3

Combat and Operational Behavioral Health: An Update to an Old History

Chapter 1

COMBAT AND OPERATIONAL 

BEHAVIORAL HEALTH: AN UPDATE TO 

AN OLD HISTORY 

ELSPETH CAMERON RITCHIE, MD, MPH*; and CHRISTOPHER G. IVANY, MD†

INTRODUCTION

BEHAVIORAL HEALTH CHALLENGES FOR THE US MILITARY

HISTORY OF THE PSYCHIATRY VOLUMES OF THE TEXTBOOKS OF MILITARY 

MEDICINE

SUMMARY

*Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002

†

Major, Medical Corps, Psychiatrist, Department of Behavioral Health, Evans Army Community Hospital, Building 7500, 1650 Cochrane Circle, Fort 

Carson, Colorado 80913; formerly, Division Psychiatrist, 4th Infantry Division, Fort Hood, Texas
4

Combat and Operational Behavioral Health

INTRODUCTION

In the years since the attacks of September 11, 2001 

(also known simply as “9/11”), the United States has 

been at war in both Iraq and Afghanistan, and has 

responded to myriad natural disasters and terrorist 

incidents. Although all wars produce stress casualties, 

during and after different wars these casualties have 

manifested in many ways, both with physical and 

psychological symptoms. With the notable exceptions 

of the data collected by the Walter Reed Institute of 

Research and the Mental Health Assessment Teams (to 

be described later in this volume), only a few articles 

have begun to appear in the literature about the behavioral health lessons learned during the conflicts in 

Afghanistan and Iraq. A plethora of practical information is not yet in the scientific literature. This volume 

seeks to consolidate, in real time, the information that 

is emerging, both to guide current policy and practice, 

and for the future.

Lessons learned include areas such as: (a) management of behavioral health issues on the battlefront; 

(b) care of the physical and psychological needs 

of the wounded; (c) reintegration of soldiers with 

their families; (d) return of soldiers with psychological symptoms to the battlefield; (e) deployment of 

troops into humanitarian and disaster situations, 

such as the 2004 tsunami and Hurricane Katrina in 

2005; and (f) the special needs of children of service 

members, including the families of the wounded 

and deceased.

The disaster literature, which draws heavily on the 

combat literature, tends to focus on a single traumatic 

event. War is related to, but different from, disasters. 

It may start as unexpectedly as disasters do, but then 

persist for years. Unlike victims of disaster, service 

members are generally prepared for battle. They 

may or may not, however, be prepared for the sights, 

sounds, and smells of starving populations as seen in 

Somalia or mass graves, such as in Bosnia.

BEHAVIORAL HEALTH CHALLENGES FOR THE US MILITARY

The military has extensive mental health capabilities. Yet these capabilities sometimes fail to meet significant needs that emerge from recent deployments. 

These include service members home on leave brought 

to a civilian emergency room by a concerned family 

member; demobilized National Guard and reservists 

who may be remote from a military treatment facility 

or Veterans Affairs (VA) facility; and family members 

distraught over the frequent deployments of their 

soldier kin. 

A recurrent issue is that of stigma and barriers to 

care. Numerous programs, which will be described 

in this volume, exist to encourage military personnel 

to seek help. But there are also considerable potential 

consequences of seeking mental healthcare. These 

include: leadership ignorance of psychological issues; 

the requirement to report to command if a soldier 

enrolls in the Alcohol and Substance Abuse Program; 

security clearances; and other potential impacts on the 

soldier’s career. All of these issues are currently being 

addressed by the leadership.

Suicides are highly publicized, but they do not necessarily represent the status of the mental health of the 

force. US forces are all screened, employed, and have 

access to free healthcare—all factors that reduce the 

incidence of suicide. The Army continues to strive to 

reduce these rates further. However, the rate of suicide 

in the Army has continued to rise every year since 

2004. The rate has just surpassed that in the civilian 

world, where age- and gender-adjusted rates are about 

20/100,000/year. The US Army’s suicide prevention 

training has been revised to reflect the motivations 

of soldiers who kill themselves. Suicide prevention, 

therefore, is a topic of enormous significance to the 

Army.

Over the next few years, based on historical data, 

many service members will leave the Army or other 

military services. Traditionally, about 10% of former 

soldiers who seek care do so through the VA. At the 

present time (late 2009), about 40% of former soldiers 

who seek care are using the VA. Most of the rest obtain it through standard civilian healthcare sources. 

Thus it is critically important that civilian providers 

know about the psychological issues facing soldiers 

and families. 

The signature weapon of today’ wars, both in Iraq 

and Afghanistan, is the blast. The clinicians’ experience 

of caring for victims of these weapons is the result 

of years of technological, medical, and psychiatric 

advancements. But the history of military psychiatry 

is replete with attempts to answer many questions 

similar to the ones that the US military now faces. 

Military psychiatrists have only intermittently succeeded in capturing those historical lessons learned 

for contemporary application. 

Many questions remain. How can the responses of 

military and civilian mental health systems be optimized? What has been learned about mental health 

risks facing today’s soldiers and their families? How 

can practitioners engage returning soldiers, and what 
5

Combat and Operational Behavioral Health: An Update to an Old History

are likely pitfalls they may encounter? These dilemmas 

apply to all services, but the Army and Marines have 

been most heavily involved in the ground conflict and 

therefore constitute the focus of the text. 

HISTORY OF THE PSYCHIATRY VOLUMES OF THE TEXTBOOKS OF MILITARY MEDICINE 

As the American military engaged in the armed conflicts of the 19th and 20th centuries, its mental health 

officers fought parallel battles treating service members’ psychiatric wounds. Like battlefield commanders learning from past successes and failures, these 

pioneering clinicians developed potent strategies in 

the war against mental illness. For decades, however, 

despite numerous therapeutic advances, only a small 

number published their findings, leaving invaluable 

lessons vulnerable to the passage of time.

The disparate preservation and distribution of 

these “lessons learned” hindered future generations 

of mental health clinicians from acquiring crucial lessons on war psychiatry. For example, the World War 

II psychiatrist Frederick Hanson had to rediscover 

the principles of forward treatment of combat stress 

casualties in the midst of the North African campaign even though Thomas Salmon had established 

their effectiveness 25 years earlier during World War 

I.1,2 Likewise, in the opening months of the Korean 

conflict, US Army physicians, unaware of the benefit 

of quickly treating combat stress cases close to their 

units, evacuated nearly one quarter of the fighting force as psychological casualties.3

 Fortunately, 

Colonel Albert Glass, well-versed in the practice of 

combat psychiatry in the course of his World War II 

tour under Hanson, sharply reduced combat stress 

casualties by implementing principles now known 

as “PIES,” or proximity, immediacy, expectancy, and 

simplicity.

It was not until 20 years after the conclusion of 

World War II that the preeminent Army psychiatrists of 

the day, led by Colonel Glass, compiled the key behavioral health lessons of the campaign. The first volume 

of Neuropsychiatry in World War II appeared in print 

in 19664 and the second in 1973.5 These two volumes 

became the foundation of modern combat psychiatry. 

Although valuable for their historical preservation 

of the failures and ultimate successes of psychiatry 

in World War II, the delay in publication prevented 

two decades of clinicians from applying their messages. In addition, the volumes could not account for 

the sizable cultural shifts of the 1960s, which would 

heavily influence the presentation of combat stress in 

the Vietnam War.

The Vietnam War and its social aftermath further 

demonstrated the effectiveness of forward treatment of 

combat stress and introduced new principles, such as 

the etiology and management of disorders of frustration and loneliness.6,7 At the conclusion of the Vietnam 

era, these essential tenets, hard won through decades 

of painful experience, were preserved only as an oral 

tradition and in scattered literary sources. 

Even before the end of the Vietnam War, several 

luminaries of the military psychiatric community 

realized that a comprehensively compiled, refined, 

and codified source of military psychiatric experience 

from this era was required to preserve the accumulated 

data and perpetuate its application in future conflicts. 

Lieutenant Colonel Kenneth Artiss took an interest in 

producing an inclusive textbook but left military service in 1964. Even before the beginning of the Vietnam 

War, Colonel Franklin Del Jones emerged as the lead 

editor of the daunting project.8,9 Jones, one of the few 

career military psychiatrists who had completed a tour 

in Vietnam, also distinguished himself as a pragmatic 

clinician, expert pharmacotherapist, knowledgeable 

military historian, and master teacher. 

Jones, a humble, soft-spoken Texan, had been 

mentored by Albert Glass, well-known throughout 

the military for his implementation of the forward 

treatment of combat stress casualties in Korea. Jones 

also shared Glass’ steadfast commitment to preserve 

and develop the psychiatric lessons learned in past 

armed conflicts.9

 Throughout his Army career, Jones 

had held numerous prominent clinical, academic, and 

administrative positions such as Director of Psychiatric Education at Walter Reed Army Medical Center 

and the Consultant to the Surgeon General, US Army, 

but his greatest passion remained writing. As the 

leader of the textbook project, Jones invited authors 

from all armed services, multiple backgrounds, and 

various disciplines, but imbued the work with his 

own belief that practical experience takes precedence 

over speculation and theory. Jones retired from active 

military service in 1988 with the rank of colonel. He 

battled a severe autoimmune disorder, but nonetheless 

poured himself into the textbook project by personally 

authoring or coauthoring 18 of the 38 chapters, and 

researching and editing the remaining 20. During the 

first Gulf War (Operations Desert Shield and Desert 

Storm, 1990–1991), Jones provided bound copies of 

relevant draft chapters to the psychiatry consultants 

for the Army, Navy, and Air Force. These consultants, 

in turn, distributed these to psychiatrists throughout 

the theater of operations to enable them to use the 

lessons learned from previous wars in this rapidly 

evolving conflict. Through collaboration with the 
6

Combat and Operational Behavioral Health

Borden Institute, the endeavor blossomed into two 

volumes, one published in 1994 (Military Psychiatry: 

Preparing in Peace for War2) and the other in 1995 (War 

Psychiatry10) in the Textbooks of Military Medicine series. 

Jones died in 2005, remembered as an epic contributor 

in the annals of military psychiatry.

With the publication of Military Psychiatry and War 

Psychiatry, members of the military mental health 

community could for the first time quickly reference 

a central repository of military-specific psychiatric 

knowledge from Napoleonic times through the 

Persian Gulf War. Faculty at the Army’s teaching 

hospitals integrated the texts into the curriculum for 

psychiatric residents and distributed them to psychologists, social workers, chaplains, and even to the 

US Army War College, which educates the Army’s 

most promising combat arms leaders. Behavioral 

health clinicians based much of their intervention at 

the Pentagon on September 11, 2001, on the principles 

of forward treatment.8,11 Perhaps most significantly, 

the generation of mental heath officers deployed 

as part of Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) avoided mistakes 

made by their predecessors in the opening stages of 

previous wars. Instead, they rapidly adapted and 

implemented time-tested psychiatric treatment of 

US military fighters.

Lessons found within the volumes can guide contemporary mental health leaders as they set policies 

that improve on those of the past. The importance of 

an efficient transition of care for soldiers from active 

duty to the VA system is highlighted by the difficulties in the post-Vietnam era. The clinical presentation 

of posttraumatic stress disorder (PTSD) in OIF and 

OEF soldiers is presaged by Jones’ description of the 

evolution of the syndrome from World War I through 

the Vietnam War. Post–World-War-II lessons depict 

the benefit of systematic emphasis on education and 

rehabilitation in recovery from PTSD. The textbooks 

present historical insights into many contemporary 

mental health issues.

Military Psychiatry and War Psychiatry spurred further useful debate about military and combat psychiatry. Since their publication in the mid-1990s, clinicians, 

researchers, and administrators have made countless 

advances integrating surveillance, education, treatment, and new neurobiological research, and adapting 

their practice to the post-9/11 world. These advances 

will be described further in this volume. 

Today’s military mission also differs greatly from 

that of Jones’ era. Combat doctrine now emphasizes 

modular forces engaging in asymmetric wars involving multiple deployments, intense urban warfare, and 

without clearly defined front lines. An expanding body 

of research and clinical experience is illuminating the 

psychiatric impact of these new and demanding missions on service members and their families. Inspired 

by the Jones’ texts, the military mental health community continues on a historically informed journey 

of debate and documentation. 

SUMMARY

Although it has only been 15 years since the publication of Jones’ two volumes on military psychiatry, a 

contemporary literary resource that encapsulates military behavioral health knowledge and experience has 

been overdue. Inspired by Doctors Glass, Jones, Artiss, 

and many others, this newest version of the behavioral 

health volumes of the Textbooks of Military Medicine

provides clinicians with an indispensable weapon in 

the battle against the psychiatric illnesses that affect the 

men and women in uniform and their families.

There has been considerable discussion about the 

title of this book, which will be briefly summarized 

here. Early on, it was clear that “psychiatry” was too 

discipline specific. However, the question was what 

to replace it with. The Army has shifted from “mental 

health” to “behavioral health.” The Department of 

Defense is beginning to use “psychological health.” 

Some like the term “behavioral medicine”; other dislike the apparent emphasis on disease.

Parallel discussions ensued about whether to use 

the term “military” or “uniformed,” as the Public 

Health Service plays a central role in responding to 

disasters. “Combat” describes the wars, but also leaves 

out the responses to natural disasters. Thus the title, 

“Combat and Operational Behavioral Health,” was 

chosen to cast the widest net possible. 

There are some caveats. Inevitably, this is not the 

whole story. In the 4 years it has taken to produce the 

book, there have been multiple new efforts. Rather 

than hold off publication to have time to judge their 

effectiveness, they are simply mentioned in the conclusion. Although there has been an effort to include 

as many sources and military services as possible, 

many practitioners are too busy during these times 

to write. In addition, new lessons are learned all the 

time. There are two first-person accounts, which are 

included as appendices, as they are more first-person 

accounts than scholarly chapters. However, their stories add to the depth of understanding of what it is 

like to be a practitioner in an immature and dangerous 

theater. There is also an account of media coverage of 

soldiers’ behavioral health in Iraq during Operation 
7

Combat and Operational Behavioral Health: An Update to an Old History

Iraqi Freedom 05-07, which is included as the third 

appendix. Finally it is hoped that this volume is a 

valuable addition to the literature, and a timely guide 

for practitioners and leaders.

 REFERENCES

1. Glass AJ. Psychiatry at the division level. In: Hanson FR, ed. Combat Psychiatry: Experiences in the North African and 

Mediterranean Theaters of Operation, American Ground Forces, World War II. Bulletin of the US Army Medical Department. 

Washington, DC: Government Printing Office; 1949: 45–73. 

2. Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military Psychiatry: Preparing in Peace for War. In: Zajtchuk R, 

Bellamy RF, eds. The Textbooks of Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon 

General, Borden Institute; 1994.

3. Ritchie EC. Psychiatry in the Korean War: perils, PIES, and prisoners of war. Mil Med. 2002;167:898–903.

4. Anderson RS, Glass AJ, Bernucci RJ, eds. Neuropsychiatry in World War II. Vol I. Zone of the Interior. Washington, DC: 

Government Printing Office; 1966. 

5. Anderson RS, Glass AJ, Bernucci RJ, eds. Neuropsychiatry in World War II. Vol II. Overseas Theaters. Washington, DC: 

Government Printing Office; 1973. 

6. Jones FD. Experiences of a division psychiatrist in Vietnam. Mil Med. 1967;132:1003–1008.

7. Jones FD, Johnson AW. Medical and psychiatric treatment policy and practice in Vietnam. J Soc Issues. 1975;31:49–

65.

8. Ritchie EC, Cassimatis E, Emanuel R, Milliken C, Gray SH. The contributions of Kenneth Leslie Artiss, MD. J Am Acad 

Psychoanalysis Dynamic Psychiatry. 2003;31:663–673.

9. Ivany CG, Gray SH. Franklin Delano Jones, MD, and War Psychiatry. J Am Acad Psychoanalysis Dynamic Psychiatry. 

2007;35:1–12.

10. Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 

1995.

11. Milliken CS, Leavitt WT, Murdock P, Orman DT, Ritchie EC, Hoge CW. Principles guiding implementation of the 

Operation Solace plan: “Pieces of PIES,” therapy by walking around, and care management. Mil Med. 2002;167(9 

suppl):48–57.
8

Combat and Operational Behavioral Health