of skippers,

mates, and chief and assistant engineers were noted

to be worn out nervously and physically as the war

went on.

Chronic Sequelae

Margolin et al22 studied 40 survivors of torpedoing who were continuing at sea. They found that

75% had persisting emotional reactions with 25%

being categorized as severe or sufficient to make it

impossible or inadvisable for the seaman to return

to sea. Alcoholism or previous psychiatric history

predisposed to severe and incapacitating reactions,

both during and after any emergency. There was a

suggestion that persons aged between 45 and 60

were especially susceptible to severe reactions. The

incidence of severe reactions was particularly high

among seamen from tankers; and there appeared to

be little correlation between where a seaman was at

the moment of attack and severity of the after effects.

Margolin et al noted that among seamen who

were ambulatory and returning to sea there were

surprisingly few psychosomatic disturbances. This

was in sharp contrast to what had been reported

among seamen who had been hospitalized. It was

the authors’ impression that the seaman in whom a

severe psychosomatic disturbance developed had

few qualms about “giving in” to the illness and

accepting hospital care and to some extent felt that

it was a legitimate reason for not going back to sea.

Askevold25 studied Norwegians who had been

sailors in the Merchant Navy during World War II.

Of 35,000 who had sailed for the allied forces, 6,000

were killed by bombs or torpedoes. Most survivors
War Psychiatry

220

had lived years during the war with a real fear of

death. In examining a sample of these sailors some

30 years later, he found striking similarities between those with concentration camp syndrome

(known as the “KZ” syndrome) and ex-war sailors.

He compared a matched group who were not war

sailors for four symptom groupings: (1) asthenic

symptoms (fatigue, irritability, lack of initiative,

and emotional incontinence); (2) autonomic and

somatic symptoms (dizziness, sweating attacks,

dyspepsia, impotence, and somatic pain); (3) anxiety symptoms (nightmares, restlessness, disturbed

sleep, and isolation); and (4) organic brain symptoms (impaired memory and concentration difficulties). The mean symptom load for ex-war sailors

was 13.6 as opposed to 3.5 for the comparison group.

There was also a higher relative frequency for each

of the single symptoms in the war sailor group and

a very similar relative frequency within each symptom group for both war sailors and concentration

camp survivors.

It was evident to Askevold that of those still at

work, the symptom load was high enough to warrant war pensions and their work capacity was marginal. He coined the term “War Sailor Syndrome” to

describe the chronic effect on these sailors.

Treatment

Psychiatric treatment for American Merchant

Marines during World War II was at rest centers

established by the War Shipping Administration

and the United Seamen’s Service. A major part of

the treatment at rest centers was conducted in

groups. For the Merchant Marine at sea there were

not only no psychiatrists, but no doctors at all.

Treatment of the individual casualty as conducted

at the rest centers was noted to be a “thin battle line

tactic” given the resources available; “defense in

depth” through the addition of preventive measures was recommended.26 The preventive measures were to be through change of those factors

external to the seaman and also by group education

and treatment.

It was soon evident that many factors influenced

the condition apart from actual battle experience.

Factors external to the sailor himself included the

presence or absence of adequate medical equipment, safety devices, food, convoy protection, sanitation, hours of work, and factors influencing morale including relations between officers and men

and worries about personal affairs. Encouragement

was given to captains to not fill a sick bay with paint

and rope so that sailors might take a new interest in

health because they had a clean sick bay used as a

headquarters for sick call; for appetizing preparation of food and getting men to eat a balanced diet;

for ensuring that the medicine chest contained supplies necessary to meet shipboard emergencies; and

for adding pharmacists’ mates (the World War II

U.S. Navy rating equivalent to today’s U.S. Navy

corpsman) to the crews of merchant ships.

A second category of preventive focus was a

recommendation to prepare sailors so that men

would not be overwhelmed by fear. The idea was

that when a man is taught to anticipate danger and

to understand his reactions and how to deal with

them, he is better prepared to cope with the danger

and to meet the next experience. Seamen could be

helped to understand ways of preventing and relieving their own nervous tension; commanders

could be given training in the appreciation of the

elements in a satisfactory psychological state and

the methods by which it could be attained. Preconditioning by simulation was also considered.26

One preventive measure not discussed in relation to the Merchant Marine was screening, presumably because of the necessity of having crews to

man ships and possibly because of the difficulties in

instituting such a process for personnel who were

not members of the armed forces. There is little to

indicate that any preventive measures were instituted prior to the end of the war.

It is instructive to contrast these Merchant Marine casualties with those of the submarine service.

They obviously differ as to the rates of casualties,

and possibly to the chronicity of sequelae after

wartime. Screening, personality type, motivation,

and stressors appear to have been different.

It is possible to project that for merchant vessels

subject to sinking in the future, there will be near

universal acute symptomatology among the crew

with some 25% developing symptomatology that

will preclude going to sea under similar circumstances. With increasing exposure to possible death

even higher numbers of incapacitated could be expected.

Surface Warriors

History

Surface warfare takes place among those ships

and missions which are conducted on the surface of

the seas. This is the traditional sphere of naval

warfare. Prior to World War I the ships of the line

of naval battle were the U.S. Navy and always had

been psychologically. Older officers counseled:
221

U.S. Naval Combat Psychiatry

“Stay in the big ships”; “work your way to the top

in a big ship; that’s where the real Navy is”; “don’t

waste your time in little ones”....“There always has

been a mystique involving the self-contained little

world of a large ship, combatting the far greater

elements of wind and sky and the huge, trackless,

sometimes malevolent sea. But not only did a big

ship become a living, sentient being to those who

served her, she was also a community of kindred

souls, of men who thought alike and worshipped at

the same shrine....Perfection of the ship becomes

its own objective. Battle has nothing to do with it,

although one always talks of battle, battle is harmful to the ship, and should be avoided if possible,

though not so one can notice. To sailors of the old

time, enlisted men and officers, their ship was their

home and their religion.”27(pp422–423)

After World War I most of the U.S. Navy’s officers and men went to sea and most of the sailors were

in either the “destroyer Navy” or the “battleship

Navy.” The “cult” of the battleship existed not just

in the U.S. Navy but in the Royal Navy as well.

Naval strategic thinking was described by Henry L.

Stimson, President Taft’s Secretary of War, as “the

peculiar psychology of the Navy Department, which

frequently seemed to retire from the realm of logic

into a dim religious world in which Neptune was

‘god,’ Mahan his prophet, and the U.S. Navy the

only true church.”28(p421)

Destroyer sailors were of a different breed from

the rest of the U.S. Navy. Their ships were faster

and rolled more than the squat battleships and

cruisers. And so the men rolled too, walking with

a swagger on land, boasting of storms in which

destroyers keeled so far that they took sea water

in their stacks. Battleship sailors looked down

at the ocean; destroyer sailors said they looked at

the ocean in the eye. Destroyers were tactically

used like bullets. A man aboard a destroyer

in battle knew that he and his ship were expendable. That kind of knowledge gave a man a certain

bravado.29

Psychiatric Casualties

Sailors see their ships as having a spirit and

fatigue can affect not just individuals but entire

crews and ships. In training prior to World War II,

American crews were kept in condition watches

(Condition 2 was one half of the crew in battle

stations and Condition 1 was regular action stations) for days on end. Thus, they may have been up

for General Quarters during morning and evening

twilight and required to do ship’s maintenance

during working hours so they were in general deprived of rest. The British Navy had derisively said

of the U.S. Navy that in the event of war with the

United States they would keep their fleet safely in

harbor for a couple of weeks, after which America

would collapse from the unremitting strain of indiscriminate and unrealistic readiness at all times.

Case Study 2: Crew Exhaustion

On the night of 8–9 August [during World War II] a

combined U.S. and Australian force of five fine cruisers

was caught totally by surprise in the vicinity of Savo

Island, off Guadalcanal, by a superior Japanese force. All

hands in the American squadron, including those on

watch, were exhausted from days on end without rest.

Although technically in alert status, they were so tired as

to be literally asleep on their feet....More than a thousand

allied sailors were killed in the five cruisers....The Commanders of the ships involved were castigated for their

individual lack of alertness. Yet...the fault lay in unrealistic demands for readiness at all times, with the inevitable

result that although awake and on their stations, their

crews were not truly alert....Commanders in the Pacific

began to think more about the human demands being

made on their eagerly willing crews.27(p462)

Comment: This example shows the validity of the

concept of sleep and rest discipline in U.S. Navy combatants as has been shown in land troops.

Case Study 3: Stress in the Falklands

The scenario reported by the Royal Navy psychiatrist,

who was with the Naval expedition during the 1982 Battle

of the Falklands, can be seen as typical of U.S. Naval

surface operations. As their task force approached the

Falkland Sound:

“We were unsure before entry as to whether or not it

had been mined. The rather ironical story is told of a

frigate identified as an ‘Irish Minesweeper’ which was

tasked to go in ahead of Canberra to determine whether

or not any mines were present—apparently we would

know whether or not this was the case if she blew up—

fortunately she did not and we and the rest of the fleet had

safe passage....All seemed calm and peaceful until about

two hours after the assault began when suddenly the

Argentinian aircraft appeared. From then on there was a

succession of air strikes and we grew in our admiration of

the skill and daring of the Argentinian pilots....We functioned as the major medical facility during the course of

that day taking casualties direct from the ships which

came under fire, including those that were sunk. Again, I

found myself in a situation of dealing with a group of

survivors from the aftersection of Ardent and during the

course of the day, was in a position to support the nursing

and medical staff who were busily engaged in their duties

treating the wounded....The battle plan had to be changed

rapidly when it became apparent how effective the Argentinian Air Force was. A mad scramble followed to put

ashore the major medical logistics and at that stage it had
War Psychiatry

222

not been allowed for the task force psychiatrist to deploy

ashore on such short notice. So I found myself going out

to sea with our survivors and wounded and there followed

an intensive period of active intervention...dealing with

the bereavement associated with the wounded and the

survivors of the ships....The emotional needs of survivors

can be dealt with under the following headings: There was

initial relief of escape almost immediately followed through

by the anxiety about the threat of further attack and fear of

further trauma. Mixed with this was the anger not only

directed at the enemy but at the units to which they

belonged and the designers of the ships were found

wanting in certain areas. There was the grief at the loss

of companions and of course the ever familiar guilt at

survival, this especially so amongst the single men who

constantly queried why it was they who had survived and

their companions, married men with young families, had

been killed....After the fall of Stanley...we began our

triumphant journey home. The fascinating feature of this

journey for me was the amount of working-through people

were doing all around me. The three weeks allowed a

tremendous opportunity for reliving the battle scenes,

making formal contact with critical figures and providing a

setting for significant emotional catharsis....I am convinced this is one of the reasons why we have seen so few

psychiatric casualties from amongst the Royal Marines in

association with the Falklands crisis.”30(pp143–145)

Comment: O’Connell31 estimates that among the survivors of those ships that were lost there have been some

20 to 25 psychiatric casualties who developed chronic

post-traumatic stress disorder. This from a crew of 230 to

250 would be a rate of 10% which would be in accord with

the experience in the U.S. Navy after such incidents as

suffered by the USS Stark.

Medical Organization

The medical department aboard a larger ship is

headed by a medical corps officer who is designated

as the ship’s medical officer. That officer is responsible for maintaining the health of personnel, making medical inspections, and advising the commanding officer (CO) on hygiene and sanitation

conditions. When no medical officer is assigned,

hospital corps (enlisted) personnel run the department, but are assigned to the Operations Department for military and administrative functions.

Currently, within the surface warfare community,

it would be medical department personnel that

would address psychiatric needs. It is thus crucial

that the medical officer be trained in the principles

of combat psychiatry, particularly of the importance of the support of the crew, including the

medical officer, in assisting return to duty after

acute reactions. The following case, one the author

had the opportunity to review for the Board for

Correction of Naval Records, is illustrative.

Case Study 4: A Missed Therapeutic Opportunity

The case was of a Lieutenant Junior Grade who had

been aboard a destroyer during World War II throughout

the Pacific campaign. He had generally performed well.

During the battle of Leyte Gulf he was involved in escorting a convoy to Mindinao. During that escort, lasting some

3 days, several ships were hit by Kamikazi pilots. As they

burned, the ships “disintegrated” causing the crew to

realize that they were carrying ammunition. After some 72

hours of being on General Quarters, he was on the Bridge

and had given his life jacket to a seaman who had forgotten

his. This was in spite of the fact that he could not swim. A

Kamikazi plane came directly at the Bridge. As it hit, he

“found himself” going over the side of the ship, falling about

30 to 40 ft into the water. Fortunately he was not pulled

through the ship’s screws. He struggled in the water; and,

just as he felt that he was going to drown, he was picked

up by a small U.S. Army vessel. Subsequently, he was put

into an U.S. Army hospital. A few days later his ship’s

medical officer came to the hospital. The officer hoped

that the medical officer would come to talk to him; but he

saw the medical officer glance at him with a “look of

disgust” on his face. After that he developed increasing

symptoms of combat fatigue and was never able to be

returned to duty. Had the ship’s medical officer been able

to speak with him, he might have been able to return to

ship’s crew and not have become a chronic casualty.

Comment: A ship’s medical department may have the

option of brief admission to the sick bay for such “fatigue”

cases. The ship’s medical officer, as a member of the

ward room, can communicate with other division heads

and their chiefs to ensure that an individual sailor knows

that he is needed back in the division. The medical officer

aboard ship should not forget that he has more than just

military authority in the eyes of the crew. The medical

officer is also seen in the professional role of healer, one

who cares, and mediator.

Naval Air Warriors and Carrier Battle Groups

History

As Beach27 reports, new technology changed the

conditions of battle at sea prior to World War II but

U.S. Naval leaders were slow to change tactics:

As the range of guns increased in battleships, spotting of the rounds became progressively more uncertain. This led to spotting by aircraft and each

battleship was outfitted with small planes for that

purpose. The idea of a ship devoted solely to

handling wheeled aircraft on a long flat deck received little encouragement....Only aviators asked

newly pertinent questions; what use was a battle

line with weapons of 20 mile range if aircraft carriers could send weapons with greater accuracy 10

times as far? Or the antagonistic, ambitiously cynical one; why was a 20th century Navy still enam-
223

U.S. Naval Combat Psychiatry

ored of the 18th century line of battle? Did the

psychological appeal of a line of great grey ships

with glorious heritage from the days of sail, somehow affect the strategic thinking of the Fleet Commanders of the 1930s?27(p446)

During the later part of World War II battleships

became relegated to a primarily shore bombardment role in support of amphibious landings. They

were never in battle with similar ships, but became

fleet escorts for the great number of aircraft carriers

that were turned out after Pearl Harbor.

The Queen of Battles of the Pacific war, lifting the

crown from the battleship (which had never worn

it in combat), was the aircraft carrier. In contrast to

the long peacetime gestation of the battleship, the

carrier leaped almost at birth into relentless combat. For years, Naval aviators had stressed the

superiority of 3-dimensional combat over 2-dimensional strategy tied to the surface of the sea. Suddenly, war at sea in three dimensions took over

from war in two dimensions and sea/air power

dominated Naval tactics. Surprise became the basic ingredient of Naval combat. The slow inexorable confrontation of all available forces...was no

longer germane to the ability to carry out a Naval

mission quickly. To strike where needed and with

stunning speed was the new way of war on the sea.

In this outlook, Naval aviators and submariners

were joined, for both groups had shared the 3-

dimensional concept from the beginning....A plane

came from nowhere in only minutes, did heavy

damage, and disappeared....All the old ways of

bringing ships into battle were outmoded; they

now fought from places of invisibility, over the

horizon, widely dispersed, or submerged.27(p446–449)

Psychiatric Casualties

The USS Wasp, an aircraft carrier, was torpedoed

on the 15th of September 1943, while escorting

reinforcements to Guadalcanal. The senior medical

officer aboard was Commander Bart W. Hogan, a

psychiatrist later to become the Surgeon General of

the Navy. He surveyed survivors32 and discovered

the following reactions on board after the torpedo

attack: 38% felt calm; 33% felt excited, nervous,

tense, or shocked; 9% were very fearful; and 20%

had no report. Twelve hours after the torpedo

struck, 27% felt relief and thankfulness; 25% felt

concern for shipmates; 46% were fearful, apprehensive, or nervous; and 2% had no report. Three

weeks later, 46% expressed themselves as being

normal and regretful; 37% stated that they were

nervous, apprehensive, even jumpy; 80% were unaware of any physical change; 33% stated they were

unaware of any emotional change; and 43% had a

slight emotional change.32

Hogan related that during the service of the USS

Wasp it had brought reinforcements to Malta and

was then escorting reinforcements to Guadalcanal

at the time that it was sunk. In all that time, only two

minor neuropsychiatric cases developed. He called

for tribute to the 18-, 19- and 20-year-old men who

were winning the war and remaining stable. The

crew on board at that time numbered over 1,080

with approximately 180 officers.

During a combat deployment to Vietnam, 121

U.S. Navy aviators were studied aboard an aircraft

carrier.33 Their illness patterns revealed a total of

116 illnesses amongst the 121 officers with 26% of

the officers developing 73% of the illnesses. Five

percent were responsible for 22% of the illnesses.

Out of the 116 illnesses, 8 were noted to be neuropsychiatric in origin with the bulk of those being

related to insomnia and one case each of hyperventilation, dizziness, and neuritis.33 The illness rate

was comparable to the overall rates for the enlisted

crews of several other ships which had been previously studied. Illness rates were elevated during

the combat periods compared to the in port periods

with an exception being a sudden operational shift

which occurred to another country.

A modern aircraft carrier with an airwing embarked accommodates about 570 officers and 5,720

enlisted men. From her decks operate nearly 100

aircraft—fighter, attack, electronic countermeasures,

electronic warfare, reconnaisance planes, and helicopters.

When a carrier battle group left port in the 1980s

with an airwing, escort and support vessels with

amphibious landing capability from elements of the

Fleet Marine Force, as many as 20,000 men accompanied it. It was usually during the first month out

that most psychiatric morbidity occurred. Routinely, some 100 cases required psychiatric evaluation during a cruise.34

One psychiatrist35 also designated as a U.S. Naval flight surgeon, who had been the senior medical

officer aboard an aircraft carrier, contrasted two

cruises that carrier made. One cruise was made to

the Arabian Sea during a period in which hostilities

might have started. That cruise lasted some 156

days. Prior to the cruise, in order to assist families,

arrangements had been made to ensure that allotments or direct mail deposits for pay checks were

taken care of because mail service could not be

expected to be regular. Crews and families were

informed that sailors would probably not be available for assistance and that emergency leave would
War Psychiatry

224

be difficult. This cruise occurred during a period

that a “reason to be there” was perceived by the crew.

The carrier left the line briefly and returned for another 158 days. During a total of 256 days on line, there

was one psychiatric medical evacuation. This was of

a person who had fraudulently enlisted and had been

getting Stelazine, an antipsychotic medication, by

mail from a civilian general practitioner.

This was contrasted with another cruise lasting

almost 200 days when the perceived purpose of the

mission was not as clear. During that cruise, crew

members felt continuing responsibility for what

was going on at home and were “worried” quite

often during that cruise. The average number of

medical evacuations was some 2 to 3 per month.35

Medical Organization

The medical department aboard an aircraft carrier includes a senior medical officer who is also a

U.S. Naval flight surgeon as well as additional general medical officers. There would usually be a

general surgeon aboard during a cruise. An aircraft

carrier has extensive sick bay capability including

surgery and intensive care. When aircraft squadrons are aboard they usually bring their own flight

surgeon and medical section aboard with them.

It is through the medical department that psychiatric services must generally be provided. These

generally consist of those services the medical staff

feels comfortable providing. Flight surgeons have

an extensive psychiatric component to their training syllabus. For those diagnostic and treatment

services beyond the expertise of the medical department, consultation is sought at the Naval Hospital,

either in port or home port, or medical evacuation is

initiated.

Marines: Amphibious Warriors

History and Doctrine

It is generally held as an axiom that the entire

purpose of navies and seapower is to influence

land. The most direct form of such influence is

through the landing of troops. Historically, landings were rarely attempted in which troops were

opposed during the landing and had to fight their

way ashore.

The history of modern amphibious warfare began in Gallipoli in 1915 with disasterous results. In

the United States, General John A. Lejeune was

Commandant of the Marine Corps from 1920 to

1929. He was searching for a unique role for the U.S.

Marine Corps and extensively studied the landing

at Gallipoli. He ignored the maxim that developed

after the operation which was that the advantage in

such an operation was always with the defender. It

was his opinion that the operation had failed for the

more mundane reason of incompetence of execution. He set upon making the amphibious assault

landing a U.S. Marine Corps specialty. Subsequent

history in the Pacific campaign during World War II

proved his foresight.

The culture and doctrine of the U.S. Marine Corps

differ in general from those of the U.S. Army. The

U.S. Marines more often believe that an all-out

assault at the beginning of a battle will ultimately

result in success with fewer casualties than the

alternative which provides for a slower assault

waiting for an overwhelming force to be brought to

bear.

Psychiatric Casualties

Case Studies 5 and 6 relate different aspects of

U.S. Marine operations in the pivotal battle of

Guadalcanal. Case Study 5, contributed by Colonel

Joe Fagan, discusses factors that protected U.S.

Marines from becoming incapacitated from combat

stress. Case Study 6 discusses some of the severe

stressors faced by U.S. Marines and their psychiatric sequelae reported in the press at that time as

“Guadalcanal nerves.”

Case Study 5: The Protective Effect of Unit Morale

Generally speaking, the success or failure of military

operations is more dependent upon group activity than on

individual effort. Esprit de corps is often considered

synonymous with group morale. It is high when individuals feel that they belong to a unit, place unit interests

above their own, and are willing to strive for the goals of

the unit.

“Creature comforts” (such as good food and post exchange [PX] availability)36 are less essential for group

success than unit identification and cohesion. Because

individual morale is more volatile than unit morale, the

unit, by providing a stable sense of group, can dampen

and compensate individual morale fluctuations over a

period of time.

To illustrate this concept, the Battle of Guadalcanal is

studied because the success at Guadalcanal was related

to the staying power of the U.S. Marines more than

anything else. This staying power is a manifestation of

leadership and morale.

The Battle of Guadalcanal was pivotal. Churchill concluded that Guadalcanal was one of those battles that,

won or lost, would change the entire course of events in

the world. Admiral Nagona, Chief of the Japanese Naval
225

U.S. Naval Combat Psychiatry

General Staff, and General Kawabe, Deputy Chief of the

Japanese Army General Staff, reported during an interview after the war that Guadalcanal was the turning point

for them in the Pacific in World War II, marking their shift

from the offense to the defense.

The amphibious invasion of Guadalcanal, 7 August

1942, was, fortunately, essentially unopposed. However,

from that day on life was very difficult for the U.S. Marines.

When the Japanese realized what had happened, their air

and naval attack on the U.S. Navy task force supporting

the U.S. Marines was so intense that the naval supply

ships were forced to withdraw on 9 August 1942 without

unloading a substantial amount of supplies needed by the

U.S. Marines. Supplies present in insufficient quantities

included barbed wire, radio batteries, medical supplies,

and camouflage materials.37,38 The Japanese air and

naval forces subsequently enjoyed control of the sea and

air around Guadalcanal. Consequently, the Japanese

were able to land reinforcements and supplies as needed

while the U.S. Marines received only a trickle of supplies

and reinforcements.

A comparison of combat power of the U.S. Marines and

the Japanese forces is difficult to quantify as accurate

records are lacking and the situation was dynamic over

time. Initially, the U.S. Marines landed 10,000 to 11,000

troops while the Japanese had a force on the island of

2,000 to 5,000 soldiers and laborers. The Japanese, upon

realizing that the U.S. forces were confronting them in

their drive to Australia, began to exercise their air and

naval superiority to concentrate their forces to drive the

U.S. Marines from the island. The Japanese were able to

field a force of 26,000 to 29,000 troops which they maintained at that level despite substantial losses throughout

the bulk of the campaign. The U.S. Marines gradually built

up their forces so that by mid-October they had about

23,000 troops and by the time the 1st Marine Division was

relieved in early December the level had reached about

45,000.39

The Japanese from August through November utilized

about 37,000 men and sustained losses estimated between 20,000 and 28,000 troops. The U.S. Marines,

utilizing fewer troops experienced substantially fewer

losses. The 1st Marine Division during the 4 months of

combat sustained about 2,736 losses. For a better comparison with the Japanese figures, the U.S. forces in all

sustained about 6,000 losses.37,39 The ratio of Japanese

losses to U.S. losses is about 4 to 1. However, numerical

comparisons do not tell the story of Guadalcanal.

Although the Japanese for most of the campaign enjoyed air and naval superiority in terms of combat power,

the U.S. Marine pilots fought with the same will and

determination as did the ground troops. Their force never

exceeded 60 planes,37 but their impact upon the Japanese

planes and ships was substantial. The fighting on the

island itself could but be described as a series of protracted small unit operations savagely fought in conjunction with a perimeter defense of Henderson Field. While

each engagement was significant, a survey of the overall

campaign will indicate those factors that allowed the

Marines to defeat the Japanese.

Every man was critical with each unit deployed on the

perimeter in an overextended front since there were no

replacements or reserves. As the area of the perimeter

was small, no spot could serve as a respite from the

attacks, shellings, and bombings.40 Henderson Field and

the nearby hospital were constant targets and thus provided no greater safety than the front lines. When limited

reinforcements did arrive on 17 September 1942, they

permitted slight relief although they served to thicken the

thinnest ranks and to permit the battle weary U.S. Marines

to launch counterattacks as well as to maintain their

perimeter defense. While the U.S. Marines were winning

the battle, they were increasingly incapacitated by attrition, fatigue, and disease. The Japanese in a sense held

the U.S. Marines in a constant state of siege.

Two weeks after the amphibious landing, the U.S.

Marines turned back the first major Japanese offensive at

the Tenura River. In mid-September, the Japanese again

marshalled their forces although they were stopped at the

Battle of the Ridge. A defeat for the U.S. Marines would

have been devastating and was prevented by only the

narrowest of margins. Near the end of October, the U.S.

Marines held against the most furious of the Japanese

attacks at the Matonikau River. Fighting these battles

over and over sapped the strength and vitality of the men

who were already suffering from malnourishment, fatigue,

malaria, dysentery, and a host of other tropical maladies.

However, they continued to fight and to fight well. From

this point on, the tide of the battle swung toward the U.S.

Marines although the actual fighting continued for some

time. ln lieu of tactical or logistical advantages, the U.S.

Marines had utilized will, determination, and leadership.

The Guadalcanal Campaign can be examined within

the framework of what many consider nine essentials for

“individual” morale during combat.

1. Good food. The U.S. Marines landed, having lost

weight while on board the transport ships. After

landing, and largely because of the withdrawal of

their supply ships, they again had a substandard

diet offered only twice a day from 12 August 1942

on. Although their diet did fluctuate considerably

over the course of the campaign, typically it was

cold and consisted of combinations of beans, hash,

rice, spam, and so forth, both for breakfast and

supper. Captured enemy food supplies were the

difference between a starvation diet and one above

that point during the early phases of the operation.38,41

2. Special rations and PX. There were none.

3. Physical comfort. Prior to landing, the U.S. Marines had been confined in crowded troop transports for a minimum of 29 days.37 Upon landing,

they were met by a tropical climate with high temperatures and humidity. A shortage of water complicated their situation. Sleep and rest were effectively curtailed by Japanese float planes nicknamed

“Louie the Louse” who dropped flares and “Washing Machine Charlie” who dropped impact fused

bombs almost nightly. In addition, Japanese naval
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forces shelled Henderson Field quite regularly.

The Japanese were able to fulfill their purpose of

denying the U.S. Marines any rest and to wear them

down mentally and physically. Because of the

nightly attacks the men generally slept in their

foxholes which often had about 6 inches of water in

them. Improving your foxhole was said to be the

universal recreation on Guadalcanal.37

4. Good health. Malaria, dengue fever, and numerous fungal infections were endemic in Guadalcanal.

In addition, an epidemic of dysentery required about

a month to control. Estimates were that at any

given time 20% of the U.S. Marines were incapacitated by the dysentery. As the epidemic was

brought under control, severe fungal infections,

aggravated by the men being generally without

proper footgear and standing in water, severely

limited the mobility of the men on an ongoing basis.

The main health problem, however, was malaria.38

It reached epidemic proportions shortly after the

acute dysentery was brought under control. During

the campaign about 7,000 U.S. Marines were hospitalized with malaria. Because of the manpower

shortage, the criteria for hospitalization was a fever

greater than 103 degrees Fahrenheit or about 4

degrees above normal. These conditions, of course,

coexisted with malnutrition, fatigue, and battle

wounds.37

5. Clean and adequate clothing. The military uniforms didn’t stand up to the tropical environment

and resupply was limited and sporadic. The men

often fought barefoot with fatigue cutoffs. In midSeptember they did receive about 20,000 pairs of

boots so that the men wouldn’t have to fight barefoot.37 Bathing and washing facilities were quite

limited.

6. Dependable policy of rotation. Rotation was not

possible as every man was needed for the defensive positions.

7. Combat relief. The 1st Marine division experienced essentially constant combat from 7 August

1942 until relieved by U.S. Army forces 7 December 1942, when the worst of the battle was finished.

Initially the U.S. Marines believed that they would

have air and naval support and be relieved by U.S.

Army troops in about 3 weeks and that they would

be returning to New Zealand. When this did not

occur, most despaired ever leaving Guadalcanal.

8. Regular delivery of mail. This certainly improved

morale within the 1st Marine Division. Data are not

available as to how often the mail was delivered.

The first delivery of mail did occur 1 September

1942.42 As one officer observed, each man seemed

as happy as if he’d been given $100 at the mere

thought of getting mail. Some said that mail should

have priority over food.42 The delivery of mail

seems to have been a positive factor for morale.

Presumably the mail was delivered on a sporadic

basis but details are not available.

9. Information. This may have had the greatest impact in terms of improving morale. General

Vandegrift used a billboard near the center of the

perimeter to display a graphic representation of the

perimeter defense of Henderson Field so that each

man, and each unit, could visualize their part as

well as the part played by others in their mission.

They also knew that if they could hold Henderson

Field the pilots would be able to provide some air

protection for them. Consequently, there was a lot

of pride in their “air corps.” On the same billboard

next to the baseball scores was a running account

of the number of Japanese aircraft “their” pilots had

shot down. Another example of the impact of command information on the men was their reaction

when notified that Admiral Halsey was assuming

command of the South Pacific Naval Forces. One

officer reported that, “I’ll never forget it—one minute

we were too limp with malaria to crawl out of our

foxholes—the next minute we were running around

shouting like kids” upon hearing the news.37 The

men believed that he would send them assistance.

This appraisal of the nine elements finds that the U.S.

Marines were substantially lacking in terms of good health,

physical comfort, good food, PX and special rations, clean

and adequate clothing, a dependable policy of rotation,

and combat relief. They did possess adequate command

information and benefitted greatly from delivery of mail.

However, they were lacking substantially in seven of the

nine essentials and yet maintained good morale.

The morale possessed by the 1st Marine Division was

not expressed by happy or contented troops with the usual

attention to dress, appearance, or protocol but by grimfaced U.S. Marines doing a very difficult and dangerous

job but doing it well. As General Vandegrift observed,

“They look like a bunch of Gypsies, but they’ll fight because they’ve got it in here (tapping his chest).”42 Possibly

group morale in combat is best observed by noting how

well the men carry out their mission.

Another perspective on morale in combat is gained by

looking at the psychiatric casualty rate, sometimes used

as a measure of morale.43 A report by medical officers

treating the wounded evacuated throughout the Pacific

indicated that the 1st Marine Division on Guadalcanal had

about the lowest rate of psychiatric casualties of any of the

Pacific campaigns.40 In general the Pacific theater had a

higher ratio of psychiatric to wounded casualties than the

European theater43 with the exception of Guadalcanal.

Perhaps more important, however, was the fact that even

the nonpsychiatric casualties showed emotional reactions of a severity which would often have been considered incapacitating in other campaigns but not at

Guadalcanal. Most of the men who were evacuated for

psychiatric reasons had already been treated and returned to duty several times on Guadalcanal before it was

necessary for them to he evacuated from the island.40

This suggests excellent treatment of psychiatric casualties in combat, the need to conserve manpower wherever
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U.S. Naval Combat Psychiatry

possible, and the feeling of the men that they didn’t want

to leave their fellow soldiers behind. This group cohesion

prompted the men to continue under conditions that at

other times, other places, would have resulted in evacuation. As previously noted, group morale is considered

high when individuals feel like they belong to a unit, place

unit interests above their own, and are willing to strive for

the goals of the unit. This was seen on Guadalcanal

where group morale sustained the U.S. Marines when

individual morale, often dependent on “creature comforts,” was lacking. The unit was able to keep the individuals going.

General Vandegrift took some other steps which also

contributed to unit morale. He set up his personal tent and

command post alongside his men and by sharing their

hardships and risks he obtained immunity from criticism in

regard to the hardships they endured. Their frustration

was displaced to the “swab jockeys” who “hauled ass” and

the “dog faces” who didn’t relieve them. This allowed the

men to avoid losing faith in their “own” chain of command.

General Vandegrift also recognized early on that his

men in response to the “siege” conditions under which

they were operating were “more than ready for a fight...they

were aching for one.”37 This was because enforced

passivity in the face of an ever present threat will lead to

hopelessness if not countered by measures that allow for

the channeling of the frustration into action. Thus General

Vandegrift decided on a series of limited attacks on the

Japanese to reduce the tension and to keep the Japanese

off-balance.41 The strategy worked quite well, in part

because the experience of success against the Japanese

helped to destroy the myth of the invincible Japanese

soldier. On other occasions, General Vandegrift, in addition to genuine battlefield decorations, used mock awards

ceremonies to break the misery and fear with humor using

captured Japanese medals.42

In addition, from General Vandegrift on down the chain

of command, the officers were expected to and did lead by

example when necessary. There were examples of colonels and their staffs taking the “point” on river crossings

when the men seemed to be holding back—ominously

eyeing the forbidding dark woods. The colonels’ effort

was enough to resolve the situation. They also were able

to convey to the men that they [the men] were capable of

carrying out their mission despite the difficulties and that

the officers fully expected them to do so in the tradition of

U.S. Marines. The men were able to put forth second and

third efforts that were essential for their defense to hold.

Comment: This study illustrates that morale in combat

does not depend upon “creature comforts” but rather upon

the quality of leadership and the cohesiveness of the

small unit. In essence, it is not the hardships that the men

endure that destroys morale, but rather that the unit itself

can help them endure.

Case Study 6: Guadalcanal Nerves

The World War II amphibious campaign in which American doctrine would be tested began on 7 August 1942

when the amphibious assault on Guadalcanal began the

island-hopping strategy which would mark the campaign

in the Pacific. The assault was covered extensively by the

press and brought the terrible realities of such warfare

home to the American public for the first time. The landing

was not opposed, so was not an assault landing in the

sense of a frontal assault against a determined opposition. The stressors of the campaign were, however,

unique and resulted in psychiatric sequelae labeled in the

press as “Guadalcanal nerves.”23

“Fear of all kinds entered the picture. Most men

experienced fear as they approached the beach. Some

tell you of their fear of being afraid and exhilaration as

soon as they went into actual combat. But new attacks,

new bomb near hits would relight fear—and all this was

sure to take some toll. As the weeks passed, hope left

most of these men—hope of winning the battle, hope of

being aided or rescued. They were alone on the island

and their expected relief did not come. They had no way

of knowing why it did not arrive. Soon they were sure that

none of them would get off the island—they were expendable, doomed. Soon this helpless hopelessness overwhelmed them and contributed in no small part to their

final collapse.”43(pp94–95)

Comment: Other factors in psychiatric breakdown included gross sleep deprivation from Japanese activities

at night, weight loss as high as 45 pounds, rain, heat,

insects, dysentery, malaria, and an exposure lasting

months. Ultimately the result of exhaustion, fear, malnutrition, and disease in this jungle combat environment

took a physical and mental toll. Numbers of psychiatric

casualties evacuated are not uniformly recorded. One

observer noted that aboard one ship which evacuated

casualties 48 of 350 total casualties were psychiatric.44

From his experiences in treating those casualties, he

concluded that “By and large men were fighting to get

home” rather than for some more abstract reason; that

“Every unit should have an experienced Sergeant or

Lieutenant with it”; that “Men should go into battle with a

unit—not alone”; and that you should “Keep the feebleminded out of the jungle,” recalling that when men with a

mental age of 12 were sent into the jungle with their units

they were more prone to “crack” and “then others around

them would crack.” This worry presages current concern

about “contagion” of stress casualties in a unit.

Those psychiatric casualties evacuated to the

United States from Guadalcanal seemed remarkably uniform to observers after their arrival. They

suffered from

headaches, lowered thresholds to sharp noises,

periods of amnesia, of panic, sensory somatic complaints, marked muscular hypertonicity, tremors

generalized or limited, functional palsies....Many

arrived with cotton stuffed in their ears, and on the

returning transport many of them required physical restraint if there was test firing....[T]hree weeks
War Psychiatry

228

after combat, they had, according to their own

statements, improved immensely....The fear that

they would be thought ‘yellow’ was universal....We

found one of our first duties to these newly arrived

patients was to endeavor to relieve them of this

thought of cowardice.43(p94)

One enlisted U.S. Marine rifleman lived to reflect

and has written of his experiences in the amphibious assaults on Peleliu and Okinawa.

As a Marine infantryman I was no better than

average, I served through two major campaigns...I

was wounded twice, cited for bravery once, and

two times I was too frightened to do the job to

which I was assigned...I know...that every man

has his limit; but just as some men are taller and

heavier, so some men can go longer and take more.

Bravery is a fickle thing. It runs in some kind of

cycle: it comes and it goes. One day a man is a lion

in the fight: the next day a mouse...I have seen men

who were brave when their feet were dry, cowards

when they were wet; brave when they were warm,

cowards when they were cold; brave when they

were full, cowards when they were hungry; brave

as long as they got their sleep, but cowards when

they didn’t. We often contrast bravery and cowardice. We think there is nothing between the two,

but most men who know war know that there

is.45(pix,x)

In preparing to board an AMTRAC (amphibious

transport craft) prior to his first landing he recalled

that,

I caught fear from the men around me. I was deeply

shamed for them and for myself. Later I got used to

fear. It was like a scar or a limp that I had to learn

to live with. I learned always to control what

showed in my face, my hands and my voice. And

I let it rage on inside. I never lost my fear, but I lost

my fear of fear, because it became such a familiar

thing.45(p4)

In commenting on motivation and loyalties during combat he notes that,

In a war, loyalties shrink down past country and

family to one or two men who will be with you.

They become more important than anyone else in

the world, more precious than father and mother,

sister and brother, wife and girl. Only a few lonely

men go though a war without buddies.45(p9)

Some months later Davis was assigned with an

officer with whom he had many hours to talk and

discovered the healing value of such recollection

and retelling.

[H]e was the one who finally cured me of my

nerves. He had been in many campaigns, and he

liked to tell ‘sea stories.’ He got me telling stories

of what happened on Peleliu; and somehow, in the

telling, the campaign didn’t seem so bad. I began to

sleep nights again.45(p9)

After the battle of Leyte Gulf had been won by

the U.S. in late 1944, it had likely become clear to

Japan that the ultimate objective of the U.S. operations in the Pacific would be an actual invasion of

mainland Japan. Iwo Jima was anticipated to be a

halfway station to provide fighter escort and emergency refueling for air raids of the Japanese home

islands.

One of Japan’s most capable generals was put in

charge of the defense of Iwo Jima. As a result, the

amphibious landing was one of the most heavily

contested and deadliest operations in history. Of

23,000 Japanese troops who opposed the landing all

but 200 died. The 60,000 Marines suffered 5,931

dead and 17,372 wounded.39

The Fifth Marine Division had a total of 2,779

killed in action. There were 1,285 wounded who

needed evacuation. There were 590 hospital cases

of combat fatigue, 369 of which were evacuated

and 221 returned to duty. That number was

closely approximated by the number of sick

(nonbattle injury) of which 329 were evacuated

and 252 returned to duty. Cases requiring evacuation for either combat fatigue or wounds would

total 1,654 of which 22% would have been combat

fatigue.39

Psychiatric Casualties in Medical Personnel

One group not often thought of in planning for

battle fatigue casualties is the medical personnel.

On Iwo Jima, 195 corpsmen were killed and another

529 were wounded. Seven doctors were also killed

and 12 wounded.46

A battalion at that time consisted of some 900

U.S. Marines and the medical section had a battalion surgeon, an assistant battalion surgeon, a chief

corpsman, 48 corpsmen and 16 assigned litter bearers. Litter bearers were thought to have the shortest

life expectancy during amphibious operations as

they had to stand upright to bear litters.

Case Study 7: Doctors in Distress

Dr. James Vedder was the battalion surgeon for the

Third Battalion, 27th Marines with the Fifth Marine Division.47 He described some physicians who became psychiatric casualties at Iwo Jima:
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U.S. Naval Combat Psychiatry

As he moved forward, he encountered another group

of medics providing care and asked about one of the other

doctors, who responded in a low monotone from from

directly behind, “Here I am Jim. I’m doing all right.”...He

wheeled around to face Dr. Webber, who was standing

stiffly upright, his face a frozen mask and his blank stare

fixed on the horizon. Dr. Vedder continues, “We moved

out into the open country, and I noted that Webber had not

moved or spoken. His hands were still jammed into his

pockets, and his immobile face was pointed in the direction of the western horizon.”

The next day, D-Day +2, litter bearers brought Dr.

Webber who had been with the First Battalion, 27th

Marines to Dr. Vedder’s aid station. After the litter bearers

had deposited his large-boned, well-muscled body, a

careful survey by Vedder discovered no recognizable

wounds but all his muscles were contracted and his eyes

were rolled upwards so that only the white sclera were

visible. It was impossible to rotate him in any direction. As

he lay there, breathing deeply at a normal rate with a

ruddy color of good health on both cheeks, Vedder noted

that “his bladder was functioning properly” as a large area

in the crotch of his pants was soaked with urine. The

accompanying medic noted that there had been no injury:

“He just stiffened out like a plank during the night.” Vedder

wondered whether Webber could be feigning these unusual symptoms in order to get evacuated. To test this

possibility, he gave him a jab in the thigh with the sharp

point of a mosquito forceps. Webber uttered a loud grunt,

his back arched up off the litter, but soon he settled back

on the litter with a sigh, groaned and his bladder contracted.

After evacuating Dr. Webber, Dr. Vedder wondered

what had caused the collapse:

“Physically he was stronger than most of us. But

emotionally, he was far from strong. For weeks he had

been living in a state of anxiety and terror that mounted

daily as we neared the shores of Iwo Jima. Perhaps he

had become a casualty long before he set foot on the

black sands of this bloody island, with this paralysis

merely the final stage.”

The next morning, the Battalion Surgeon from the Third

Battalion, 26th Marines wandered into Dr. Vedder’s aid

station in a state of acute agitation. Vedder commented:

“Between spells of sobbing, choking, and trembling, he

managed to blurt out his unbearable problems. His unit

had suffered heavy casualties when they had traversed

our shell torn road the afternoon before. Their present aid

station was located a few hundred yards to the northwest.

They were working in open country without any suggestion of concealment. His men were being picked off at all

too frequent intervals. His turn was sure to come soon.

He just couldn’t take it any more. He had felt like running

off and hiding many times in the last 72 hours, but duty had

forced him to stay on with his men. Now he did not care

what happened....It was obvious that he was emotionally

unfit to continue to function as a doctor at least for the time

being. His evacuation tag was labeled ‘combat fatigue.’

Without further ado, he was loaded on a passing truck with

two Marines who had also ‘cracked up.’

“About a half hour after that evacuation, the Assistant

Battalion Surgeon of the Third Battalion, 26th Marines

“drifted into our aid station with the remnants of his

medical section. Until the present, he had been an eager

young physician willing to cope with the vagaries of

military life. Now he appeared quite discouraged and

despondent. Losing nearly half his men in the past 24

hours had been a severe blow. The recent collapse of his

battalion surgeon was more than he could handle. He

came to us for both help and companionship....He said

‘Jim, I am all alone out there. Can I tie in with you until

replacements arrive?’ Several hours later, they were

again functioning as a medical military team.”

Dr. Vedder had to balance evacuation and other requirements in the case of a corpsman who had been sent

up as a replacement.

“When I finally returned to my foxhole, I found De Wolfe

still huddled up on his litter nervously gnawing on a ‘K’

ration biscuit. He presented a sad picture of total dejection. It seemed unlikely that he would ever become an

asset to our medical section. My impulse at that moment

was to sign him out as a combat fatigue and send him to

the rear...but second thoughts ruled out this simple solution and the morale of the whole group had to be considered. After all, De Wolfe had yet to serve any front line

duty. Many of his comrades, who were just as frightened

as he, were functioning well under adverse conditions. If

De Wolfe were sent back now, how many others would

elect to follow the same course? So De Wolfe had to go

back to H Company.”

While going through the cemetery, after the campaign

was over, Dr. Vedder chanced upon a grave marked with

the name De Wolfe. He recalled how hard he had worked

to persuade De Wolfe to overlook his fears. He knew that

in his last days he had been an asset to the medical

section serving his fellow men and felt certain that his

mother and family would have been proud of him.

“A feeling of acute depression engulfed me as I walked

out of the cemetery. I wondered if the price paid was really

worth it. As I slowly headed back towards my jeep, one of

the frequently used war slogans came to mind. ‘Our

Marines were willingly laying down their lives for their

country’. This statement was sheer nonsense for the

overwhelming majority of the men felt that they would be

spared, and that it would be the next guy that would get

killed or wounded. They had no intention of laying down

their lives for their country or anything else. Each man

believed he would be one of the lucky ones to return

home. Those that lost or never did have this feeling of

invulnerability would sooner or later crack up.”47(pp198,199)

Comment: The psychological toll of combat will also be

paid by medical personnel. These vignettes are particularly illustrative of that principle in the context of an

amphibious assault against a motivated enemy.

During the Persian Gulf War reported psychiatric casualties were low in U.S. Marine Corps units.

A classic amphibious assault did not take place

although the threat of one riveted Iraqi attention.
War Psychiatry

230

The 2d Marine Division psychiatrist was located

forward with the division headquarters and saw 25

referrals. He was able to return 22 of them to duty

at the front. The 1st Marine Division Psychiatrist

was able to personally educate over 7,000 personnel

about combat stress and its management before the

war started.48

Once again, reason to not forget about medical

department personnel in planning for casualties

was seen—particularly mental health personnel.

One division psychiatrist developed disabling posttraumatic stress disorder on the first anniversary of

the ground war. Interestingly, half of the mental

health officers assigned to U.S. Marine Corps units

in the first few months of the operation were returned to the continental United States before the

ground war began—including one who was deployed while on antidepressant medication.

Medical Organization and Planning

Medical assets within Marine Corps Forces include organic support for all combat and combatsupport organizations of battalion/squadron size

or larger. At the battalion level each Infantry Battalion has organic medical assets that consist of two

medical officers and 65 hospital corpsmen during

combat. The Battalion Surgeon is a special staff

officer. Within the battalion, a medical team of 11

corpsmen is assigned to operate with each rifle

company in combat. The division medical section

consists of a division surgeon, an administrative

officer, an environmental health officer, and a psychiatrist. There are at present no specifically delineated duties for the psychiatrist who acts as an

advisor and assistant to the division surgeon.

The division surgeon performs general duties

under the cognizance of the G-4 (Assistant Chief of

Staff [Logistics]) with respect to medical matters.

Responsibilities include planning and supervising

treatment and evacuation. The division psychiatrist must advise the division surgeon in these matters as they relate to psychiatric casualties.

Corresponding to the division surgeon are the

wing surgeon for the Marine Air Wing and the

group surgeon for the Fleet Services Support Group.

Within the Fleet Service Support Group there is a

medical battalion designed to provide second echelon (Echelon 2) support.

A medical estimate is prepared by the landing

force surgeon and his staff and is intended to be a

logical comparison of the medical requirements of

each course of action. Casualty estimates are the

doctrinal responsibility of the G-1 (Assistant Chief

of Staff [Personnel]). Without this estimate, including numbers of psychiatric casualties, planning will

be inadequate. The planner should be aware of the

possibility of such casualties and outline courses of

action with the division psychiatrist.

There must be close cooperation between the

landing force surgeon and the amphibious task

force surgeon on D-Day of an operation. Units will

go ashore with their organic medical support. Handling of combat fatigue or combat stress reactions

by personnel organic to the combat units going

ashore would be optimal. Once ashore, evacuations

rearward will usually be to a battalion aid station

after triage by corpsmen working at the company

level. Further to the rear, as time goes on, will be a

beach evacuation station or Echelon 2 collecting

and clearing company. These are points where

combat fatigue or combat stress casualties can be

pooled. The logistics of amphibious operations are

such that it must be remembered that evacuation

may bypass a lower echelon and end up at a much

higher echelon—possibly at sea.

Those ships taking part in an amphibious operation have medical treatment capability as well.

Amphibious assault ships include the LHA (landing ship, helicopter, assault) which resembles an

aircraft carrier and is capable of transporting approximately 1,900 troops with the vehicles required

to land them. They are normally designated as

primary casualty receiving and treatment ships

(PCRTS) in an amphibious operation. They have

the largest medical capability of any ship currently

in commission with medical spaces including two

major and two minor operating rooms, 60 hospital

beds, including an intensive care area and 225 to 230

overflow beds. It is possible for the LHA to be

augmented with support personnel and the potential of receiving psychiatric casualties on these ships

could be considered during the planning phase.

An LPH (landing ship, platform, helicopter) is

designed to transport a battalion landing team utilizing vertical assault capability. They can carry

about 900 to 1,000 troops and the medical spaces are

limited to about 90 beds. They are not practical for

use as primary casualty receiving treatment ships

(PCRTS) although it is possible to use them in this

capacity by using troop spaces as operating rooms

and wards. They can be used as secondary casualty

receiving treatment ships (SCRTS) and might be

considered for psychiatric casualties. The medical

department would require augmentation or training for such treatment.
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U.S. Naval Combat Psychiatry

Other ships [known as “L” class ships for their

“landing ship” designator letters] have more limited

medical capability such as Dock Landing Ships (LSD),

Amphibious Cargo Ships (LKA), Tank Landing Ships

(LST), and Amphibious Command Ships (LCC).

Currently there is no specific U.S. Navy doctrine

that details the handling of combat stress reaction

or psychiatric casualties. Such casualties will only

be considered if included in the medical mission

statement.

During the Persian Gulf War, The Medical Officer of the Marine Corps, Rear Admiral Dick

Ridenour, himself a psychiatrist, requested that the

author consult with the U.S. Marine Corps forces in

theater on the handling of combat stress casualties

as there were conflicting reports on requirements

coming from different sources in theater.

There were several organizational problems encountered. One of the foremost was a senior staff

surgeon who reported that he did not believe in the

concept of stress casualties and did not like the fact

that additional resources had been sent into theater

to handle them despite his not requesting them. The

second was fragmentation of command and control

for medical services such that a “system” that would

have to cross unit and echelon of care boundaries was

next to impossible to coordinate because of a third

problem, which was lack of doctrine.

Those additional mental health assets sent

into the theater through the intervention of Rear

Admiral Ridenour were nevertheless in place in

four combat stress centers arrayed across the

front at the beginning of the ground war. The four

centers were under separate commands and

had markedly differing philosophies for treatment

based on preferences of the senior mental health

officer assigned. Each had the capacity to handle 45

patients.

There was also difficulty coordinating requirements for treatment with the U.S. Navy who

controlled the echelon 3 Fleet Hospital assets.

Thus, mental health officers at each unit were essentially deciding what treatment mission they would

perform without coordination. Despite these problems the tremendous dedication and talent of

the U.S. Naval mental health personnel assigned,

and sometimes their ingenuity in working around

the organizational problems, resulted in successful

performance of the mission. An interesting sidelight is that each psychiatrist involved in the Persian Gulf War was furnished drafts of five chapters

of this volume, delineating combat psychiatry principles, by their respective surgeon general psychiatry consultants.

CARE OF CASUALTIES

There is no record of the existence of hospital

ships in the U.S. Navy prior to the outbreak of the

Civil War when extensive use was made of hospital

ships by the Federal forces operating on the Mississippi River. Also isolation ships made from former

river barges were in use for smallpox patients.

The U.S. Navy’s first hospital ship was the Red

Rover, which was a side-wheeler that Union forces

had captured from the Confederacy and converted to a hospital ship. The U.S. Navy’s first

volunteer nurses served aboard the Red Rover. Hospital ships were also used in the Spanish-American

War and World War I. At the end of World War II,

there were 12 hospital ships in the U.S. Navy. During the Vietnam conflict, two hospital ships,

the USS Repose and the USS Sanctuary, were used

offshore.

Lieutenant Commander Strange was aboard the

USS Repose in 1966 off the coast of Vietnam.49 The

Repose had 500 beds, 48 of which constituted the

psychiatric unit. The staff consisted of one psychiatrist, one psychiatric nurse, and nine hospital corpsHistory of Hospital Ship Operations

Spain appears to have been the first of modern

nations to utilize the tactical advantages of hospital

ships sailing with their fleet during the Armada.

The British began using hospital ships sometime

after an experience in 1626 when many men became

sick and were distributed to the whole fleet, two to

each ship, by which means, “the sickness was increased to such a degree that were scarce hands

enough to carry the fleet home.” The French toward

the end of the 17th Century recommended that 100-

bed hospital ships, devoted exclusively to the care

of the sick and disabled be attached to the French

Fleet in proportion of one hospital ship to every 10

ships of the line.

A real history of the modern hospital ship begins

about the middle of the 19th Century when, during

the Crimean War in 1854, England employed a fleet

of transports to convey home the sick and wounded.

In some 22 months over 100,000 patients were transferred home.
War Psychiatry

232

men. It was an open unlocked unit; patients were

allowed freedom of movement aboard the ship commensurate with their degree of illness and responsibility. Patient census fluctuated greatly between

12 and 35. Stays ranged from overnight to 60 days

or more.49

Mean length of inpatient care was 13.5 days.

During that 7 months period, the Repose steamed in

a scheduled pattern and received patients sent from

major hospitals ashore at which time it functioned

as a third echelon of treatment. Frequently, however, the ship furnished direct combat support with

casualties being evacuated directly from medical

units in the field with no previous specialty evaluation, placing the Repose in the role of second-echelon treatment.49

This fluctuation of echelons of care, depending

on how a patient is evacuated, can certainly be

expected in future operations. The availability of

any medical support towards which helicopter or

small craft evacuation is occurring can certainly

bring casualties immediately to the hospital ship.

During Lieutenant Commander Strange’s tour, 143

psychiatric patients were seen with 54% referred to

the ship by psychiatrists and 46% arriving aboard

ship with no initial psychiatric contact elsewhere.

Out of the patients, 67% were classified as character

and behavior disorders, 20% psychoneurotic, and

13% as psychotic.49(p37)

The U.S. Navy today has two hospital ships,

USNS Mercy and USNS Comfort. They are designed

as 1,000-bed medical treatment facilities and have a

psychiatrist assigned as a member of the medical

treatment facility. During the Persian Gulf War

each had a psychiatric ward prepared that could

have handled 50 to 100 patients.

Rear Admiral H. James T. Sears, a psychiatrist,

was assigned to the USS Repose early in his military

career. He still recalls the formative influence of

that tour on his decision to stay in the U.S. Navy.50

He remembered the psychiatrist was often used as

a triage officer when necessary. He also recalled the

tremendous stress experienced by the crew of the

hospital ship and the necessity of remembering to

“care for the caregivers.”

Rear Admiral Frances T. Shea, former head of the

U.S. Navy Nurse Corps, served a tour as the Operating Room supervisor aboard the Repose.

51 She

recalled that when adjusting to the initial shock of

caring for casualties, people are not prepared for

the catastrophic casualties that will come to the

operating room. When her tour was up and she

returned stateside, she felt guilty—that she didn’t

do enough, didn’t care enough, that she left her

shipmates and patients behind. She realized after

returning to hospital work that she still couldn’t

talk to patients, particularly if she knew that they

might die. That feeling went on for years compounding her guilt.

She found that the role of the nurse as comforter,

consoler, and sympathetic listener heightened the

stress she had already been experiencing. For her,

understanding and admitting that she had been

under great stress was therapeutic. She now relates

that she has no difficulty visiting patients and can

talk openly about experiences that were painful.51

In planning for future hospital ship operations,

the tremendous stress of caring for casualties in a

1,000-bed medical facility should be considered and

staff psychiatric support should be added to the

mission. Some of this same emotional toll will be

borne by psychiatrists. Perhaps it would be best

that no psychiatrist be assigned in echelon 3 facilities without other mental health support.

Psychiatric Care of the Combat Injured

The combat wounded have psychiatric needs

that must be addressed.52 When someone is injured,

their sense of personal invulnerability has been

breached and they may become extremely reliant

upon medical personnel for reassurance. Such reassurance can be of immense aid to those who have

sustained minor injuries and it is essential for those

who have major injuries. It is noteworthy that

casualties may become anxious at each step of the

evacuation chain. Many feel that the personnel

where they are have kept them alive and they do not

want to leave.

Traditionally, medical staff gather historical information about the injury itself but do not talk to

the patients about their emotional reaction to the

injury. Medical staff have their own need for denial

about the carnage that they see and may rationalize

not discussing injuries with patients on the basis

that “They have suffered enough; they do not need

to talk about it any more.” At stateside medical

facilities many medical staff will have their own

fantasies about what the combat experience was

like. Working with those staff in an educational

way can be helpful.

Patients are more than willing to recount their

experiences. They are primarily young and may be

placed into semiprivate, if not private, rooms which

can be equated with “good care.” They tend to do

better, however, in more open environments where
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U.S. Naval Combat Psychiatry

they can see and support each other. Group therapy

time can be built into ward schedules if the injured

are grouped together in a specific ward environment. A group “debriefing” format can be most

helpful. A strong need of the patients is to find out

what happened to friends. There is usually much

time spent trying to reconstruct what was happening at the time that they were injured. In facilitating

the grief of these patients, particularly those who

may have lost shipmates, a memorial service of

some sort is essential.

Hospitals may be visited by dignitaries, family

members, and the press, creating many time demands upon the injured. The families of those most

severely injured may feel that the patient would be

“better off dead.” As time progresses, and they

become used to the disability, those families often

do not remember this initial reaction. Confronting

that reaction is not helpful but providing education

and structured experiences where they can help the

patient in some meaningful way is. Some patients

may consolidate their symptomatology into a classic post-traumatic stress disorder from some time

about 6 weeks after injury and on.

Unusual situations can occur in the treatment of

the combat injured. Care of the enemy injured and

noncombatants may arouse different emotional responses in medical personnel. Injuries in combat

may be self-inflicted. The psychiatric needs of those

personnel may be unique. One suspected case of a

self-inflicted injury, a U.S. Marine who was medically evacuated from Grenada, resulted in the patient ultimately being transferred to a psychiatric

ward with what appeared to be a brief reactive

psychosis. His behavior included reporting an atrocity (which he had not committed) to nursing staff,

seclusion in his room, not eating, and hoarding his

bandages. Interestingly, his treatment team consisted entirely of women including the mental health

professional and a chaplain. Even though the other

casualties suspected that he had a self-inflicted injury, this was never mentioned by the group members in therapy.

Experience shows that female therapists are accepted by male casualties and it appears they can

reassure the male wounded about social acceptability better than male therapists can. One specific

concern reported on clinical checklists is anxiety

about sexual functioning.

There is no specific planning for the allocation of

psychiatric resources to care for the needs of the

combat injured. It was the author’s experience that

caring for 25 such casualties from Grenada and

Beirut at the National Naval Medical Center consumed an immense amount of resources for approximately 45 days. The psychiatric consultant

may be limited to liaison work with other medical

staff in helping these patients.52

When examining the Grenada and Beirut casualties, some parallels and differences were found.53

Both groups tried to reconstruct their experiences

but they used different approaches. Casualties

from Grenada were able to recall incidents with

each other in reconstructing their experiences; however, those from Beirut, having been injured while

asleep, had no ability to reconstruct. They felt

initially that they didn’t know what happened and

then read about it as they would have about somebody else. They spent time talking to other casualties about where they were in the building and

where they ended up: “How were you blown up?”

This appeared to be a more passive reconstruction

of events than that carried on by the casualties from

Grenada.

There were sleep differences reported on symptom checklists. In group treatment, the Grenada

patients who had problems with dreams reported

nightmares about killing, thinking of dead bodies,

touching dead bodies, and killing people. Those

who were casualties from Beirut, where the headquarters had been blown up, had more problems

with sleep initiation because they were fearful of

returning to sleep. They would sometimes “play

possum” and act as if they were sleeping to the

nursing staff but not sleep. This was confounded by

the fact that they had crossed several time zones.53

The casualties from Grenada had less survivor

guilt at the time than the Beirut casualties. Beirut

casualties already manifested survivor guilt. Group

goals were different. The U.S. Marines who had

been in Grenada wanted to get back to their units

immediately as their units were going to Beirut.

They had high morale and wanted to rejoin their

units. The Beirut casualties primarily wanted to go

home. Parenthetically, once they got home, they

wanted to get away from home.53

The Grenadan casualties were more embarrassed

by public attention. They did not want it or seek it

out; they appeared to be comparing themselves

with the Beirut casualties in the sense that they were

only in combat for a day or a few hours and that the

other casualties had been many months in Beirut.

The Beirut casualties while in the hospital responded

more positively to attention. When they went home

and were afforded honors such as parades, they had

great difficulty in tolerating that attention.53
War Psychiatry

234

SPECIAL PSYCHIATRIC RAPID INTERVENTION TEAM

History

Separate from the sequelae of stress in combat,

psychiatrists in the U.S. Navy have long noted that

there are psychiatric responses to disasters that

affect sailors and marines long after the trauma

itself. Often, personnel referred for evaluation with

emotional or behavioral problems do not connect

their problems or the onset of difficulties with a

disaster they may have survived.

Disasters at sea are not uncommon nor are deaths

due to operationally related training or other activities ashore. In November of 1975, the USS Belknap

and the USS Kennedy collided, resulting in many

deaths and extensive damage to the USS Belknap.

Afterwards, the USS Belknap was towed to the Philadelphia Naval Shipyard with a portion of its crew,

many of whom subsequently had outpatient psychiatric evaluations at the Philadelphia Naval Hospital. They had symptoms such as depression,

sleepiness, poor concentration, and intrusive

thoughts about the accident. These symptoms were

noted to persist despite treatment. This was seen

again after that psychiatry department moved to

the Portsmouth Naval Hospital which was near the

USS Belknap’s home port.54

In January of 1977, a liberty launch collision

in Barcelona Harbor in Spain resulted in some survivors who had long-term emotional problems

that resulted in medical board action, early discharge, or psychiatric hospitalization. At that time,

the staff at Portsmouth Naval Hospital felt that

these problems appeared similar to those that were

combat related. They formulated a clinical hypothesis that use of the same techniques proved in the

combat setting might be useful in preventing or

minimizing adverse psychiatric sequelae in disaster victims.

The first opportunity to test this hypothesis was

in October of 1978 when a collision sank the USCGC

Cuyahoga in the Chesapeake Bay offshore from

Maryland. The U.S. Coast Guard requested that a

team of mental health professionals work with the

survivors. This occurred after the team leader had

contacted them and informed them of the team’s

availability. That team saw themselves as following the basic combat psychiatry principles of immediacy, proximity, and expectancy in that the intervention was provided rapidly at the home port of

the USCGC Cuyahoga with the 18 survivors. Furthermore, group cohesion and early return to duty

were strongly encouraged.55

Preliminary clinical observations suggested that

the intervention was successful and that survivors

“appeared to be in much better physical and emotional health than would be expected based on the

available literature on disaster victims.” The special psychiatric rapid intervention team (SPRINT)

concept was thus initially validated and the capability and need for a rapid contingency response

was ultimately recognized. In February of 1983

SPRINT became one of the U.S. Navy’s Mobile

Medical Augmentation Readiness Teams (MMART).

Organization and Mission

These contingency response teams are located at

U.S. Navy hospitals at Portsmouth, Virginia; San

Diego, California; and Bethesda, Maryland. The

composition of a full SPRINT is two psychiatrists, a

clinical psychologist, a chaplain, a psychiatric nurse,

and four corpsmen (neuropsychiatric technicians).

They are required to be trained and immediately

available in the event of a contingency, be it combat

or disaster. There is no specific doctrine as to

intervention methodology.

After-action reports and interviews after some 13

SPRINT deployments resulted in recurring observations.54 A period of receptivity lasts about 24 to 72

hours after the initial tragedy. Anger is commonly

expressed and is directed at any convenient focus

such as lack of training, inanimate objects, adverse

weather, and personnel up and down the chain of

command. Loss of ships has special meaning for the

survivors who lose not only shipmates but their

unit identification, place of work, personal belongings, and abode. In those cases, salvaging part of

the ship as a memorial is found to be beneficial.

Team members dealt with survivor guilt, bereavement, and issues of death. Survivor guilt analogues

were also seen in wives who felt guilty that their

husbands had survived and were concerned about

how to deal with the wives of the deceased in their

community. There has also been a persistent denial

of death by spouses when bodies recovered are not

recognizable. Speculation, misunderstanding, and

rumors tend to make all situations worse and disseminating accurate information is often essential

prior to any resolution of symptoms.

Intervention Techniques

Successful interventions have had some common

technical components. These involve the planning
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U.S. Naval Combat Psychiatry

and training of team members; the notification process; arrangements for deployment and travel; and

the structure of the intervention.

Planning and Training Phase

Team members must be selected, trained,

and given an opportunity to work with each other.

Given that the best training is that which is most

realistic, they must train in environments similar

to those where they will be expected to work. As

they may have to go to sea, they need to have the

skills that others expected to go to sea must have,

such as fire fighting, and disaster control. They

must be prepared to deploy within 24 hours of

notification and will often be expected to leave

sooner. This entails some detailed logistical preparation. Realistic training can also be seen as “service” when a team responds to incidents other than

“disasters.” This might include situations such as

a suicide at a local command. They may also participate in disaster planning at local commands

and may form liaisons in the community through

such services as the provision of suicide prevention

and stress management lectures. Through these

activities, team members can develop a necessary

attitudinal shift towards prevention rather than

reaction to already developed pathology. A team

without such a philosophy will seldom be requested.

The team can also learn the useful “consultant’s

stance” as an appropriate approach to interventions of any size.

Notification Phase

At some point in time, team members will be

notified that they are in an alert status to respond

to a disaster or will hear through official or unofficial channels about a disaster. It is during this

phase that some “systems” knowledge related to

U.S. Navy organization is most helpful. After a

large-scale disaster, the U.S. Navy community, particularly at higher echelons, is now sophisticated

and understands the need for response teams. They

conceive of such a team as being able to handle

acute problems but do not often see the team in

terms of prevention. Thus, liaison is needed with

the appropriate commanders’ staff, usually a staff

surgeon or senior medical officer, to explain what

assistance is available or has the potential to be

most helpful. If the disaster has occurred at sea, the

primary planning priority would be assistance to

the crew of the casualty. A second planning priority

would be aid ashore for families of victims and

survivors. A third planning priority is ashore in

support of the surviving injured who would be

evacuated to local hospitals. The Bureau of Medicine and Surgery, Operational Readiness Division,

is charged with ensuring execution of MMART,

including SPRINT, deployments. (Some disaster

responses may be handled by teams within local

areas without activation; and, as long as they do not

degrade SPRINT capability, they are usually considered a local command issue.)

This is the period of time during which the Specialty Advisor for Psychiatry and the officer in

charge of the SPRINT can coordinate with line medical staff to ascertain preliminary data in order to

plan the most effective intervention possible given

resource, transportation, berthing, and other constraints. Liaison can also be initiated with local

family service centers as well as hospital commanders where the injured may be evacuated.

Past experience indicates that the primary intervention sites will be with the crew, either at sea or in

home port with the home port being an additional

site for aid in the support of families. It is also

necessary during this period to transfer patient care

responsibilities of deploying team members safely

and expeditiously. In those situations in which an

entire SPRINT is not deployed, careful consideration must be given to which team members will be

deployed.

For those teams that must operate somewhat

independently, it is crucial that there be team members with professional and operational experience.

Which professional disciplines are required for team

makeup can create delicate questions. Everyone

usually wants to go.

Deployment and Travel Phase

Some teams must travel to an intervention site

away from their home port. Deployments are often

on short notice and may require travel to sites

where passports are needed. Loss of sleep and

attendant fatigue can be degrading factors for team

effectiveness once on site. Logistical coordination

for berthing and local transportation can be timeconsuming so that identification of points of contact

prior to team departure can aid immensely.

From the time of departure until arrival at an

intervention site there is rarely any new information available to team members so that the information they have when they depart will be dated by

the time of their arrival. Some flexibility must be

given to the officer-in-charge of the team for planning purposes. This also requires that the officer-
War Psychiatry

236

in-charge have demonstrated flexibility in fluid situations. A team that travels with fewer members

usually travels with greater ease.

In several recent interventions at sea, the team

has been composed of three members. These “designer teams” have proved highly effective. They

must utilize a triage system or prioritization of care

once aboard ship. The officer-in-charge can usefully conceive team functioning in a utilitarian manner by trying to provide the greatest good for the

greatest number of personnel as well as consulting

to the unit itself. The mission that the team leader

has as a goal is a limited one in attempting to restore

the status quo ante as much as possible.

Intervention Phase

Interventions with military units should begin as

soon as possible after arrival. The officer-in-charge

must brief the commanding officer, executive officer, and senior medical officer as to team mission,

capabilities, and intervention methodology. At this

time the “consultant’s stance” is most helpful. This

allows the SPRINT members to handle the question,

“Who do you work for?” by responding that they

work for the commanding officer of the ship or unit.

This will usually alleviate some anxiety as almost

all disasters are associated with official investigations. All “outsiders” will be viewed with initial

suspicion.

The concept of a “trauma membrane” surrounding the disaster victims and bonding them together

is useful. Team members who come from a cultural

background similar to those of the trauma victims

can foster identification between the group victims

and the SPRINT. With such identification, victims

have an initial trust in those “there to help them”

that helps separate the SPRINT members from investigators or other “outsiders.”

This initial phase is also crucial in beginning to

debrief the command structure of the ship. The

“consultant’s stance” has the team “learn” about

what happened to the ship or unit. The team while

doing this can, in essence, model for the commanding officer how the intervention will work.

Team members must also meet with members of

the wardroom, which consists of all the commissioned officers aboard ship, as well as the Chief

Petty Officer’s Mess which consists of the senior

enlisted leadership aboard ship. These groups will

have the most information available and the team

can begin to assess how much of that information is

accurate and up to date. Such assessment is crucial

and one of the first interventions that may be recommended is the dissemination of as much information to as many people as possible. This is

helpful for two primary reasons: (1) rumor is always rampant and rumor may serve many separate

functions in a unit—accurate information can lessen

some destructive agendas; and (2) one of the initial

steps in dealing with such trauma is the need for the

victim to place himself in some context.

After meeting with these initial groups during

which time the debriefing technique described below has been used, the team must integrate itself

into the organizational structure of the unit in some

way and begin further triage and intervention. If

there is a medical department aboard ship, this

provides a natural organizational placement for the

intervention as well as clearly identifying the mission as a medical one. Triage is ongoing and gathering information from the leadership and medical

department aboard ship will help in the initial identification process. Some individuals who are either

dysfunctional or are considered by the crew as

having suffered sufficient stressors that they should

be dysfunctional are usually first identified through

this process. These individuals can be provided

individual assessment and treatment as necessary

including recommendation for medical evacuation

if indicated, although this would usually be the last

resort as recovery could be expected to be most

facilitated aboard ship, among shipmates and crew.

It must be remembered that symptomatology for

most individuals would be most acute immediately

following the trauma.

The second triage task is to identify “at risk”

individuals and groups. These are usually those

individuals who were most intimately involved

with the trauma. The first subset is those who were

in danger of dying at the time of the initial trauma

or who knew the casualties. A second “at risk”

subset is those who were in danger during damage

control or fire-fighting operations in the immediate

post-trauma period. A third “at risk” group is those

who handled bodies, body parts, or the more severely wounded. This last group must include the

medical department personnel. These “at risk”

groups should usually have a group intervention.

Such groups are most effective if there are about 25

or less people in a group. Such groups should be

planned to fall within the organizational structure

of the ship so that people within similar divisions

debrief together.

Those identified “at risk” individuals and groups

as well as the wardroom and Chief Petty Officer’s

Mess would normally be provided with a debriefing. Evolution of this technique has stemmed from
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U.S. Naval Combat Psychiatry

observations that there appear to be specific needs

that can be addressed efficiently.

Techniques utilized successfully have included

three basic components: the first component is cognitive or informational, the second component is

related to identifying, experiencing, and validating

emotions, and the third component is “educational”

in nature.

Disasters are, in some respects, not much different from combat and, as S.L.A. Marshall56 noted,

those who participate in a combat action are likely

to be confused by the events that took place.

Marshall’s interviews after combat with all members of a group who participated in an action were

aimed at getting the “facts.” His caveat that an

interviewer must remember that he or she is not

conducting a critique, takes part in no tactical debate, does not become personal or emotional, and

avoids any reflection on any individual as he would

the plague, is sound advice today. Through such

reconstruction of events, cognitive errors and distortions can be corrected by the group and the

individual can place himself or herself in a larger

context.

The phase of the intervention dealing with emotions is more familiar to mental health professionals

and usually coexists in part with the phase dealing

with cognition. The debriefer must be ready to deal

with emotional responses including anger. Generally, participants have a cognitive construct that

they should not have experienced feelings or that

they should be able to deal with their feelings without discussion with their shipmates. As individuals

describe their emotional reactions or begin to experience emotional reactions during the session, other

participants will identify with these reactions. It is

important to validate and acknowledge their feelings. If there is any one crucial component of the

intervention, it is in getting the message across that

these are normal human reactions to extremely abnormal events.

In the “educational or teaching phase,” material

is presented that should aid the individual in current and future adaptation. Such information may

include what the usual responses to overwhelmingly abnormal events are, what sort of symptom

time course individuals can expect, and adaptive

means of coping with symptoms. How to deal with

families and children are always important questions

for survivors. Caution should be exercised to some

degree in description of potential sequelae which can

become a suggestion that such sequelae will occur.

An appropriate suggestion would be that acute

symptomatology is normal and time limited.

A debriefing format, adapted from those developed by Marshall56 for conducting interviews after

combat and by Mitchell,57 for Critical Incident Stress

Debriefing, is shown in Exhibit 9-1. Utilization of

this technique with those groups and individuals

identified as being “at risk” also allows ongoing

triage of individuals by the team. By dealing with

groups from the same divisions within the ship, the

team fosters bonding in the division amongst shipmates. The attitude of expectancy of recovery and

return to the prior level of functioning is crucial to

the success of this technique.

Another critical part of dealing with the aftermath of disaster is a memorial service. Such memorial services allow the team to “point” towards

some concrete event and facilitate grief reactions.

The military has great strengths in its rituals for

handling such memorial services. Liaison with the

pastoral care department can be most helpful. Usually such memorial services will be held ashore with

families. Occasionally, they will be at sea or overseas. SPRINT members are invariably invited to

participate in these ceremonies with the crew with

whom they have bonded.

Termination with the crew needs to be considered. Interventions last for varying periods of time

depending upon circumstances. It is a matter of

judgment as to when to terminate the intervention.

A good key is when crew members begin to talk

about difficulties they had prior to the trauma. Too

lengthy an intervention could be counterproductive. When a ship is ashore, ongoing liaison with

gradual termination can be maintained through

liaison with the medical department.

Interventions with U.S. Navy families must be

considered. Past experience in this area has led the

U.S. Navy to develop guidelines for commanders

ashore in responding to these disasters. SPRINT

members can provide a consulting role to activities

tasked with providing services. SPRINT members

can successfully advise the local base commander,

through staff, on areas of intervention. The team

can also coordinate with Family Service Centers as

consultants and for the provision of individual services, when necessary.

Debriefing groups similar to those above have

been used successfully with families as well as with

staff at crisis centers on base. A common question

is what to expect from spouses returning from sea.

Training for casualty assistance calls officers

(CACOs) is indicated.

Other anticipated problem areas will realistically

include information flow. There are always expectations that more information will be available
War Psychiatry

238

EXHIBIT 9-1

PREPARING FOR AND CONDUCTING DEBRIEFINGS

Preparation

1. The debriefer should read everything available on the incident.

2. During this phase, the debriefer should identify the group, notify them, get space, arrive early, set up the

room, meet the people to be debriefed, and talk informally with them. The debriefer should also listen for

information and cues related to the incident.

Debriefing

1. Introductory Phase

a. This phase should be controlled, slow, and designed to motivate participation by each member of the

group.

b. This phase is conducted by the team leader. Other team leaders are not identified at this time.

c. The team leader introduces himself or herself, discusses why he or she is qualified to do a debriefing,

discusses confidentiality, and emphasizes that discussions are designed to help them or others like

them.

2. Fact Phase

a. This is the transition between the introductory phase and the reaction phase.

b. The debriefer should ask participants to go around the room to give the following information (and note

that this is the only time in debriefing they will have to speak up and they do have the right to pass):

who they are,

their role at the event, and

their perspective of what happened to them at the event.

c. Other team members are interspersed in the circle. Their introductions of themselves can help participants maintain emotional control by periodically deescalating the rising tension in the room as their

turn comes up for introduction while the event is discussed.

d. During this phase the participants are guided in cognitively thinking about the facts and allowed to

internalize them.

e. Because thoughts are easier to discuss than feelings, this phase allows participants to feel more secure in

dealing with the feelings that they are experiencing.

3. Reaction Phase

a. During this phase reactions are sought more than just feelings.

b. If a participant should cry, the debriefer acknowledges, validates, and moves on to the next person.

c. Each participant is encouraged to talk about his or her own issues, not the overall operation and not

other issues.

d. This phase is usually very intense with a great deal of anger.

e. This phase usually lasts 45 minutes to one hour.

4. Signs and Symptoms Phase

a. There is some natural movement from the reaction phase into this phase.

b. The debriefer asks questions such as, “How did you know your reaction was different than usual?”

c. The purpose of this phase is to help participants identify symptoms within the four categories of

physiological, cognitive, emotional, and behavioral, at the scene, later at home, and at the time of the

debriefing.

5. Teaching Phase

a. Incident-specific material is provided to the group.

b. This phase is usually lengthy.

c. Examples of material presented include how to deal with the spouse, children, stress reactions, grief,

what to expect in the future in terms of feelings and thoughts about the event that might occur.

d. This is not an appropriate time to teach stress management techniques such as deep relaxation or

meditation.

6. Reentry Phase

a. The atmosphere of the group now comes back around to normal.

b. Debriefing should close when it seems natural.
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U.S. Naval Combat Psychiatry

sooner than is realistic. What people want appears

to be information. Once the information related to

casualty lists is known, emotion can escalate quite

rapidly. Medically unstable cases can be expected

because great stress can exacerbate already existing

medical conditions. Examples include pregnant

women or someone with a history of seizure disorder who begins hyperventilating. Medical assistance should therefore be available.

Before groups are notified of casualty lists, individuals are under great stress, extremely vigilant,

and aware of any changes. It is therefore difficult, if not impossible, to unobtrusively locate and

notify someone in such a group of the death of

a loved one. Acute emotional reactions are not

something with which crisis center workers, other

than clinicians, necessarily have familiarity. Anger

is an emotion known to accompany loss and can be

expected. It may also be directed at authority figures. There are individuals who will be missed by

usual methods of notification as they would not be

listed in service records. A pregnant fiancée of a

casualty, for instance, would not usually be known

to assistance officers as someone who should be

notified. This person may show up at a crisis center.

The amount of mental health services demanded in

these situations can be overwhelming and as many

resources as possible will sometimes need to be

mobilized.

Debriefing for the team members themselves is

necessary. During the intervention, team members

must debrief each other on an ongoing basis. Work

days are seldom shorter than 20 hours during the

acute phase of an intervention and fatigue rapidly

sets in. The team also identifies strongly with the

crew and must undergo their own emotional reaction. A more formal debriefing of the team members is most effectively performed after return to

home port.

One phenomenon that team members have

learned to expect is the feeling of others in their

departments that they “left them behind” and

that the assignment is perceived as “glamorous”

while others must pick up the duties they have

left behind. The team must reintegrate into the

department. After-action reports from the team

facilitate any changes that may be necessary and

pass on lessons learned in a recorded format to

future teams.

The media usually has intense interest in disasters. SPRINT members must realize that what the

media seem to seek is a “human interest” story that

will allow them to provide responses of “real

people.” Media requests are time consuming and

may have potential for negative outcomes. They

also provide great opportunity for public education

about disaster response in general as well as dissemination of information to those who may be

affected by the disaster. Interviewees should be

aware that sensitive questions relating to policy

may be raised. Public affairs officers can be helpful

in preparing for such questions.

For those memorial services at which the President or other high ranking persons may be present, the Secret Service, whose mission is the

protection of the President, may make inquiry

about whether any individuals “debriefed” have

made threats against the President’s life. None

have been encountered to date. The Secret Service

may also request assistance should support be

necessary for family members during a memorial

service.

Outcomes of past SPRINT interventions have

been generally determined to be successful based

on broad criteria. There is a paucity of data as

to outcome. An intervention with survivors of a

fire aboard the submarine USS Bonefish58 resulted

in a 1-year outcome of no psychiatric medical

board action; no disqualifications for submarine

service, either voluntary or involuntary; no naval

service attrition through a less than expected retention rate; and one individual known to be under

psychiatric treatment. Outcome as judged by

unit effectiveness could be judged by the record of

the USS Iowa which deployed on a Mediterrean

cruise and successfully completed that cruise,

including contingency operations. The USS Iowa

deployed some 2 months after the tragedy

aboard and subsequent intervention. A similar

outcome was experienced with the USS Lexington

in November 1989 after a crash aboard the

flight deck. The ship returned to its usual duties in

a brief period of time after the intervention. The

success of outcomes can, of course, not be attributed

solely to SPRINT intervention, but must reflect directly on the commanding officers and crews of

those particular vessels.

The SPRINT concept and techniques will continue to evolve as has U.S. Naval psychiatry. Applications to the many unique U.S. Naval subcultures

and to the constantly changing world will be a

challenge that will be met by U.S. Navy psychiatrists and mental health clinicians as they have met

the challenges of the past.
War Psychiatry

240

SUMMARY AND CONCLUSION

ticularly submarines and amphibious transports,

can exacerbate minor irritants into major confrontations.

Through experience, the modern U.S. Navy

through methods of personnel selection, critical

incident debriefing following disasters, and refined

leadership has become an efficient force with minimal psychiatric casualties.

Modern naval forces are comprised of volunteers

who meet rigorous entrance standards and are further screened psychologically for specific assignments, such as submarine service, before assignment. Naval personnel may be assigned combatant

duties in surface, undersea, aviation, or ground

combat environments, each of which presents a

unique “cultural” milieu, requiring adaptation of

the general principles of combat psychiatry. There

is also some “plasticity” in the presentation of symptoms between these milieus. Through the use of

rapid intervention teams in disasters and combat,

naval services have been in the forefront of current

paradigms of treatment and prevention.

Although the U.S. Navy has unique combat roles,

the principles of combat psychiatry derived from

World War I and World War II ground combat have

found applicability in maritime combat. For combat stress breakdown, restoration of physiological

deficits (rest, sleep, nutrition) in an atmosphere of

expectation of return to duty and avoidance of

evacuation usually suffices to restore the casualty

to duty. Maintaining cohesive forces through good

leadership while living and working together with

shared hardships and dangers helps prevent breakdown in sailors and marines just as it does in soldiers.

There are unique “cultural” aspects to naval service. Some aspects of naval life prevent or promote

psychiatric breakdown. Shipboard life reduces the

potential for evacuation during combat and may

account for lower rates of psychiatric casualties.

Long separations from families during deployments

in both peacetime and wartime result in increased

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