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Operational Psychiatry in Operation Enduring Freedom 

Appendix 2

OPERATIONAL PSYCHIATRY IN 

OPERATION ENDURING FREEDOM

BRYAN L. BACON, DO*; MATTHEW J. BARRY, DO†; and JAMES DEMER, MD‡

INTRODUCTION

A BRIEF HISTORY OF AFGHANISTAN

US MILITARY INVOLVEMENT IN AFGHANISTAN

US ARMY MENTAL HEALTH OPERATIONS IN DEPLOYMENT

Preparation

Outreach

Prevention

Education

Consultation

Clinical Operations

MENTAL HEALTH OPERATIONS IN AFGHANISTAN

Chain of Command

Logistics

Communication

Travel

Documentation

Data Collection

CONCLUSION

case studies

*Major, Medical Corps, US Army; Disaster Psychiatry Fellow, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814; formerly, Chief, Behavioral Health, Bavaria Medical Department, Vilseck, Germany

†

Major, Medical Corps, US Army Reserves; Staff Psychiatrist, Department of Behavioral Health, Rochester Veterans Affairs Outpatient Clinic, 465 

Westfall Road, Rochester, New York 14620; formerly, Major, Medical Corps, US Army; Chief of Psychiatric Service USA MEDDAC and 10th Mountain 

Division Psychiatrist, Fort Drum, New York 

‡

Attending Child Psychiatrist, Inpatient Child Psychiatry Service, Hutchings Psychiatric Center, 7682 Warrior’s Path, Baldwinsville, New York 13027; 

formerly, Major, Medical Corps, US Army; Division Psychiatrist, 10th Mountain Division, Fort Drum, New York
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Combat and Operational Behavioral Health

INTRODUCTION

The mental health mission in support of Operation Enduring Freedom (OEF) possesses numerous 

challenges unique to the region and history of the 

nation. To best understand the complexities associated with mental health operations in this theater, a 

logical starting point is a brief history of Afghanistan 

itself and the United States military involvement in 

support of OEF. This will provide the basic construct 

as to the evolution of the mission and its inherent 

obstacles. 

The appendix will then cover deployment-related 

mental health issues and an overview of the mental 

health mission in OEF. Five clinical cases are presented 

at the end of the appendix to facilitate learning by emphasizing the wide array of subject matter that will test 

the skills of the deployed mental health clinician. 

A BRIEF HISTORY OF AFGHANISTAN

The Islamic Republic of Afghanistan has a turbulent 

history dating back to 2000 bce and has endured countless warring factions and oppressive regimes. From the 

Aryans to Alexander the Great, from Genghis Khan 

to the Soviet Union, and most recently, the Taliban, 

Afghanistan has known little stability and peace.

Afghanistan, or “Land of the Afghans,” emerged 

from the Iranian state of Khorasan and won its independence from Britain in 1919. Failing economic and 

social reforms in the 1960s and 1970s led to public 

discontent and invigorated the Marxist People’s 

Democratic Party of Afghanistan (PDPA). In 1978, the 

PDPA overthrew the government and established the 

Democratic Republic of Afghanistan. Unfortunately, 

political infighting and Marxist-based reforms imposed upon the overwhelmingly Muslim population 

fueled a rebellion and ultimately a civil war. To bolster 

the communist influence, the Soviet Union deployed 

the 40th Army in December 1979. The Soviet war in 

Afghanistan, aimed at crushing the antigovernment 

Mujahideen insurgency and empowering the PDPA, 

ended in failure 9 years later.

The social, economic, and cultural void that ensued 

provided fertile ground for the rise of the Taliban, a 

politico-religious force that oppressively imposed a 

strict interpretation of Sharia law. By the mid-1990s, 

the Taliban had seized control of the majority of the 

country. Their tenure was relatively short, however, as 

the Taliban’s support and harboring of international 

terrorists led to its demise in 2001. Significant steps 

toward achieving national self-sufficiency and stability have occurred recently. A ratified constitution, free 

elections, emphasis on education, and enhancement of 

a national infrastructure are all prominent examples 

of this progress. 

Although the recent discovery of vast mineral 

stores, valued at approximately 1 trillion US dollars, 

may translate to economic security and prosperity for 

the nation, the realization may take decades. Currently 

Afghanistan remains one of poorest nations outside of 

Africa, and one that relies on an agriculturally based 

economy. Unfortunately, only 1% of its land is suitable 

for agroindustry, and only one-tenth of that used for 

farming. Cash crops are in demand and poppy production fills that void. Poppy production accounts for 

57% of Afghanistan’s gross domestic product. Aside 

from Afghanistan’s reliance on the poppy industry, the 

ongoing insurgency, susceptibility to corruption, high 

rates of illiteracy and unemployment, oppression of the 

female population, rugged terrain, and rich history of 

tribalism present formidable challenges to the nation 

and its people.

US MILITARY INVOLVEMENT IN AFGHANISTAN

In response to the terrorist attacks of September 11th, 

President George W Bush demanded on October 7th, 

2001, that the Taliban “close terrorist training camps; 

hand over leaders of the al Qaeda network; and return 

all foreign nationals, including American citizens, 

unjustly detained in your country.” This ultimatum 

was rejected. On October 20th, 15 land-based bombers, 25 Navy strike aircraft, and Tomahawk missiles 

from US and British ships launched the first strikes of 

Operation Enduring Freedom. The initial aerial assault 

targeted terrorist strongholds in Kandahar, Jalalabad, 

and Kabul, and was soon followed by the deployment 

of ground forces.

The theater of operations in Afghanistan has matured significantly since the onset of military action. 

A multinational coalitional force, dominated by US 

personnel, is now directed by the International Security Assistance Force (ISAF). The North Atlantic Treaty 

Organization (NATO) took command and coordination 

of the ISAF in August 2003; it represents NATO’s first 

mission outside the Euro-Atlantic area. ISAF’s role is 

to assist the government of Afghanistan and the international community in maintaining security within its 

area of operation. ISAF supports the government of 
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Afghanistan in expanding its authority to the rest of the 

country, and in providing a safe and secure environment conducive to free and fair elections, the spread of the rule of law, and the reconstruction of the country. 

US ARMY MENTAL HEALTH OPERATIONS IN DEPLOYMENT

The primary mission for US Army psychiatry and 

the mental health team derives from the US Army 

Medical Department’s mission to “conserve the fighting strength.” In the combat theater, mental health 

providers accomplish this mission through an array of 

services that assist the chain of command in controlling mental illness and combat and operational stress 

through sound prevention programs and effective 

treatment modalities that establish the expectation of 

recovery. 

Mental health providers deploy immediately 

with a combat force and may include psychiatrists, 

psychologists, psychiatric nurse practitioners, social 

workers, or mental health technicians. Typically, the 

total number and type of providers vary from one 

rotation to the next. Assets are often in the form of 

combat and operational stress control (COSC) teams, 

division mental health providers, brigade behavioral 

science officers, and technicians or activated reservists, and may incorporate all branches of the military 

at any given time. Such a convoluted arrangement 

demands a well-delineated command structure and 

working agreements between all parties to greatly 

improve mission effectiveness and quality of care. 

To successfully execute the mission in any combat 

endeavor, providers must employ sound preparation, 

outreach, prevention, education, and consultative and 

clinical practices.

Preparation

Predeployment planning is often limited in its scope 

or absent altogether. However, when the opportunity 

avails itself, the behavioral health professional should 

identify the mission, its requirements, and available 

assets. Familiarizing oneself with the theater prior 

to deployment is crucial and can be accomplished 

in myriad ways, ranging from participation in the 

predeployment site survey to a simple call or email to 

the team that will be replaced. Reviewing after-action 

reports and speaking with providers from previous 

deployments may be beneficial as well. Collecting 

pertinent and accurate information will greatly assist 

with the determination of staffing needs. Once staff 

members are identified, it becomes possible to know 

the team prior to departure. Furthermore, establishing 

relationships with commands, chaplains, and medical providers and screening deploying troops before 

departure will serve the mission well. 

Outreach

Recent combat operations have engaged the enemy 

in a low-intensity, nontraditional battlefield. Such 

conflicts are characterized by an insidious sense of 

randomness and loculated pockets of activity within a 

large geographical space, using conventional weapons 

typically combined with asymmetrical tactics (“terrorism”) and applied use of intelligence. 

In accommodating this type of mission, troops are 

often strategically scattered across the area of operations and reside in rustic installations called firebases 

or forward operating bases (FOBs). Based on mission 

necessity, the troop population, capability, and firepower, these outposts are in a nearly constant state of 

fluidity. Accordingly, it is critical that a relationship 

develops between key personnel at the smaller forward 

posts and mental health providers in theater. Meeting 

the senior leadership, medical assets, and chaplaincy 

will be essential, as they will serve as liaisons between 

individual and unit needs, and the mental health assets. Assigning specific providers (who periodically 

visit their catchment) to particular FOBs and firebases 

will further this dynamic by advocating for basic needs 

to improve morale. These behavioral health personnel 

provide a sense of familiarity to both the local troop 

population and leadership, and a commitment to 

Figure A2-1. The mental health mission in OEF demands 

mobility from its providers.
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continuity of care for those relying on their services 

(Figure A2-1 and Figure A2-2). 

Prevention

From a classic medical model, prevention is any 

activity by which an individual avoids the development of a disease or condition (primary prevention), 

diagnoses a disease in an early stage or prevents its recurrence (secondary prevention), or avoids a disease’s 

worsening and restores oneself to an optimal level of 

functioning (tertiary prevention). The importance of 

prevention efforts cannot be understated in the theater; 

they can play a pivotal role in troop readiness and 

mission effectiveness. 

Most often, deploying service members receive 

an array of predeployment training that typically 

includes psychoeducational briefs on broad mental 

health topics, such as the emotional cycle of deployment or general psychiatric symptomatology. However, this training is not guaranteed, and the content 

and quality may vary; primary prevention must be 

Figure A2-2. Credibility is gained not only with clinical 

knowledge but also by sharing soldiers’ experiences, such as 

foot patrols (a); sharing in their daily activities in remote locations (b); or just enjoying an Asian sunset with them (c).

a b

c

augmented in theater. An excellent means of accomplishing this is securing a platform at the theater-wide 

inprocessing brief that all arriving US personnel attend. Another option is meeting with local chaplains 

and medical providers to provide information on 

common symptoms and issues, and how to engage 

mental health services.

As in any wartime period, there will be certain 

military occupational specialties (MOSs) with greater 

exposure and risk for emotional issues. These groups 

should be identified early and visited regularly utilizing the “therapy by walking around” concepts 

described by Milliken with the goal of providing a 

means of decompression, assessment, and formal 

mental health services if needed. Typically, mortuary 

affairs, combat medics, medical evacuation (medevac) 

crews, physicians (surgeons and trauma doctors in 

particular), nurses, chaplains, vehicle drivers, and 

senior leadership, among others, would benefit from 

secondary prevention.

Following a discrete, often traumatic event, tertiary 

prevention may be implemented. Currently, there is 

much debate as to the value and efficacy of critical 

incident stress management or debriefings, the sevenstep Mitchell model in particular. Army mental health 

now supports the concept of traumatic event management (TEM), which enables the clinician to develop 

a program tailored to the specific needs of the unit 

considering the actual event, theater tempo, unit history, and response. 

Regardless of the model employed, tertiary prevention will be a high-profile item in theater. Clinicians 

will be responsible to intervene at their discretion, 
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Operational Psychiatry in Operation Enduring Freedom 

while assessing, supporting, and educating various 

command elements that may still be fluent in the “antiquated” critical incident stress management (CISM) 

dialect. 

Education

Developing a modified, yet aggressive, education 

plan will enhance quality of care while blunting the 

workload burden. A well-trained mental health technician can effectively serve as an intake coordinator, 

supportive or skills-based therapist, group facilitator, 

prevention specialist, liaison to the enlisted ranks, 

and representative to forward installations. Investing 

time in supervision and basic instruction will greatly 

improve the efficiency of the deployed team.

Besides enhancing intrinsic resources, educational 

efforts intended for medics, physician assistants, physicians, and chaplains can improve care throughout the 

area of operations. Broad topics such as terminology, 

diagnostic assessments, basic psychopharmacology, 

relaxation training, and sleep hygiene instruction can 

effectively accelerate initiation of treatment plans and 

reinforce their efficacy, reduce the need for unnecessary evacuations, and filter legitimate mental health 

cases from administrative or occupational issues of 

discord. 

Consultation

Deployed mental health providers serve as the 

subject matter experts for mental health and combat 

and operational stress. Commanders will often seek 

the expertise and recommendations of the behavioral 

health professional concerning individual or unit issues in the forms of a command-directed mental health 

evaluation or unit climate assessment, respectively. 

Furthermore, input will be requested for larger policy 

issues affecting the deployed force, such as suicide 

prevention, sexual assault programs, and redeployment planning. The behavioral health provider will 

also serve as a theater-wide consultant to medical 

providers from all branches of the US military, as well 

as those employed by civilian contracting agencies and 

coalition nations. 

Clinical Operations

Although much of the mission will be firmly rooted 

in the principles and practices of COSC, placing a 

provider at each site in theater is impossible because 

of the numerous forward locations and limited mental 

health staffing resources. Thus, the mental health assets 

are typically divided into smaller teams and placed 

at several mature locations that have sizeable troop 

populations, access to intratheater transportation, 

and appropriate medical, intelligence, and command 

support services. 

The pace of routine clinical work in the deployed 

setting is usually less demanding than one might 

experience while in garrison. It is recommended that 

set hours of operation are established and an on-call 

schedule is developed to preserve boundaries and 

protect against burnout while maintaining availability 

for those in need. The scope of practices in the clinic 

depends on the vision, resources, and staffing of the 

unit but ordinarily consists of individual counseling 

and brief therapy, time-limited skills and cognitive 

behaviorally based groups, medication management, 

mental status evaluations (for special schools/duties 

or administrative separation), command-directed 

evaluations, and seminars on topics such as anger 

management, stress reduction, smoking cessation, and 

relationship issues.

As with all clinical operations, standard operating 

procedures should be developed and followed. Roles, 

responsibilities, command structure, documentation, 

record storage, admission, evacuation, on-call coverage, and policies for various programs (such as suicide 

prevention, command-directed evaluations, TEM, and 

so forth) are topics that should be formally outlined in 

a standard operating procedure that is clear, concise, 

and understood by all members of the mental health 

team.

MENTAL HEALTH OPERATIONS IN AFGHANISTAN

In late 2001, mental health assets sparsely populated 

the Afghanistan theater of operations. A pair of mental 

health technicians supported Kandahar, and a team of 

four (social worker, occupational therapist, and two 

technicians) were in Uzbekistan before relocating to 

Bagram Airfield in early 2002. A psychiatrist and social worker in Kuwait provided consultative services. 

Each rotation since then has witnessed an improved 

presence. 

Common presentations include occupational discord, 

partner-relational problems, sleep problems, and stress. 

Psychosomatic, anxiety, and depression conditions represent a modest number of overall cases, while psychotic 

disorders and purely combat-related presentations are 

fairly rare. One can expect a robust stream of requests 

for command-directed evaluations and other administrative psychiatry tasks, and providers must maintain 

a healthy skepticism for secondary gain issues. 
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Effective screening and prevention programs, access 

to care in theater, and an underlying expectation of 

recovery has led to a return-to-duty rate in excess of 

98% in recent years. Despite the success, Afghanistan 

presents an array of unique obstacles that may compromise satisfactory execution of the mental health 

mission. These obstacles must be addressed to ensure 

mission effectiveness. 

Chain of Command

Serving under ISAF, there are many layers of command intricacies that are often magnified by jointservice endeavors and the modularity of the Army. 

Providers should anticipate working closely with 

other branches of service and learn to negotiate across 

command structures. Further, roles and responsibilities, and the chain of command, should be promptly 

established so that all stakeholders understand mission specifics. 

Logistics

Clinical operational sites are selected based upon 

activities in theater, troop populations, and the availability of infrastructure, intelligence, command support, resources, and travel opportunities. Considering 

these variables, recent clinical sites in Afghanistan 

have included Bagram, Kandahar, Orgun-E, Jalalabad, Kabul, and Salerno. With troops spread across 

the theater, and highly mobile in response to mission 

evolution, clinical sites may have to change during 

the course of a rotation. Additionally, temporary prepositioning of mental health assets at selected FOBs 

and firebases based on tactical operational intelligence 

can be a valuable tool. Ultimately, COSC forward activities must possess flexibility to accommodate the 

fluid battlefield.

Communication

Although the theater has evolved significantly, 

telephone and Internet access remain unreliable. 

Developing contingency plans and creative problem 

solving must suffice until communication systems 

fully mature.

Travel

Movement throughout the area of operations is 

critical to mission success but remains profoundly 

inefficient. COSC teams tasked to forward locations 

routinely wait multiple days for travel on both sides 

of the mission. Flights are often cancelled due to 

combat operations, maintenance issues, or weather 

conditions. Ground convoys present many of the 

same limitations, along with the risk for attack from 

improvised explosive devices (IEDs) and vehicleborne improvised explosive devices (VBIEDs). To 

ameliorate this situation, establish a good rapport 

with the local air and ground movement request 

officers, learn all the potential means of travel to 

particular areas (scheduled “ring” helicopter flights, 

special rotary flights, C-130 and STOAL [short take 

off and landing] flights, and ground convoys), and 

prepare for delays.

Documentation

OEF has introduced the electronic theater medical 

information (TMIP) program. This will ultimately help 

with patient care, but not all locations will possess the 

same technology or maintenance capabilities. Establish 

documentation standard operating procedures and 

rely on “FOB logs” to create a patient list and foster 

seamless transitions of care at each site. 

Data Collection

Historically speaking, there has never been a consistent outcome measure or statistical collection system 

that has passed between rotations. Hence, it is nearly 

impossible to compare relevant statistical rates with 

previous deployments. TMIP will assist with some of 

the demographic and diagnostic data collection, but 

the development of a comprehensive program that 

provides meaningful outcome measures has yet to be 

implemented.

CONCLUSION

Providers face an array of challenges in delivering 

quality mental health services in the deployed setting. 

Further, OEF introduces unique obstacles that synergistically complicate the already challenging mission. 

However, relying on sound strategies firmly rooted in 

conceptual military psychiatry will foster a comprehensive system of care for soldiers on the ground and will 

be effective in conserving the fighting force. 
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case studies

Case Study A2-1: Importance of History of Present Illness 

(HPI) 

Situation: A married active duty Army E4 white male with 

no past psychiatric history self-presented to the mental health 

clinic in Bagram complaining of suicidal ideation and poor 

sleep for the past 5 days. The soldier explained that his wife 

was possibly cheating on him and the only way to salvage 

the marriage was getting home. If he could not get home, 

“life is not worth living.” A detailed interview and suicide assessment revealed low risk for self-harm, with no plan. He 

had just returned from midtour rest and recuperation (R&R) 

leave 3 days prior to presentation and was waiting in transient 

status at Bagram for a flight back to his FOB.

Assessment: marital discord, occupational problem with 

conditional suicidality.

Treatment: supportive therapy daily while awaiting flight, 

symptom relief with Ambien, return to FOB as soon as possible. 

Teaching points:

1. Expect to see a bump in self-referrals during the 

midtour R&R leave window.

2. Conduct a thorough evaluation of every soldier.

3. Target tangible symptoms such as sleep; educate 

and support.

4. Firmly set expectation that service members will 

return to their unit.

5. Identify funneling points for R&R and establish a 

clinical presence at those locations. When soldiers 

return to theater, they often have to wait days for 

travel back to their FOB. During that time they are 

in transient status with no significant accountability. 

Work with unit liaisons at such sites to assign daily 

tasks for these personnel and expedite their return 

to the FOB and unit.

Case Study A2-2: Traumatic Event Management Gone 

Wrong

Situation: A tragic helicopter crash occurred in theater 

resulting in several deaths. Approximately 1 week later, the 

clinic was asked by the chaplain and flight surgeon to assist 

with a “debriefing.” Eager to help with this high-profile incident, mental health resources were pledged in support.

Process: The accident was detailed by the flight surgeon; 

the chaplain provided the unit history. A suitable place of 

meeting familiar to the unit was selected. Due to the number 

of individuals, it was decided to have two sessions—one for 

officers and another for enlisted. The sessions began with 

the commander providing a review of the accident and an 

update on the investigation. He then entertained questions. 

Troops were then allowed to depart or continue with the voluntary group debriefing. All stayed, many of them reluctantly. 

Unknown to the mental health providers, members of the 

command stayed in the room, taking notes. The chaplain 

assumed a role as a co-facilitator, yet would leave the group, 

interrupt, and make off-target statements. The resentment 

among the soldiers was palpable and the provider was clearly 

seen as an agent of the command.

Teaching points:

1. Obtain a thorough unit history; an inadequate 

report was provided in this situation because 

there was long-standing animosity, stemming 

from myriad issues, between the soldiers and 

command.

2. If your TEM includes a group modality, make sessions truly voluntary, with no command influence 

and no note taking.

3. Determine who is facilitating before proceeding.

4. Be sensitive: don’t patronize or insult the dynamics 

by splitting up teams that may include both officers 

and enlisted.

Case Study A2-3: Use Skills and Get Creative

Situation: A unit was involved in a noncombat motor vehicle accident in an area densely populated with civilians. 

Despite their best efforts, civilian casualties and deaths 

resulted. As the soldiers began to aid the injured, the crowd 

swelled in number and voracity. Many soldiers likened the 

masses and situation to the film Blackhawk Down. All feared 

for their safety as the atmosphere soon became confrontational; rocks and other debris rained down on the soldiers. 

Upon return to their FOB, the unit commander requested 

assistance for his soldiers. A psychiatrist visited the FOB, 

spending a few days helping soldiers normalize their reactions and consolidate their feelings. He suggested, if at all 

possible, a graduated return to activities outside the wire. 

Accordingly, a humanitarian mission was arranged at a 

nearby village. The psychiatrist accompanied the unit on the 

convoy, serving as a primary care physician for the medical 

component of the humanitarian mission. He was also present for the soldiers, many of whom were ambivalent about 

departing the confines of the FOB.

Teaching point:

1. Credibility is achieved through clinical competence, 

effective communication, honesty, and relating 

with soldiers. Creative approaches in developing 

rapport will augment this process.

Case Study A2-4: The Barber From Russia

Situation: The division psychiatrist was walking across 

the post and came upon a suspicious young man squatting 

alone by the roadside. Efforts to negotiate the language bar-
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rier were fruitless, so the psychiatrist went for help. The man 

followed and lunged for the officer’s sidearm. The psychiatrist 

swatted the hand away; the man then retreated to seclusion. 

Shortly thereafter, the military police brought the man to the 

combat support hospital; they had found him scaling a fence 

to a minefield. A Russian interpreter translated a psychiatric 

diagnostic interview. The young man had a history of depression that was treated successfully in Russia. He was hired 

by a contractor to work at the installation barbershop. Since 

his arrival in Afghanistan, he became increasingly depressed 

with ruminations, hallucinations, and suicidal ideation. He 

was maintained at the combat support hospital (CSH) with 

a company escort and improved slightly with olanzapine. He 

was evacuated from theater 48 hours later and returned to 

Russia for definitive treatment.

Teaching points:

1. Although there are rigorous screening procedures 

for US service members, the same cannot be said 

for the large numbers of contractors working in 

support of OEF.

2. As one of only a few behavioral health subject matter experts in the country, you will find that skills in 

cultural psychiatry—from local Afghan nationals to 

civilian contract employees and Coalition forces—

will be tested.

3. There are no inpatient psychiatric units in the CSH 

system. If individuals need admission, they can 

usually board in the CSH with an escort until they 

are evacuated.

Case Study A2-5: Keep the End State in Mind

Situation: Medical providers in southeastern Afghanistan 

became increasingly frustrated with the medical rules of 

engagement (ROE) of perserving “life, limb, or eyesight” as 

they pertained to the hundreds of local nationals who came 

to the front gate begging for medical care. The physicians 

organized and contacted the Minister of Health as well as 

the dominant nongovernmental organizations that were providing medical assistance in Kandahar. In the process, the 

former dean of the then-defunct medical school was found, 

a medical library was created through donations from the 

deployed physician’s home departments, and classes were 

taught. The US physicians instructed the medical students in 

their specialties and arranged for logistical medical support 

for the local hospital. By the end of the 12-month rotation, 

the local hospital could handle treating mild and moderate 

wounds from an IED mass casualty event in the city.

Teaching points:

1. Counterinsurgency conflicts are partially won with 

robust humanitarian efforts.

2. If frustrated by the challenges offered by deployment, do something productive to change the 

situation.