59

Combat and Operational Stress Control

Chapter 4

Combat and operational stress 

control

EDWARD A. BRUSHER, LCSW, BCD*

INTRODUCTION

COMBAT AND OPERATIONAL STRESS THREAT

Sources of Stress

Mental and Physical Stressors

COMBAT AND OPERATIONAL STRESS BEHAVIOR

Adaptive Stress Reactions

Combat and Operational Stress Reaction

Misconduct Stress Behaviors

Postcombat and Operational Stress

Posttraumatic Growth

Continuum of Combat and Operational Stress Behaviors

COMBAT AND OPERATIONAL STRESS CONTROL

Battlemind

Cohesion and Morale

Combat and Operational Stress Control as a Function of Leadership

Combat and Operational Stress Control Professional Disciplines 

Religious Support for Combat and Operational Stress Control 

COMBAT AND OPERATIONAL STRESS CONTROL INTERVENTIONS

Combat and Operational Stress Control Management Principles

Combat and Operational Stress Control Functional Areas

SUMMARY

ATTACHMENT: BATTLEMIND TRAINING 

*Lieutenant Colonel, Medical Service Corps, US Army; Deputy Director, Behavioral Health Proponency, Office of The Surgeon General, 5109 Leesburg 

Pike, Skyline 6, Suite 693, Falls Church, Virginia 22041-3258; formerly, Combat Operational Stress Control Program Manager, US Army Medical 

Command, Fort Sam Houston, Texas
60

Combat and Operational Behavioral Health

INTRODUCTION

though rates of COSR casualties have remained high 

in 21st century wars, losses due to COSR have significantly decreased as a result of institutionalizing COSC 

into military operational functioning. In today’s combat environment, military leaders can expect to retain 

and return to duty (RTD) over 95% of service members 

who experience COSR. COSC is a tactical consideration 

that must not be overlooked or minimized. COSC is 

one of ten identified medical battlefield operating 

systems (the other nine being command, control, and 

communication; hospitalization and surgery; preventive medicine; veterinary services; laboratory, blood, 

and dental services; health service logistics; combat 

stress control; patient evacuation and regulation; and 

area medical support).

Service members—especially military leaders—

must learn to recognize COSR’s symptoms and 

prevent or reduce its disruptive effects. This chapter 

provides an overview of the US Army Combat and 

Operational Stress Control Program as outlined by 

Field Manual 4-02.51, Combat and Operational Stress 

Control (July 2006)1

 and Field Manual 6-22.5, Combat 

and Operational Stress Control Manual for Leaders and 

Soldiers (March 2009).2

Combat and operational stress includes all the 

physiological and emotional stresses encountered as 

a direct result of the dangers and mission demands 

of combat and other military operations. Combat and 

operational stress control (COSC) in the US Army may 

be defined as programs developed and actions taken 

by military leadership to prevent, identify, and manage adverse combat and operational stress behavior 

(COSB) in units. These programs optimize mission 

performance; conserve fighting strength; and prevent 

or minimize adverse effects of combat and operational 

stress reaction (COSR) on soldiers and their physical, 

psychological, intellectual, and social health. COSC’s 

goal is to return soldiers to duty expeditiously. COSC 

activities include routine screening of individuals 

when recruited; continued surveillance throughout 

military service, especially before, during, and after 

deployment; and continual assessment and consultation with medical and other personnel from garrison 

to the battlefield. 

Within US military operations historically, COSRs 

(negative reactions in the spectrum of COSB), have 

accounted for up to half of all battlefield casualties, 

depending upon the difficulty of the conditions. AlCOMBAT AND OPERATIONAL STRESS THREAT

In today’s battlefield, everyone is a soldier. Whether 

serving in the infantry, providing healthcare, or providing logistical support, all military personnel face 

the threat of attack from a dedicated enemy force. 

Routine existence in a combat zone places all service 

members at risk for exposure to a range of significant 

stressors. In peacetime as well as war, the effects of 

combat and operational stress are experienced by all 

soldiers in every type of military operation, including combat-like conditions present throughout the 

entire spectrum of military operations. These operations range from training, all phases of deployment, 

peacekeeping, humanitarian missions, stability and 

reconstruction, and government support missions, to 

missions that may include weapons of mass destruction or chemical, biological, radiological, nuclear, and 

explosive weapons. 

It is important to understand that combat and operational experiences affect all soldiers and reflect all activities soldiers are exposed to throughout the length of their 

military service, whether a complete career or single enlistment. Service members continually face the potential 

for deployment and combat, long and arduous training 

missions, and separations from families. These stressors 

are greatest during actual combat, but often begin with 

notification of a deployment. Combat and operational 

stress often continues after the fighting is over as the 

participants deal with the aftermath of deployment, 

whether they served in support or combat units, were 

prisoners of war, or experienced severe injuries. 

Rigorous research conducted explicitly on the 

mental health and well-being of service members and 

families during periods of major military operations is 

scarce,3

 and most studies on the mental health effects 

of combat were conducted among veterans years after 

their military service ended.4 However, deploymentrelated stressors have been linked to increased rates 

of subsequent health problems. Studies have found 

exposure to severe combat stressors relates to the subsequent development of a range of physiological diseases.5

 Other studies have documented the association 

between exposure to deployment-related stressors and 

the development of psychiatric disorders.4,6–8 Deployment is also associated with increased symptoms of 

posttraumatic stress disorder,4 depression,4,6 and anger 

problems.9,10 Furthermore, although symptom reports 

may be low during the immediate postdeployment 

period, studies with soldiers have found that these 

symptoms increase 3 to 6 months later.11,12 In all, an 

estimated 20% to 30% of US military personnel returning from current combat operations report significant 

psychological symptoms.12 
61

Combat and Operational Stress Control

EXHIBIT 4-1 

COMBAT AND OPERATIONAL STRESSORS

Combat Stressors

•	 Personal injury

•	 Killing of combatants

•	 Witnessing the death of an individual

•	 Death of another unit member

•	 Injury resulting in the loss of a limb

Operational Stressors

•	 Prolonged exposure to extreme geographical environments such as desert heat or arctic cold

•	 Reduced quality of life and communication resources over extended period of time

•	 Prolonged separation from significant support

systems such as family

•	 Exposure to significant injuries over multiple missions such as witnessing the death of several unit 

members over the course of many combat missions

Sources of Stress

Combat stressors come from a range of possible 

sources, including singular incidents with potential 

to significantly affect the unit or soldiers experiencing them, multiple combat incidents, or prolonged 

exposures due to continued operations in hostile 

environments. The effects of these stressors are experienced prior to, during, and after military operations 

and missions. Sometimes stressors are related to a 

significant or multiple potentially traumatic events 

(PTEs). A PTE is an event that causes an individual or 

group to experience intense feelings of terror, horror, 

helplessness, or hopelessness, and is perceived and 

experienced as a threat to one’s safety or to the stability 

of one’s world. Guilt, anger, sadness, and dislocation 

of world view or faith are potential emotional and 

cognitive responses to PTEs. The combined effect of 

combat and operational stressors results in COSB (see

Exhibit 4-1 for examples of both combat stressors and 

operational stressors). 

Although many stressors in combat situations result from deliberate enemy actions aimed at killing, 

wounding, or demoralizing US soldiers and US allies, 

other stressors are due to the natural environment, 

such as intense heat or cold, humidity, or poor air 

quality. Still others result from leaders’ own calculated or miscalculated choices (for example, decisions 

about unit strength, maneuvers, the time of an attack, 

and plans for medical and logistical support). Sound 

leadership works to keep operational stressors within 

tolerable limits and prepares troops mentally and 

physically to endure them. In some cases, however, 

excessive stress can affect the decision making and 

judgment of both leader and soldiers, resulting in 

missed opportunities, or worse, in high casualties or 

failure to complete the mission. 

Finally, some of the most potent stressors are interpersonal in nature and can be due to conflict in the 

unit or on the home front. Extreme reactions to such 

stressors may involve harm to self (as in the case of 

a soldier who becomes suicidal on discovering his 

wife wants a divorce) or to others (as in the case of 

a soldier who impulsively fires a weapon at the unit 

noncommissioned officer out of rage over perceived 

unfairness). These stressors must be identified and 

when possible, corrected or controlled.

Mental and Physical Stressors 

A mental stressor is one in which the brain receives 

information about a given threat or demand, but this 

information results only in indirect physical impact 

on the body. Instead, its primary effect is to place 

demands on and evoke reactions from the perceptual, cognitive, or emotional systems of the brain (eg, 

information overload, perceived lack of control, or 

grief-producing losses). A physical stressor has a direct, 

potentially harmful effect on the body. These stressors may be external environmental conditions (such 

as temperature) or the internal physiologic demands 

required by or placed upon the human body (such as 

the need for hydration or an immune response to a 

viral infection).

Exhibit 4-2 provides examples of the two types of 

physical stressors (environmental and physiologic) 

and the two types of mental stressors (cognitive and 

emotional). Also, physical stressors cause mental stressors when they result in discomfort, distraction, and 

threat of harm, as well as when they directly impair 

brain functions. Mental stressors can lead to adaptive or maladaptive stress behaviors that decrease or 

increase the exposure to physical stressors.

COMBAT AND OPERATIONAL STRESS BEHAVIOR

Stress has both physical and behavioral effects. 

Stress may increase disease rates by disrupting hygiene and protective measures, as well as impairing 

the body’s immune defenses. Stress may progress 

to behavioral health disorders, including suicidal or 

homicidal behaviors. Some stressors contribute to 
62

Combat and Operational Behavioral Health

EXHIBIT 4-2 

examples of COMBAT AND OPERATIONAL STRESSORS

Physical Stressors

•	 Environmental

° Heat, cold, wetness, dust

° Vibration, noise, blast

° Noxious odors (fumes, poisons, chemicals)

° Directed-energy weapons/devices

° Ionizing radiation

° Infectious agents

° Physical work

° Poor visibility (bright lights, darkness, haze)

° Difficult or arduous terrain

° High altitude

•	 Physiologic

° Sleep deprivation

° Dehydration

° Malnutrition

° Poor hygiene

° Muscular and aerobic fatigue

° Overuse or underuse of muscles

° Impaired immune system

° Illness or injury

° Sexual frustration

° Substance use (smoking, caffeine, alcohol)

° Obesity

° Poor physical condition

Mental Stressors

•	 Cognitive

° Information (too much or too little)

° Sensory overload or deprivation

° Ambiguity, uncertainty, unpredictability

° Time pressure or waiting

° Difficult decision (rules of engagement)

° Organizational dynamics and changes

° Hard choices vs no choice

° Recognition of impaired functioning

° Working beyond skill level

° Previous failures

•	 Emotional

° Being new in unit, isolated, lonely

° Fear and anxiety-producing threats (of death, 

injury, failure, or loss)

° Grief-producing losses (bereavement)

° Resentment, anger, and rage-producing frustration and guilt

° Inactivity, producing boredom

° Conflicting/divided motives and loyalties

° Spiritual confrontation or temptation causing 

loss of faith

° Interpersonal conflict (unity, buddy)

° Home-front worries, homesickness

° Loss of privacy

° Victimization/harassment

° Exposure to combat/dead bodies

° Having to kill

misconduct that requires disciplinary action and may 

take a soldier from duty for legal action and incarceration. Stress can also result in battle and nonbattle 

injuries through inattention, clumsiness, and reckless 

behavior, including equipment loss and friendly fire 

incidents. Excessive stress in combat contributes to 

lapses in operational and tactical judgment and to 

missed opportunities that could increase the numbers 

of soldiers injured over time. 

“COSB” is the term used to describe the range of 

reactions, from adaptive to maladaptive, to the full 

spectrum of combat and operational stress soldiers 

are exposed to throughout their military experience.1–14 Figure 4-1 shows how combat and operational 

stress and PTEs can lead to both adaptive reactions 

and COSR, as well as postcombat and operational 

stress (PCOS), which may include either posttraumatic growth (PTG) or posttraumatic stress disorder 

(PTSD). 

Combat and operational experiences impact every 

soldier in some way, although not everyone handles 

the stress in the same way. Soldiers surveyed in Iraq 

indicate that those who experienced the most combat 

were the most likely to screen positive for a behavioral 

health (BH) problem, including PTSD. Nearly one third 

of soldiers operating “outside the wire” (ie, outside 

the secure area of the base camps) may be experiencing severe negative symptoms related to combat and 

operational stress exposure, which can potentially 

affect the unit’s mission capability.14

In fact, current research shows that soldiers continue 

to struggle with PCOS symptoms long after deployment. Soldiers do not reset quickly after coming home, 

and up to 17% of returned veterans may continue to 

struggle with negative PCOS effects even 12 months 

after coming home.14 Leaders and soldiers must recognize the continued effects of combat and operational 

exposure. Understanding these effects will help sol-
63

Combat and Operational Stress Control

Combat and Operational Stress

Significant PTE

(Combat Stressors)

Multiple PTEs

(Operational Stressors)

Combat and Operational Stress Behaviors

Postcombat and Operational Stress Behaviors

Adaptive 

Reaction COSR

PTG PTSD

Figure 4-1. Model of stress and its potential soldier and 

family outcomes. 

COSR: combat and operational stress reaction

PTE: potentially traumatic event

PTG: posttraumatic growth

PTSD: posttraumatic stress disorder

diers plan accordingly to support each other and those 

entrusted to them. This is especially important while 

sustaining prolonged or multiple deployment rotations 

as well as combat operations. 

Adaptive Stress Reactions

With effective leadership and strong peer relationships, stressors can lead to adaptive stress reactions 

that enhance individual and unit performance. Examples of adaptive stress reactions include

	 •	 horizontal bonding—the strongpersonaltrust,

loyalty, and cohesiveness that develop among 

peers in a small military unit;

	 •	 vertical bonding—personal trust, loyalty, and

cohesiveness that develop between leaders 

and their subordinates;

	 •	 esprit de corps—a feeling of identification and

membership in the larger, enduring organization with understanding of its history and 

intent (organizations may include the unit 

[battalion, brigade combat team, regiment, 

or division], the branch [infantry, artillery, or 

military police], and the Army); and 

	 •	 unit cohesion—the binding force that keeps

soldiers together and performing the mission 

in spite of danger and adversity. 

Cohesion is a result of soldiers knowing and trusting 

their peers and leaders and understanding their dependency on one another. It is achieved through personal 

bonding and a strong sense of responsibility toward 

the unit and its members. The ultimate adaptive stress 

reactions are acts of extreme courage and almost unbelievable strength. They may even involve deliberate 

heroism resulting in the ultimate self-sacrifice.

Combat and Operational Stress Reaction

Focused stress is vital to survival and mission accomplishment. However, stress that is prolonged or too 

intense results in COSR, which impairs the ability to 

function effectively. The Army uses the term “COSR” 

(approved by the Department of Defense) in official 

medical reports in reference to negative adaptation to 

high-stress events and PTE exposures. When coded 

(ie, diagnosed), COSR represents individuals in need 

of formal or informal COSC support and interventions 

to identify, treat or normalize, and transition the negative effects of combat and operational stress. Although 

many reactions look like symptoms of mental illness 

(such as panic, extreme anxiety, depression, hallucinations), they are actually transient reactions to the 

traumatic stress of combat and the cumulative stresses 

of military operations. 

Military leaders, soldiers, and medical providers 

must understand the difference between COSR and 

PTSD. COSR is not the same as PTSD. COSR, representing negative adaptation to high-stress and potentially 

traumatic events, is considered a subclinical diagnosis 

with a high recovery rate if appropriate attention and 

time is provided. PTSD, on the other hand, is an anxiety disorder associated with serious traumatic events 

and characterized by such symptoms as survivor guilt, 

reliving the trauma in dreams, numbness and lack of 

involvement with reality, or recurrent thoughts and 

images. PTSD is a clinical diagnosis as defined by the 

Diagnostic and Statistical Manual of Mental Disorders

and the International Statistical Classification of Diseases 

and Related Health Problems. PTSD is one of many possible long-term outcomes resulting from combat and 

operational stress exposure (collectively classified as 

PCOS). 

COSR and PTSD may share some common symptoms in presentation; however, COSR is recognizable 

immediately or shortly after exposure to traumatic 

events and captures any recognizable reaction resulting from this exposure. PTSD has specific chronological requirements and symptom markers that must be 

satisfied to diagnose the disorder. PTSD is diagnosable 

only by a trained and credentialed healthcare provider. 
64

Combat and Operational Behavioral Health

Military personnel and providers must focus their 

efforts on the management of COSR in an effort to 

shape the long-term reactions of individual soldiers 

and their units. Individuals with behavioral disorders 

that existed prior to deployment or first appeared 

during deployment may need BH support beyond the 

interventions for COSR.

Misconduct Stress Behaviors

Misconduct stress behaviors range from minor 

breaches of unit orders or regulations to serious violations of the Uniform Code of Military Justice and the 

law of land warfare.1 Misconduct stress behaviors are 

most likely to occur in poorly trained, undisciplined 

soldiers under extreme combat stress. Misconduct 

stress behaviors may also become a major problem 

for highly cohesive units with strong esprit de corps. 

Such units may come to consider themselves entitled 

to special privileges and, as a result, some members 

may relieve tension unlawfully when they stand down 

from military operations. They may resort to illegal 

revenge when a unit member is lost in combat. Stresscontrol measures and sound leadership can prevent 

such misconduct stress behaviors, but once serious 

misconduct has occurred, soldiers must be punished 

to prevent further erosion of discipline. Combat stress, 

even with heroic combat performance, cannot justify 

criminal misconduct.

Postcombat and Operational Stress

PCOS describes a range of possible outcomes along 

the continuum of stress reactions that may be experienced weeks or even years after combat and operational stress exposure. PCOS may include PTG (the 

adaptive resolution), mild COSR, or the more severe 

symptoms often associated with PTSD. It is imperative 

to understand this continuum and know the difference 

between adaptation, COSR, and PTSD. 

Posttraumatic Growth

PTG refers to a phenomenon in which positive outcomes occur among survivors of traumatic experiences 

such as car accidents, fires, sexual abuse or assault, 

military combat, and being a refugee.15 PTG among 

trauma survivors has included improved relationships, renewed hope for life, an improved appreciation 

of life, an enhanced sense of personal strength, and 

spiritual development.16

Continuum of Combat and Operational Stress 

Behaviors

The distinctions among adaptive stress reactions, 

misconduct stress behaviors, COSB, COSR, PTG, and 

PTSD are not always clear. Indeed, the categories of 

combat and operational stress behaviors may overlap. 

Soldiers with adaptive stress reactions may also suffer 

from COSR. Soldiers in combat experience a range of 

emotions, usually outside of their daily experience, and 

their behavior influences the immediate safety of the 

unit and mission success. Combat and combat-related 

military missions can also impose combinations of 

heavy physical work; sleep loss; dehydration; poor 

nutrition; severe noise, vibration, and blast; exposure 

to heat, cold, or wetness; poor hygiene facilities; and 

perhaps exposure to infectious diseases, toxic fumes, 

or harmful substances. These ranges of emotions and 

mission-related conditions in combination with other 

influences, such as concerns about problems back home, 

affect the ability to manage perceived or real danger, 

and diminish the skills needed to accomplish the mission. Some reactions sharpen abilities to survive and 

win; other reactions may produce disruptive behaviors 

and threaten individual and unit safety. Outstanding 

combat soldiers who have exhibited bravery and heroism may also commit misconduct stress behaviors. 

PCOS may develop after someone has experienced 

or witnessed an actual or threatened traumatic event. 

It is common for stress reactions to persist or arise long 

after exposure to distressing events. If PCOS interferes 

with the ability to do jobs and enjoy life, and it seems 

to continually get worse, it could lead to PTSD. Most 

soldiers do well, but for some, persistent symptoms of 

postcombat stress may require support or medical care. 

When there is impairment in social or occupational 

functioning, a clinical assessment is warranted. COSC 

is important to sustaining Army strength over the long 

term and reducing the costs to society, the Department 

of Defense, soldiers, and families.

COMBAT AND OPERATIONAL STRESS CONTROL

COSC is a full-spectrum behavioral health support 

program that spans all military operations and deployment cycles, not just in the theater environment. The 

goal of COSC is to enhance unit cohesion and combat 

capability in the face of high-stress operational environments and to maximize PTG. COSC is effective 

when it incorporates not only soldiers but also their 

extended support system, including significant relationships, families, and external resources. COSC is a 

comprehensive process that identifies soldiers, Army 

civilians, and their families who may need assistance 

with the challenges of deployment, and ensures that 
65

Combat and Operational Stress Control

they are better prepared and sustained throughout the 

deployment cycle.17 Figure 4-2 illustrates the seven 

stages of deployment cycle support.

The purpose of COSC is to promote soldier and 

unit readiness by:

	 •	 enhancing adaptive stress reactions,

	 •	 preventing maladaptive stress reactions,

	 •	 assisting soldiers with controlling COSR,

and

	 •	 assisting soldiers with behavioral disorders.

Battlemind

The term “Battlemind” represents the US Army 

psychological resiliency building program (see also 

the attachment to this chapter). The term describes a 

soldier’s resiliency skills or inner strength to face fear 

and adversity during combat with courage. Battlemind training enhances the psychological readiness 

of every soldier for a stronger and more resilient force. 

It targets successful individual and organizational 

recognition of traumatic brain injury, PTSD, suicide 

risk, and other predictable stressors from military 

operations to mitigate the effect on mission and readiness. There are four main objectives of Battlemind 

training for soldiers and their families: (1) mental 

preparation for the rigors of combat and military 

deployments, (2) successful transition back home, 

(3) effective assistance for “Battlemind buddies” 

during the transition home, and (4) preparation for 

Figure 4-2. Deployment cycle support phases.

the likelihood of deploying again. Battlemind meets 

these objectives by applying a three-pillar systematic 

approach: (1) life cycle, (2) deployment cycle, and (3) 

soldier support.8

Life-cycle training is the long-term institutional 

initiative to help soldiers and leaders reduce existing 

behavioral health barriers. It facilitates organizational 

growth by targeting stigma and institutional barriers 

through cohesion and progressive leader development 

training during critical points in a soldier’s military 

career. Deployment-cycle training targets each phase 

of deployment and builds upon techniques learned 

during life-cycle training. Combat skills and the 

battle mindset are what the soldier utilizes to sustain 

and survive in high-stress operational environments. 

Battlemind skills help soldiers survive; however, those 

same skills must be adapted as soldiers transition from 

a combat or operational mission back to garrison and 

home environments. Although each soldier makes 

individual adjustments, the key to a successful transition home is to adapt combat skills so they are just 

as effective at home as they were in combat. Soldier 

support training is tailored to special populations, 

including family systems and military communities. 

Present day COSC builds on Battlemind skills as 

proven strengths in the transition to postcombat or 

operational functioning.

Cohesion and Morale

Cohesion, or the bonds among soldiers, has traditionally been posited as the primary motivation for 

soldiers in combat.18 High cohesion and morale enhance adaptive stress reactions in soldiers and organizations and are the best predictors of resiliency within 

a unit or organization. Units with high cohesion tend 

to experience a lower rate of COSR than those with 

low cohesion and morale. Esprit de corps can transcend the problems of race and prejudice. The upkeep 

of morale and cohesion in combat is recognized as 

a vital element in the production of combat power 

in tactical units.13 Supportive leadership, regardless 

of whether a soldier has been to combat or not, is 

related to how well soldiers fare, both at a personal 

level (personal morale) and at a unit level (unit morale, cohesion, and combat readiness). This is good 

news for the military, because leaders can be trained 

to be more supportive and increase the chances of 

soldiers having higher personal morale, higher unit 

morale, better unit cohesion, and higher perceptions 

of combat readiness.19 In fact, if unit leaders do nothing more under COSC programs integrated in their 

organization than focus on unit cohesion and morale, 

they will have met what is known in the US Army as 

the “80% solution.”18
66

Combat and Operational Behavioral Health

Combat and Operational Stress Control as a Function of Leadership

COSC is a command-driven program at all levels. 

Commanders are assisted by their staff, unit leaders, unit chaplains, and organic medical personnel 

(ie, those behavioral health and medical personnel 

assigned directly to the unit). The commander may 

also receive assistance from organic COSC personnel 

at brigade level and above, and from corps-level and 

above medical company or detachment BH personnel. 

The key concern to combat commanders is to maximize 

the RTD rate of soldiers who are temporarily impaired 

or incapacitated with stress-related conditions or diagnosed behavioral disorders.

Combat and Operational Stress Control Professional Disciplines 

Five BH professional disciplines and two enlisted 

specialties support the COSC mission. The professional 

disciplines include social work, clinical psychology, 

psychiatry, occupational therapy, and psychiatric 

or BH nursing; the enlisted specialties are BH and 

occupational therapy. Although much of the COSC 

knowledge base and most of the skills are shared by 

all BH personnel, each discipline brings a unique perspective from its professional training, skills that can 

only partially be taught to others, and in some cases 

unique credentials to conduct specific assessments 

and treatments. 

Religious Support for Combat and Operational 

Stress Control 

The US Army Chaplain Corps is an invaluable 

asset in ongoing COSC support operations. Soldiers 

often approach chaplains first to obtain resources to 

address identified COSRs. Soldiers’ inner resources 

are generally rooted in religious and spiritual values. 

In combat, soldiers often show increased interest in 

religious beliefs. When religious and spiritual values 

are challenged by the chaos of combat, soldiers may 

lose connection with the inner resources that previously sustained them. The unit ministry team is the 

primary resource available to soldiers experiencing 

such dilemmas, providing assistance as they seek to refocus their spiritual values. The ministry team provides 

preventive, immediate, and restorative spiritual and 

emotional support to soldiers experiencing COSR. 

COMBAT AND OPERATIONAL STRESS CONTROL INTERVENTIONS

COSC is performed during all phases of combat operations, stability and reconstruction operations, and 

support operations. COSC assessments, performed at 

both the unit and individual level, consider a range of 

variables according to a model (Figure 4-3) that recognizes the interrelationship of biological, psychological, 

and social factors. This figure is a conceptual model of 

stress, its mitigating and aggravating factors, and potential outcomes for soldiers and families. Reviewing 

these interactions systematically, the COSC assessment 

identifies which variables can be modified to improve 

coping or outcome. Based on these assessments, 

COSC personnel recommend courses of action to the 

commander to improve unit effectiveness and soldier 

efficiency and well-being. The stress model can be 

helpful for designing COSC interventions to improve 

short-term and long-term outcomes. 

Soldier and unit readiness is best achieved through 

an active, prevention-focused approach. COSC interventions are tailored to the needs of the population, 

and their application may differ based on a particular 

level of care and other factors pertaining to the mission, enemy, terrain and weather, troops and support 

available, time available, and civil considerations 

(METT-TC). However, all preventive interventions 

seek to reduce the occurrence or severity of COSR and 

behavioral disorders, thereby sustaining soldier and 

unit readiness. COSC interventions can be divided 

into four categories:

1. universal interventions are targeted to the 

general population or an assigned AO (area 

of operations); 

2. selective interventions are targeted to a unit 

or soldier whose risk is higher than average;

3. indicated interventions are targeted to soldiers with COSR or indications of a potential 

behavioral disorder, and to units showing 

signs that mission effectiveness is being affected by combat and operational stressors; 

and 

4. treatment interventions are targeted to treat 

and follow up with soldiers with behavioral 

disorders to prevent their loss from duty.

COSC personnel must identify life- or functionthreatening medical, surgical, or psychiatric conditions 

as soon as possible and provide emergency treatment 

for those patients.

Combat and Operational Stress Control Management Principles

COSC utilizes the management principles of brev-
67

Combat and Operational Stress Control

Occupational 

Demands

Deployment 

experiences/

separations

OPTEMPO/

PERSTEMPO/

work overload

Combat 

experiences/

war-zone 

exposures

Vulnerability 

Factors

Predisposing 

(history of mental/

substance/relational 

disorder; history of 

maltreatment/

violence exposure)

Active 

(current personality/

adjustment/

subthreshold 

disorder; recent 

trauma; negative 

interactions in close 

relations; social 

support deficits)

Protective 

Factors

Organizational/

Extrafamilial

Cohesion (strong 

horizontal/vertical 

cohesion)

Leadership 

(effective 

junior/senior 

leadership)

Mentoring

Preventive 

mental health 

services 

(universal/

selective/

preventive care)

Other

Family support 

system

Adaptive skill 

development

Stressors

Environmental

Physiological

Cognitive

Emotional

Barriers

Access to care 

(availability, 

affordability, 

acceptability, 

and 

approachability/

stigma)

Soldier/Family 

Support Service

COSC services

Behavioral 

healthcare

Chaplain

Army Community 

Service

Short-Term 

Outcomes

Adaptive stress 

reactions

Maladaptive 

stress reactions

Combat and 

operational 

stress reactions

Misconduct 

stress behaviors

Behavioral 

disorders

Suicide/homicide

Long-Term 

Outcomes

Personal/

Occupational

Adaptive stress 

reactions

Renewed hope 

for life

Improved 

appreciation of life

Enhanced sense of 

personal strength

Impaired/deviant 

performance

Excessive medical 

care

Involuntary 

separation/

attrition

Social

Improved 

relationships

Aggression/

withdrawal/

avoidance

Family

Improved partner 

role

Improved caregiver 

role

Marital discord

Hostility/violence

Spiritual

Spiritual 

development

Figure 4-3. Combat and operational stress intervention model.

OPSTEMPO: operations tempo; PERSTEMPO: personnel tempo; COSC: combat and operational stress control

ity, immediacy, contact, expectancy, proximity, and 

simplicity (BICEPS). Using BICEPS is extremely important in the management of soldiers with COSR or 

behavioral disorders. COSC personnel in all BH/COSC 

elements apply these principles to all COSC interventions or activities in theater, although they may be 

applied differently based on a particular level of care 

and other METT-TC factors, as described below. 

Brevity

Initial rest and replenishment at COSC facilities 

located close to the soldier’s unit should last no more 

than 1 to 3 days. Those requiring further treatment are 

moved to the next level of care. Because many soldiers 

require no further treatment, military commanders 

expect their soldiers to RTD rapidly.
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Immediacy

It is essential that COSC measures be initiated as 

soon as possible (as soon as symptoms appear) when 

operations permit. 

Contact

Soldiers must be encouraged to continue to think of 

themselves as warfighters, rather than as patients or 

sick persons. The chain of command remains directly 

involved in soldiers’ recovery and RTD. The COSC 

team coordinates with the unit’s leaders to learn whether individuals in treatment were good performers prior 

to the COSR. Whenever possible, representatives or 

messages from the unit tell these soldiers that they are 

needed and wanted back. The COSC team coordinates 

with the unit leaders, through unit medical personnel 

or chaplains, any special advice on how to assure quick 

reintegration when the soldier returns to the unit.

Expectancy

Individual soldiers are explicitly told that they are 

reacting normally to extreme stress and are expected to 

recover and return to full duty in a few hours or days. 

A military leader is extremely effective in this role. Of 

all the things said to a soldier suffering from COSR, 

the words of the small-unit leader have the greatest 

effect because of the positive bonding process that occurs. Small-unit leaders should tell soldiers that their 

comrades need and expect them to return. When they 

do return, the unit treats them the same as every other 

soldier and expects them to perform well.

Proximity

Soldiers requiring observation or care beyond the 

unit level are evacuated to facilities in close proximity 

to, but separate from, the medical or surgical patients 

at the battalion aid station or medical company nearest the soldiers’ unit. COSRs are often more effectively 

managed in areas close to the soldier’s parent unit. On 

the noncontiguous battlefield characterized by rapid, 

frequent maneuvers and continuous operations, COSC 

personnel must be innovative and flexible in designing 

interventions that maximize and maintain the soldier’s 

connection to the parent unit. It is best to send soldiers 

who cannot continue their mission and require more 

extensive intervention to a facility other than a hospital, 

unless no other alternative is available.

Simplicity

Brief, straightforward methods should be used to 

restore physical well-being and self-confidence.

Combat and Operational Stress Control Functional 

Areas

Combat and operational stress control interventions and activities are organized into nine functional 

areas. These areas cover the full spectrum of BH care 

from preventive measures through clinical intervention.

Unit Needs Assessment

Unit needs assessment is the systematic and frequent assessment of supported units to determine the 

priority and types of BH interventions required. 

Consultation and Education

Consultation involves liaison with and preventive 

advice to commanders, staff of supported units, and 

soldiers. Education involves training in concepts and 

skills for increasing soldier resilience to stress.

Traumatic Events Management

Traumatic events management (TEM) blends other 

COSC functional areas to create a flexible set of interventions specifically focused on stress management 

for units and soldiers following PTEs. Like other 

functional areas, COSC providers must tailor TEM 

to the needs of the unit and the soldier. For military 

units, TEM is active in all phases of the deployment 

cycle and across the continuum of military operations, 

both in garrison and in deployed environments. TEM 

is a structured unit process designed to mitigate the 

impact of PTEs and to accelerate normal recovery of 

personnel involved. The goal of TEM is to enhance 

PTG and reestablish unit cohesion and structure. Examples of PTEs that might result in a TEM assessment 

and intervention include 

	 •	 heavy or continuous combat operations,

	 •	 death of unit members,

	 •	 accidents,

	 •	 serious injury,

	 •	 suicide/homicide,

	 •	 environmental devastation or human suffering,

	 •	 significant home-front issues, and

	 •	 operations resulting in the death of civilians

or combatants.

If a unit experiences a PTE, unit leadership may 

request a TEM assessment to determine potential 
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Combat and Operational Stress Control

impact. It is recommended that leadership request 

TEM assessments as close to the specific PTE as 

practically possible, but there are no time limitations 

to conducting assessments and implementing TEM 

interventions in response to PTEs that have had a 

significant impact on the performance, morale, and 

cohesion of the effected unit or organization. When 

requested, the identified TEM team will coordinate 

an assessment resulting in specific recommendations to address the identified PTE as effectively and 

efficiently as required. TEM is normally conducted 

by a team composed of medical officers, chaplains, 

behavioral health professionals, and other trained 

unit members. 

TEM’s main value is to quickly restore unit cohesion 

and readiness to return to action, through clarifying 

what actually happened and clearing up harmful 

misperceptions and misunderstandings. It may also 

reduce the possibility of long-term distress through 

sharing and acceptance of thoughts, feelings, and reactions related to the PTE. The TEM process incorporates 

multiple interventions and clinical strategies to aid the 

military leader in managing and mitigating the impact 

of PTEs. TEM responses include

	 •	 a needs assessment of the impact of the identified PTE;

	 •	 command consultation and education;

	 •	 unit and individual education;

	 •	 individual supportive intervention and counseling;

	 •	 psychological debriefings; and

	 •	 leader-led after-action debriefings.

Reconstitution Support

Reconstitution is extraordinary action that commanders plan and implement to restore units to a desired level of combat effectiveness commensurate with 

mission requirements and available resources. Reconstitution transcends normal daily force sustainment actions, but it uses existing systems and units to do so; no 

resources exist solely for this function. In reconstitution 

support, COSC personnel are responsible for providing 

restoration for soldiers and conducting COSC functions. 

This support is provided to units following traumatic 

events and during reconstitution, redeployment, and 

transition among levels of operational tempo.

Combat and Operational Stress Control Triage

Combat and operational stress control triage is the 

process of sorting soldiers with COSR or BH disorders 

based upon where they can best be managed. 

Combat and Operational Stress Control Stabilization

Stabilization is the initial management of soldiers 

with severe COSR or behavioral disorders. Their safety 

is ensured and they are evaluated for RTD potential or 

prepared for further treatment or evacuation.

Soldier Restoration

Soldier restoration involves the 1- to 3-day management of soldiers with COSR or behavioral disorders, normally near a medical treatment facility in 

close proximity to the unit. This approach uses the 

“5 Rs”: 

	 •	 Reassure of normality.

	 •	 Rest (respite from combat or break from the 

work).

	 •	 Replenish bodily needs (such as thermal comfort, water, food, hygiene, and sleep).

	 •	 Restore confidence with purposeful activities 

and contact with the soldier’s unit.

	 •	 Return to duty and reunite the soldier with 

the unit.

Behavioral Health Treatment

Patients with identified behavioral disorders receive 

ongoing evaluation, treatment, and follow-up. This 

functional area implies a therapist–patient relationship, clinical documentation, and adherence to clinical 

standards of care.

Soldier Reconditioning

Reconditioning is an intensive program of work 

therapy, military activities, physical training, and psychotherapy. Reconditioning programs are conducted 

up to 7 days (or more) in the corps area. Additional 

reconditioning may be provided in theater outside the 

combat zone. 

SUMMARY

COSC is a joint-service program that affects all 

service members and their extended support systems 

in the US military. COSC remains an effective combat 

multiplier, as it has been in past conflicts. Present-day 

COSC continues to evolve, incorporating both the 

lessons of past history and the experiences of current combat. It is strength based, utilizing objective 

and empirically validated current best practices to 
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enhance and adapt the “battlemind” of the human 

weapons system. Battlemind is essential to successful 

military operations, as well as individual adaptive 

stress reactions and posttraumatic growth. Modern 

COSC requires close collaboration between military 

leaders, doctrinal COSC disciplines, chaplains, and 

the extended medical community. True COSC is only 

obtained by leadership integration of COSC concepts 

with the supporting efforts of medical providers and 

religious support assets.

REFERENCES

1. US Department of the Army. Combat and Operational Stress Control. Washington, DC: DA; 2006. Field Manual 

4-02.51.

2. US Department of the Army. Combat and Operational Stress Control Manual for Leaders and Soldiers. Washington, DC: 

DA; 2009. Field Manual 6-22.5.

3. Johnson SJ, Sherman MD, Hoffman JS, et al. American Psychological Association Presidential Task Force on Military 

Deployment Services for Youth, Families and Service Members. The Psychological Needs of US Military Service Members 

and Their Families: A Preliminary Report. Washington, DC: APA; 2007: 5. Available at: http://www.apa.org/releases/

MilitaryDeploymentTaskForceReport.pdf. Accessed September 8, 2008.

	 4. 	 Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental

health problems, and barriers to care. N Engl J Med. 2004;351(1):13–22. 

5. Boscarino JA. Diseases among men 20 years after exposure to severe stress: implications for clinical research and 

medical care. Psychosom Med. 1997;59(6):605–614.

	 6. 	 Jordan BK, Schlenger WE, Hough R, et al. Lifetime and current prevalence of specific psychiatric disorders among

Vietnam veterans and controls. Arch Gen Psychiatry. 1991;48:207–215.

	 7. 	 King DW, King LA, Foy DW, Keane TM, Fairbank JA. Posttraumatic stress disorder in a national sample of female

and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables. J Abnorm Psychol. 

1999;108:164–170.

8. Walter Reed Army Institute of Research—Psychiatry and Neuroscience. Battlemind Training. Available at: www.battlemind.army.mil. Accessed July 27, 2009. 

9. Adler AB, Dolan CA, Castro CA. US soldier peacekeeping experiences and well-being after returning from deployment to Kosovo. Proceedings of the 36th International Applied Military Psychology Symposium. Split, Croatia: Ministry of 

Defense of the Republic of Croatia. September, 2000; 30–34.

10. McCarroll JE, Ursano RJ, Liu X, et al. Deployment and the probability of spousal aggression by US Army soldiers. Mil 

Med. 2000;165:41–44.

	 11. 	 Bliese PD, Wright KM, Adler AB, Thomas JL. Psychological screening validation with soldiers returning from combat.

In: Roy M, ed. Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Washington, DC: North 

Atlantic Treaty Organization/IOS Press; 2006: 78–86.

12. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from 

military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023–1032.

13. Cox AA. Unit Cohesion and Morale in Combat: Survival in a Culturally and Racially Heterogeneous Environment. Fort Leavenworth, Kan: School of Advanced Military Studies; 1995: 1.

14. Mental Health Advisory Team (MHAT) IV. Operation Iraqi Freedom 05-07. Office of the Surgeon, Multinational ForceIraq, and Office of The Surgeon General, United States Army Medical Command. November 17, 2006. Available at: 

www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

15. Tedeschi RG, Calhoun L. Posttraumatic growth: a new perspective on psychotraumatology. Psychiatr Times. 2004;21:4. 

Available at: http://www.psychiatrictimes.com/p040458.html. Accessed September 8, 2008.
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16. Calhoun LG, Tedeschi RG. Posttraumatic growth: future directions. In: Tedeschi RG, Park CL, Calhoun LG, eds. Posttraumatic Growth: Positive Changes in the Aftermath of Crisis. Mahwah, NJ: Erlbaum Publishers; 1998: 215–238.

17. Deputy Chief of Staff, US Army G1. Deployment Cycle Support Process. Available at: http://www.armyg1.army.mil/

dcs/default.asp. Accessed September 8, 2008.

	 18. 	 Wong L, Kolditz TA, Millen RA, Potter TM. Why They Fight: Combat Motivation in the Iraq War. Carlisle Barracks, Penn: 

Strategic Studies Institute of the US Army War College; 2003: iii.

19. McGurk D, Castro CA, Thomas JL, Messer SC, Sinclair RR. Leader Behaviors for Combat Veterans and Noncombat Soldiers. 

Silver Spring, Md: Walter Reed Army Institute of Research; 2005: 3–4.
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Combat and Operational Behavioral Health

Battlemind Training: the Development of the US Army’s Integrated System of

Mental Health Training

Background 

Battlemind training is the US Army’s integrated mental health training program. The Battlemind training 

system encompasses training targeted to all phases of the deployment cycle, as well as to the soldier lifecycle and 

medical education system. Training is designed for soldiers, leaders, and military spouses. Battlemind training 

uses a strength-based approach, incorporating “buddy aid” and focusing on the leader’s role in maintaining 

the mental health of all soldiers. 

The word “Battlemind” was coined by General Crosby Saint, Commander-in-Chief, US Army, Europe, in a 

1992 message titled “Battlemind Guidelines for Battalion Commanders.” General Saint’s message described 

Battlemind as “a warrior’s fortitude in the face of danger.” Thus, Battlemind was originally a concept created 

by the warfighter for the warfighter. In 1998, then-Major Carl Castro, as commander of the US Army Medical 

Research Unit–Europe, an overseas laboratory of the Walter Reed Army Institute of Research (WRAIR), read 

about Battlemind and recognized its relevancy for the Army at large. 

Command-Requested Mental Health Training

In 2005 the brigade commander of the 3rd Infantry Division asked Castro (at that time Chief, Department of 

Military Psychiatry, WRAIR) to present a talk on preparing leaders for combat. Castro’s presentation, “10 Tough 

Facts About Combat and What Leaders Can Do to Mitigate the Risk,” incorporated the concept of Battlemind 

in what later emerged as a module of Battlemind training. This speech was so well received that the brigade 

developed a brochure summarizing the main points for all its leaders. 

Soon after, recognizing the need for training designed for soldiers as well as those in leadership positions, 

Castro and Colonel Charles Hoge (Director, Division of Psychiatry and Neurosciences, WRAIR) began planning 

mental health training for soldiers returning from Iraq and Afghanistan. In fact, Castro and Hoge first conceptualized this training, the impetus for what is now Battlemind, while on a plane ride back to Washington, DC, 

following a briefing to senior Army leaders. Postdeployment Battlemind training, including the creation of the 

Battlemind acronym, topic areas, and actions, was then developed by Castro, Hoge, Dr Amy Adler (US Army 

Medical Research Unit–Europe), and Dr Steven Messer (Department of Military Psychiatry, WRAIR). 

Postdeployment Battlemind Training Initiated

The first two Battlemind training modules were validated under a WRAIR scientific protocol with soldiers 

returning from a combat deployment in Iraq. Battlemind training for reintegration (the original Battlemind 

training) and the postdeployment Battlemind psychological debriefing were both validated in a group randomized trial conducted with a brigade combat team in 2005.1

 Soldiers with high levels of combat experience who 

received Battlemind training reported better mental health adjustment 4 months after returning from deployment compared to those receiving standard postdeployment stress education. Soldiers in the Battlemind sessions 

frequently requested that their spouse receive the same training. This led to the development by Castro and 

Lieutenant Colonel Anthony Cox (Department of Military Psychiatry, WRAIR) of the spouse Battlemind training 

program (predeployment and postdeployment training designed for individuals or couples). 

The original Battlemind training efficacy study was replicated in 2006 with another brigade combat team.2

Results confirmed that Battlemind training reduced adjustment problems 4 months postdeployment. In addition, while conducting the initial postdeployment Battlemind training, Castro and Adler recognized the need 

for follow-up training 3 to 6 months later. This recognition was fueled by the intensity with which soldiers 

described the transition process as well as WRAIR data demonstrating that symptoms increase between return 

from deployment and 3 to 6 months postdeployment.3 Battlemind training for the 3- to 6-month postdeployment 

period was assessed in a group randomized trial in 2005 and 2006.4

 Again, results demonstrated the efficacy of 

Battlemind training in reducing mental health symptoms. Thus, Battlemind quickly evolved from a one-time 

intervention to a full program with multiple training modules designed for different points in the deployment 

and career life cycle.

In addition to PowerPoint presentations, Castro and Colonel Charles S Milliken (Division of Psychiatry and 

Neurosciences, WRAIR) and Walter Reed Army Medical Center Television created a training video with four 
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Combat and Operational Stress Control

scenarios supporting Battlemind training designed for 3 to 6 months postdeployment. Furthermore, Battlemind 

psychological debriefing techniques were adapted for implementation in-theater and provided to the Army 

Medical Department Center and School (AMEDD C&S) in February 2007.5 A Battlemind psychological debriefing training video was then developed by Castro and Major Dennis McGurk (then at the Department of Military 

Psychiatry, WRAIR), demonstrating the techniques. Battlemind psychological debriefing was integrated into the 

AMEDD C&S’s combat operational stress course by Major Todd Yosick in February 2007. This course is designed 

for all behavioral health providers and chaplains deploying to Iraq or Afghanistan.

Broadening Battlemind Training 

At the same time that postdeployment Battlemind training modules were being studied, predeployment 

modules were also being developed. Based on perceived need and the findings of the WRAIR Land Combat 

Study6 (which evaluated prevalence of posttraumatic stress disorder [PTSD], alcohol abuse, and relationship 

problems; the impact of operational tempo/combat on these problems; what factors decreased the risk; and the 

proportion of soldiers and families who are not receiving services for these problems), predeployment training 

was fielded and assessed for user satisfaction in 2007. Results from the Mental Health Advisory Team (MHAT) 

V report assessing soldier well-being in Iraq found that those who reported receiving predeployment Battlemind 

training also reported better mental health adjustment in theater.7

As deployment cycle and deployment support cycle programs were being phased into soldier training, 

other Battlemind modules were also being developed. Specifically, in 2007, Milliken initiated the development 

of Battlemind First Aid, a training program to provide medics with fundamental skills for identifying mental 

health and referral needs. This program became the blueprint for what is now Battlemind Warrior Resiliency 

Training, which targets all Army medical personnel as of 2007.

Each of the new Battlemind modules followed the same fundamental principles. Each module is researchbased and rejects a medical or deficit model, focusing instead on soldier strengths. Using examples soldiers can 

relate to, modules are designed to address misunderstood or conflicted reactions. Each module also identifies 

specific actions that soldiers can take to maintain their “Battlemind,” and emphasizes looking out for oneself, 

buddies, and subordinates. All training modules were finalized by a team of researchers from both the Department of Military Psychiatry and the US Army Medical Research Unit–Europe.

Battlemind Training and the Army Medical Department

In October and November 2006, a WRAIR team led by Castro and McGurk conducted an MHAT IV assessment 

of the mental health and well-being of troops deployed to Iraq. A key recommendation of the MHAT IV report 

was to mandate predeployment and postdeployment Battlemind training. This recommendation was accepted 

by the US Army surgeon general, the chief of staff of the Army, and the secretary of the Army. 

Battlemind training proponency was handed to AMEDD C&S in an operations order (Army Directive 2007-02) 

signed by the surgeon general on March 26, 2007.8 Under the provision, the AMEDD C&S officially developed 

the Battlemind Training System Office to train and maintain the Battlemind mission for the US Army during 

deployment, the lifecycle, and the soldier support cycle. The office was launched by Major Yosick, Colonel Brian 

Scott, Colonel Joseph Pecko, and Major Edward Brusher. The operations order also called for the creation of a 

transition office to serve as an ongoing partner in the continued research and development of Battlemind content; 

this role was maintained by WRAIR under Lieutenant Colonel Sharon McBride. WRAIR researchers continue 

to lead the development and validation of Battlemind training. 

Current Status

Since the two Battlemind offices were established, other initiatives have been launched, including (a) Basic 

Battlemind, designed for basic training; (b) the US Army Training and Doctrine Command’s development of 

“Steel Your Battlemind,” a training video for advanced individual training; and (c) Battlemind for Leaders, which 

provides junior leaders with key leadership skills and behaviors and is taught at the Basic Officer Leadership 

Course and the Warrior Leader Course. As of 2008, other modules under development include (a) Battlemind 

training for senior leaders, (b) Battlemind training for Warrior Transition Unit cadres, and (c) community Battlemind. Other nations have adapted Battlemind training as well, including Canada (which integrated the training 

into its Third Location Decompression program) in 2006, and the Netherlands in 2007. 
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The fact that Battlemind has been readily accepted within the US Army and by other nations reflects the 

degree to which the training fills an essential need. To remain relevant, the Battlemind system continues to be a 

dynamic program, creating new modules using the same fundamental principles. Moreover, Battlemind research 

initiatives at WRAIR are focused on ways to increase the efficacy of the training and ensure its adaptation to 

operational realities such as multiple deployments. Researchers at WRAIR, WRAIR’s transition office, and the 

AMEDD C&S’s Battlemind Office work as a team to ensure the development and implementation of an integrated mental health training program (“armor for the mind”) designed to help service members throughout 

their military career. The evolution of Battlemind concepts continues to influence new initiatives such as the 

Army Comprehensive Soldier Fitness Office, established in November 2008 under the leadership of Brigadier 

General Rhonda Cornum, to research resiliency training throughout the Army. 

REFERENCES

	 1.	 Adler AB, Castro CA, McGurk D, Bliese PD, Wright KM, Hoge CW. Post-deployment interventions to reduce the

mental health impact of combat deployment to Iraq: public health policies, psychological debriefing and Battlemind 

training. Paper presented at: 22nd Annual Meeting of the International Society for Traumatic Stress Studies; November 

2006; Hollywood, Calif.

2. Thomas JL, Castro CA, Adler AB, et al. The efficacy of Battlemind at immediate postdeployment reintegration. Paper 

presented at: 115th Annual Meeting of the American Psychological Association; August 2007; San Francisco, Calif.

	 3.	 Bliese PD, Wright KM, Adler AB, Thomas JL, Hoge CW. Timing of post-combat mental health assessments. Psychol 

Serv. 2007;4:141–148.

4. Adler AB, Castro CA, Bliese PD, McGurk D, Milliken C. The efficacy of Battlemind training at 3–6 months postdeployment. Paper presented at: 115th Annual Meeting of the American Psychological Association; August 2007; San 

Francisco, Calif.

5. Adler AB, Castro CA, McGurk D. Battlemind Psychological Debriefings. Heidelberg, Germany: US Army Medical Research 

Unit–Europe; 2007. USAMRU-E Research Report 2007-001. 

6. Walter Reed Army Institute of Research, Department of Military Psychiatry. Land Combat Study. Silver Spring, Md: 

WRAIR. Available at: http://wrair-www.army.mil/Psychiatry-and-Neuroscience/wrair--doms-wwd.htm. Accessed 

July 24, 2009.

7. Mental Health Advisory Team (MHAT) V Report. Operation Iraqi Freedom 06-08. Office of the Surgeon, Multinational 

Force–Iraq, and Office of The Surgeon General, United States Army Medical Command. February 14, 2008. Available 

at: http://www.armymedicine.army.mil/reports/mhat/mhat_v/mhat-v.cfm. Accessed June 4, 2009.

8. Geren P, Acting Secretary of the Army. Deployment Cycle Support (DSC) Directive. Washington, DC: DA. Memorandum, 

26 March 2007. Available at: http://www.apd.army.mil/pdffiles/ad2007_02.pdf. Accessed June 5, 2009.