i

combat and operational behavioral health 
ii

The Coat of Arms

1818

Medical Department of the Army

A 1976 etching by Vassil Ekimov of an

original color print that appeared in

The Military Surgeon, Vol XLI, No 2, 1917
iii

This book is dedicated to the many professionals committed to 

diagnosing and treating combat and operational stress casualties. 

These include our predecessors—Doctors Frank Jones, Kenneth 

Artiss, and Albert Glass—as well as the many who worked on this 

project, and those who will no doubt labor many years from now 

on the next volume in this series. All of these caregivers pursue 

this effort not just to conserve the nation’s fighting strength. They 

also believe, as do all military personnel, that we take care of our 

own—the service members who face the difficulties of combat and 

the families who support them.
iv

The TMM Series

Published Textbooks

 Medical Consequences of Nuclear Warfare (1989)

 Conventional Warfare: Ballistic, Blast, and Burn Injuries 

(1991)

 Occupational Health: The Soldier and the Industrial Base 

(1993)

 Military Dermatology (1994)

 Military Psychiatry: Preparing in Peace for War (1994)

 Anesthesia and Perioperative Care of the Combat 

Casualty (1995)

 War Psychiatry (1995)

 Medical Aspects of Chemical and Biological Warfare 

(1997)

 Rehabilitation of the Injured Soldier, Volume 1 (1998)

 Rehabilitation of the Injured Soldier, Volume 2 (1999)

 Medical Aspects of Harsh Environments, Volume 1 (2001)

 Medical Aspects of Harsh Environments, Volume 2 (2002)

 Ophthalmic Care of the Combat Casualty (2003)

 Military Medical Ethics, Volume 1 (2003)

 Military Medical Ethics, Volume 2 (2003)

 Military Preventive Medicine, Volume 1 (2003)

 Military Preventive Medicine, Volume 2 (2005)

 Recruit Medicine (2006)

 Medical Aspects of Biological Warfare (2007)

 Medical Aspects of Chemical Warfare (2008)

 Care of the Combat Amputee (2009)

 Combat and Operational Behavioral Health (2011)
v

Textbooks of Military Medicine

Published by the

Office of The Surgeon General

Department of the Army, United States of America

and 

US Army Medical Department Center and School

Fort Sam Houston, Texas

Editor in Chief

Martha K. Lenhart, MD, PhD

Colonel, MC, US Army

Director, Borden Institute

Assistant Professor of Surgery

F. Edward Hébert School of Medicine

Uniformed Services University of the Health Sciences
vi

Tracking Bin Laden, by Sergeant First Class Elzie Golden, oil on canvas, 2002. First place winner of the DINFOS 

MILGRAPH 2002 Military Graphic Competition, fine art category.

Art: Courtesy of the Army Art Collection, US Army Center of Military History.
vii

COMBAT and OPERATIONAL

BEHAVIORAL HEALTH

Senior Editor

Elspeth Cameron Ritchie, MD, MPH

Colonel, Medical Corps, US Army (Retired)

Chief Clinical Officer, District of Columbia Department of Mental Health

Former Psychiatry Consultant to The Army Surgeon General and Director,

Behavioral Health Proponency, Office of The Surgeon General

Office of The Surgeon General

United States Army

Falls Church, Virginia

Borden Institute

Fort Detrick, Maryland

2011
viii

Editorial Staff: Linette Sparacino

Volume Editor

Ronda Lindsay

Technical Editor

Douglas Wise

Illustrator

This volume was prepared for military medical educational use. The focus of the information is 

to foster discussion that may form the basis of doctrine and policy. The opinions or assertions 

contained herein are the private views of the authors and are not to be construed as official or as 

reflecting the views of the Department of the Army or the Department of Defense.

Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages cited herein. 

However, it is the responsibility of every practitioner to consult appropriate information sources 

to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs 

and procedures. The authors, editors, publisher, and the Department of Defense cannot be held 

responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does not 

imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively 

to men.

certain parts of this publication pertain to copyright restrictions.

all rights reserved.

no copyrighted parts of this publication may be reproduced or 

transmitted in any form or by any means, electronic or mechanical (including

photocopy, recording, or any information storage and retrieval system), without permission in writing from the publisher or copyright owner.

Published by the Office of The Surgeon General at TMM Publications 

Borden Institute

Walter Reed Army Medical Center

Washington, DC 20307-5001

Joan Redding

Senior Production Editor

Bruce Maston

Illustrator

printed in the united states of america

18, 17, 16, 15, 14, 13, 12, 11 5 4 3 2 1

 Library of Congress Cataloging-in-Publication Data

Combat and operational behavioral health / senior editor, Elspeth Cameron Ritchie.

 p. ; cm. -- (TMM series)

 Includes bibliographical references and index.

 1. Veterans--Mental health. 2. Post-traumatic stress disorder. 3. Combat--Psychological 

aspects. 4. War neuroses--Prevention. I. Ritchie, Elspeth Cameron. II. United States. 

Dept. of the Army. Office of the Surgeon General. III. Borden Institute (U.S.) IV. Series: 

Textbooks of military medicine.

 [DNLM: 1. Combat Disorders--prevention & control. 2. Combat Disorders--psychology. 3. Military Personnel--psychology. 4. Military Psychiatry. 5. Veterans--psychology. 

6. Veterans Health. WM 184]

 RC550.C653 2011

 616.85’212--dc23

 2011017013
ix

Contents

Contributors xiii

Foreword by The Surgeon General xxi

Preface xxiii

Section I: Setting the Stage 1

1. Combat and Operational Behavioral Health: An Update to an Old History 3

 Elspeth Cameron Ritchie and Christopher G. Ivany

2. US Army Psychiatry Legacies of the Vietnam War 9

 Norman M. Camp 

3. Preparation for Deployment: Improving Resilience 43

 Patricia Watson, Brett Litz, Steven Southwick, and Elspeth Cameron Ritchie

4. Combat and Operational Stress Control 59

 Edward A. Brusher

5. Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and 75

 Enduring Freedom: From Research to Public Health Policy

 Charles W. Hoge, Amy B. Adler, Kathleen M. Wright, Paul D. Bliese, Anthony Cox, Dennis McGurk, 

Charles Milliken, and Carl A. Castro

Section II: In Theater 87

6. The Division Psychiatrist and Brigade Behavioral Health Officers 89

 Christopher H. Warner, George N. Appenzeller, Todd Yosick, Matthew J. Barry, Anthony J. Morton, 

Jill E. Breitbach, Gabrielle Bryen, Angela Mobbs, Amanda Robbins, Jessica Parker, and Thomas Grieger

7. US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders 107

 William P. Nash

8. Expeditionary Operational Stress Control in the US Navy 121

 Robert L. Koffman, Richard D. Bergthold, Justin S. Campbell, Richard J. Westphal, Paul Hammer, Thomas A. 

Gaskin, John Ralph, Edward Simmer, and William P. Nash

9. Provision of Mental Health Services in Operation Iraqi Freedom 05–07 137

 Marc A. Cooper, Sharon M. Newton, and Jeffrey S. Yarvis

10. Psychiatric Medications in Military Operations 151

 Brett J. Schneider, John C. Bradley, Christopher H. Warner, and David M. Benedek

11. The Role of Chaplains in the Operational Army 163

 Peter Frederich, Thomas C. Waynick, Jason E. Duckworth, and Jeff Voyles 

12. Psychiatric Consultation to Command 171

 Christopher H. Warner, George N. Appenzeller, Jill E. Breitbach, Jennifer T. Lange, Angela Mobbs, and 

Elspeth Cameron Ritchie

Section III: The Road Home 189

13. The Aeromedical Evacuation 191

 Alan L. Peterson, Kelly R. McCarthy, Daniel J. Busheme, Rick L. Campise, and Monty T. Baker
x

14. Behavioral Healthcare at Landstuhl Regional Medical Center 209

 Jeffrey V. Hill, David Reynolds, and Ronald Campbell

15. Traumatic Brain Injury in the Military Population 225

 Louis M. French, Katherine H. Taber, Kathy Helmick, Robin A. Hurley, and Deborah L. Warden

16. Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following 243

 Traumatic Injuries

 Harold J. Wain, Scott C. Moran, Marvin Oleshansky, Andree Bouterie, and Christopher L. Lange

17. Oral Health Effects of Combat Stress 259

 Georgia dela Cruz and Paul Colthirst

Section IV: Reunion and Reintegration 273

18. Resetting the Force: Reentry and Redeployment 275

 Kris A. Peterson and Michael E. Doyle

19. Treatment of Deployment-Related Posttraumatic Stress Disorder 297

 Josef I. Ruzek, Jeffrey S. Yarvis, and Steven Lindley

20. The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach 325

 Harold Kudler, Alfonso R. Batres, Charles M. Flora, Terry C. Washam, Marshall J. Goby, and 

 Laurent S. Lehmann

21. Pain Management 339

 Frederick J. Stoddard, Robert L. Sheridan, Jeevendra Martyn, James E. Czarnik, and Virgil T. Deal

22. US Army Occupational Therapy: Promoting Optimal Performance 357

 Mary W. Erickson, Teresa L. Brininger, Sharon M. Newton, Amy M. Mattila, and James P. Burns

23. Provider Fatigue and Provider Resiliency Training 375

 Mary Ann Pechacek, Graeme C. Bicknell, and Lisa Landry

Section V: Surveillance and Intervention 391

24. Army Suicide Surveillance: A Prerequisite to Suicide Prevention 393

 Gregory A. Gahm and Mark A. Reger

25. Suicide Prevention in the Army: Lessons Learned and Future Directions 403

 Elspeth Cameron Ritchie, Walter Morales, Michael Russell, Bruce Crow, Wayne Boyd, Kelly Forys, and 

Steven Brewster

26. Suicide and Homicide Risk Management: Rationale and Suggestions for the Use of Unit Watch 423

 in Garrison and Deployed Settings

 Samuel E. Payne, Jeffrey V. Hill, and David E. Johnson

27. Severe Psychiatric Illness in the Military Healthcare System 441

 Geoffrey Grammer

28. Eating Disorders 449

 Gail H. Manos, Janis Carlton, and Aileen Kim 

29. Substance Use and Abuse in the Military 473

 R. Gregory Lande, Barbara A. Marin, James J. Staudenmeier, and Daryl Hawkins

Section VI. Military Children and Families 485

30. The Impact of Deployment on Military Families and Children 487

 Simon Pincus, Barbara Leiner, Nancy Black, and Tangeneare Ward Singh
xi

31. The Children and Families of Combat-Injured Service Members 503

 Stephen J. Cozza, Ryo S. Chun, and Corina Miller

32. Family Maltreatment and Military Deployment 535

 René J. Robichaux and James E. McCarroll

33. The Families and Children of Fallen Military Service Members 543

 Douglas H. Lehman and Stephen J. Cozza

34. Establishing an Integrated Behavioral Health System of Care at Schofield Barracks 563

 Michael E. Faran, Albert Y. Saito, Eileen U. Godinez, Wendi M. Waits, Victoria W. Olson, Christine M. Piper, 

Margaret A. McNulty, and Christopher G. Ivany

Section VII. Operational Behavioral Health 577

35. Disaster Psychiatry 579

 Artin Terhakopian, David M. Benedek, and Elspeth Cameron Ritchie

36. Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons 593

 Ross H. Pastel and Elspeth Cameron Ritchie

37. Operation Iraqi Freedom 05–07 Medical Civil-Military Operations: Lessons Learned in 609

 Humanitarian Assistance

 Jeffrey S. Yarvis

38. Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special 619

 Problem of Complex Emergencies

 Thomas F. Ditzler

39. Population-Based Programs and Health Diplomacy Approaches of the US Public Health 633

 Service

 Jon T. Perez, Jeffrey Coady, Kevin McGuinness, and Merritt Schreiber

40. Behavioral Health Issues and Detained Individuals 645

 Richard Toye and Marshall Smith

41. Mental Healthcare in the United Kingdom Armed Forces 657

 Neil Greenberg, Jamie Hacker Hughes, Mark Earnshaw, and Simon Wessely

Section VIII. Other Military Issues 667

42. Military Psychiatry Graduate Medical Education 669

 Carroll J. Diebold, Wendi M. Waits, Millard D. Brown, and David M. Benedek

43. Military Forensic Mental Health 693

 Elspeth Cameron Ritchie

44. Women, Mental Health, and the Military 703

 Deborah Crowley, Trisha Bender, Ashley Chatigny, Tina Trudel, and Elspeth Cameron Ritchie

45. Mental Health Support to Operations Involving Death and the Dead 717

 James E. McCarroll and Robert J. Ursano

46. Ethics and Military Medicine: Core Contemporary Questions 727

 Edmund G. Howe, Robert C. McKenzie, and Chad Bradford

47. Combat and Operational Behavioral Health: Final Thoughts and Next Steps 747

 Elspeth Cameron Ritchie and Michael Doyle

Appendix 1: Provision of Behavioral Health Services During Operation Iraqi Freedom One 751

Robert D. Forsten, Brett J. Schneider, Sharette Kirsten Gray, Colin Daniels, and Gary J. Drouillard 
xii

Appendix 2: Operational Psychiatry in Operation Enduring Freedom 767

Bryan L. Bacon, Matthew J. Barry, and James Demer

Appendix 3: Good or Bad News? Media Coverage of Soldiers: Focus on Behavioral Health in Iraq 775

During Operation Iraqi Freedom 05-07

Jeffrey S. Yarvis and Elspeth Cameron Ritchie

Abbreviations and Acronyms xxv

Index xxxi
xiii

Contributors

AMY B. ADLER, PhD

Research Psychologist, US Army Research Unit—Europe, Walter 

Reed Army Institute of Research, CMR 442, APO AE 09042-1030

GEORGE N. APPENZELLER, MD

Lieutenant Colonel, Medical Corps, US Army; Commander, US 

Army Medical Activity, Alaska, 1060 Gaffney Road #7400, Fort 

Wainwright, Alaska 99703-7400; formerly, Deputy Commander 

for Clinical Services, Command Group, Winn Army Community 

Hospital, Fort Stewart, Georgia

BRYAN L. BACON, DO 

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

MONTY T. BAKER, PhD

Major, Biomedical Sciences Corps, US Air Force; Director of Clinical Research, Warrior Resiliency Program, San Antonio Military 

Medical Center, 2200 Bergquist Drive, Suite 1, Lackland Air Force 

Base, Texas 78236; formerly, Element Leader, Mental Health Clinic, 59th Military Health System, Lackland Air Force Base, Texas

MATTHEW J. BARRY, DO

Major, Medical Corps, US Army Reserve; 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 

ALFONSO R. BATRES, PhD

Chief Officer and Director, Readjustment Counseling Service, 

Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420

TRISHA BENDER, MD

Major, Medical Corps, US Army; Division Psychiatrist, 25th Infantry Division Headquarters, Building 580, DIVSURG CELL, Schofield Barracks, Hawaii 95857-6000; formerly, Child and Adolescent 

Fellow, Tripler Army Medical Center, Honolulu, Hawaii

DAVID M. BENEDEK, MD

Colonel, Medical Corps, US Army; Professor and Deputy Chair, 

Department of Psychiatry, Uniformed Services University of the 

Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 

20814

RICHARD D. BERGTHOLD, PsyD

Commander, Medical Service Corps, US Navy; Chief of Staff, 

Wounded, Ill and Injured, Bureau of Medicine and Surgery, 2300 

E Street NW, Washington, DC 20372 

GRAEME C. BICKNELL, PhD, LISW 

Lieutenant Colonel, Medical Service Corps, US Army; Deputy 

Chief, Behavioral Health Division, US Medical Command, Building 2792, Room 112, 2050 Worth Road, Fort Sam Houston, San 

Antonio, Texas 78234-6010

NANCY BLACK, MD

Colonel, Medical Corps, US Army; Training and Program 

Director, National Capital Consortium of Child and Adolescent 

Psychiatry Fellowships, Department of Psychiatry, Walter Reed 

Army Medical Center, Borden Pavilion, 6900 Georgia Avenue 

NW, Washington, DC 20307-5001

PAUL D. BLIESE, PhD

Colonel, Medical Service Corps, US Army; Director, Psychiatry 

and Neuroscience, Walter Reed Army Institute of Research, 503 

Robert Grant Avenue, Silver Spring, Maryland 20910

ANDREE BOUTERIE, MD

Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5100

WAYNE BOYD, MDiv

Colonel, Chaplain Corps, US Army; Staff Officer, Comprehensive 

Soldier Fitness, Headquarters, Department of the Army, Zachary 

Taylor Building (NC3), 2530 Crystal Drive, Room 512B, Arlington, 

Virginia 22202; formerly, Program Manager, Directorate of Health 

Promotion and Wellness, US Army Center for Health Promotion 

and Preventive Medicine, Aberdeen Proving Ground, Maryland

CHAD BRADFORD, MD

Commander, Medical Corps, US Navy; Division Psychiatrist, 2nd 

Marine Division, Division Surgeon’s Office, Attn: Division Psychiatry, HQBN 2MAR DIV, Camp Lejeune, North Carolina 28547; 

formerly, Forensic Psychiatry Fellow, National Capital Consortium, Washington, DC

JOHN C. BRADLEY, MD

Colonel, Medical Corps, US Army; Chair, Department of Psychiatry, Borden Pavilion, Room 2022, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307; Psychiatry 

Consultant, North Atlantic Regional Medical Command and Vice 

Chair, Department of Psychiatry, Uniformed Services University 

of the Health Sciences, Bethesda, Maryland

JILL E. BREITBACH, PsyD

Major, Medical Service Corps, US Army; Neuropsychologist, 

Department of Psychology, Evans Army Community Hospital, 

USAMEDDAC, 1650 Cochrane Circle, Fort Carson, Colorado 

80913; formerly, Group Psychologist, 1st Special Warfare Training 

Group, Fort Bragg, North Carolina

STEVEN BREWSTER, MD, MPH

Colonel, Medical Corps, US Army; Commander, US Army Medical Activity–Bavaria, Vilseck, Germany, Unit 28038, APO AE 

09112; formerly, Director, Epidemiology and Disease Surveillance, 

US Army Center for Health Promotion and Preventive Medicine, 

Public Health Command, Aberdeen Proving Ground, Maryland

SUSAN MILLER BRIGGS, MD, MPH

Associate Professor of Surgery, Harvard Medical School, Director, 

International Trauma and Disaster Institute, Massachusetts General Hospital, 55 Fruit Street, White 506, Boston, Massachusetts 

02114 
xiv

TERESA L. BRININGER, PhD, CHT, OTR/L 

Lieutenant Colonel, Medical Specialist Corps, US Army; Deputy 

for Rehabilitation and Reintegration, Telemedicine and Advanced 

Technology Research Center, Medical Research and Materiel 

Command, 504 Scott Street, Building 722, Room 30, Fort Detrick, 

Maryland 21702

MILLARD D. BROWN, MD

Major, Medical Corps, US Army; Psychiatry Residency Director, 

Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett 

White Road, Honolulu, Hawaii 96859

EDWARD A. BRUSHER, LCSW, BCD

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

GABRIELLE BRYEN, MSW, LCSW 

Major, Medical Service Corps, US Army; Deputy Chief, Department of Social Work, Womack Army Medical Center, Stop A, Fort 

Bragg, North Carolina 28310; formerly, Brigade Behavioral Health 

Officer, 3rd Brigade Combat Team, 4th Infantry Division, Fort 

Carson, Colorado

JAMES P. BURNS, OTR/L, MOT 

Major, Medical Specialist Corps, US Army; Occupational Therapist, Department of Orthopaedics and Rehabilitation, Building 

2, Room 3J04, Walter Reed Army Medical Center, 6900 Georgia 

Avenue, NW, Washington, DC 20307-5001; formerly, Chief Occupational Therapist, Department of Surgery, Fort Jackson, South 

Carolina

DANIEL J. BUSHEME, MA, LCDC 

Lieutenant Colonel, Nurse Corps, US Air Force; Chief, Mental 

Health Nursing, US Air Force Medical Operations Agency, 485 

Quentin Roosevelt Road, Suite 400, San Antonio, Texas 78226-

2017; formerly, Deputy Squadron Commander and Inpatient 

Mental Health Flight Commander, Travis Air Force Base, 

California

NORMAN M. CAMP, MD

Colonel, US Army (Retired); 3105-D Stony Point Road, Richmond, 

Virginia 23235; Clinical Professor of Psychiatry, Department of 

Psychiatry, Medical College of Virginia, Virginia Commonwealth 

University, Richmond, Virginia 23298

JUSTIN S. CAMPBELL, PhD

Lieutenant, Medical Service Corps, US Navy; Deployment Health 

Senior Analyst, Department of the Navy, Bureau of Medicine and 

Surgery, Deployment Health (M3C3), 2300 E Street NW, Washington, DC 20372

RONALD CAMPBELL, MD

Chief, Inpatient Psychiatry Service, Department of Behavioral 

Health, Landstuhl Regional Medical Center, CMR 462, APO AE 

09180

RICK L. CAMPISE, PhD, ABPP 

Colonel, Biomedical Sciences Corps, US Air Force; Commander, 

559th Medical Group, 1920 Biggs Avenue, Lackland Air Force 

Base, Texas 78236; formerly, Commander, 1st Medical Operations 

Squadron, Langley Air Force Base, Virginia

JANIS CARLTON, MD, PhD

Commander, Medical Corps, US Navy; Department Head, Psychological Health and Traumatic Brain Injury, Building 7, Room 

600, National Naval Medical Center, 8901 Wisconsin Avenue, 

Bethesda, Maryland 20889; formerly, Department Head, Mental 

Health, Naval Hospital, Camp Lejeune, North Carolina

CARL A. CASTRO, PhD

Colonel, Medical Service Corps, US Army; Director, Military Operational Medicine Research Program, US Army Medical Research 

and Materiel Command, 504 Scott Street, Fort Detrick, Maryland 

21702-5012; formerly, Chief, Department of Military Psychiatry 

and Chief, Soldier and Family Readiness, Walter Reed Army 

Institute of Research, Silver Spring, Maryland

ASHLEY CHATIGNY, DO 

Captain, Medical Corps, US Army; Fellow, Department of Child 

and Adolescent Psychiatry, Tripler Army Medical Center, 1 Jarrett 

White Road, Honolulu, Hawaii 96859-5000

RYO S. CHUN, MD

Colonel, US Army (Retired); Clinical Director, Child and Adolescent Psychiatry Service, Department of Psychiatry, Walter Reed 

Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 

20307; formerly, Chief, Child and Adolescent Psychiatry Service, 

Department of Psychiatry, Walter Reed Army Medical Center, 

Washington, DC

JEFFREY COADY, PsyD

Commander, Scientist Corps, US Public Health Service; Deputy 

Team Leader, US Public Health Service Disaster Mental Health 

Team II, Department of Health and Human Services, 233 North 

Michigan Avenue, Suite 600, Chicago, Illinois 60601

PAUL COLTHIRST, DDS, MS 

Major, Dental Corps, US Army; Dental Public Health, Department of Leadership Development, US Army Medical Department 

Center and School, 2250 Stanley Road, Fort Sam Houston, Texas 

78234-6100; formerly, Staff Officer, Dental Command Headquarters, Fort Sam Houston, Texas

MARC A. COOPER, MD

Chief, Community Mental Health Service, Moncrief Army Community Hospital, 4500 Stuart Street, Fort Jackson, South Carolina 

29207; formerly, Major, Medical Corps, US Army; OIF 05-07 Theater Mental Health Consultant, Task Force 30th Medical Brigade, 

Baghdad, Iraq

ANTHONY COX, MSW 

Lieutenant Colonel, Medical Service Corps, US Army; Social Work 

Consultant, Great Plains Regional Medical Command; Chief, 

Social Work, Brooke Army Medical Center, 3851 Roger Brooke 

Drive, Fort Sam Houston, Texas 78234

STEPHEN J. COZZA, MD

Colonel, US Army (Retired); Associate Director, Center for the 

Study of Traumatic Stress, and Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814; formerly, Chief, 

Department of Psychiatry, Walter Reed Army Medical Center, 

Washington, DC

BRUCE E. CROW, PsyD

Colonel, Medical Service Corps, US Army; Clinical Psychology 

Consultant to The Surgeon General, US Army, and Director, Warrior Resiliency Program, Southern Regional Medical Command, 

Brooke Army Medical Center, Fort Sam Houston, Texas 78234
xv

DEBORAH CROWLEY, MD

Captain, Medical Corps, US Army; Child Psychiatry Fellow, 

Department of Psychiatry, 1 Jarrett White Road, Tripler Army 

Medical Center, Hawaii 96859

JAMES E. CZARNIK, MD

Colonel, Medical Corps, US Army; Command Surgeon, Joint 

Special Operations Command, PO Box 70239, Fort Bragg, North 

Carolina 28307-5000; formerly, Deputy Command Surgeon, US 

Army Special Operations Command, Fort Bragg, North Carolina

COLIN DANIELS, MD, MBA

Lieutenant Colonel, Medical Corps, US Army; Psychiatrist, 

Department of Psychiatry, Madigan Army Medical Center, 9040 

Fitzsimmons Drive, 7BLM, Tacoma, Washington 98431; formerly, 

Chief, Behavioral Health Services, 28th Combat Support Hospital, 

Operation Iraqi Freedom 2003

VIRGIL T. DEAL, MD

Colonel, Medical Corps, US Army; Surgeon, United States Special 

Operations Command, 7701 Tampa Point Boulevard, MacDill 

Air Force Base, Florida 33621-5323; formerly, Commander, Walter 

Reed Health Care System, Washington, DC

GEORGIA DELA CRUZ, DMD, MPH

Lieutenant Colonel, Dental Corps, US Army; Dental Staff Officer, 

Dental Corps Office, Office of The Surgeon General, US Army, 

5109 Leesburg Pike, Suite 682, Falls Church, Virginia 22041; 

formerly, Army Dental Representative, TriService Center for Oral 

Health Studies, Uniformed Services University of the Health Sciences, Bethesda, Maryland

JAMES DEMER, MD

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

CARROLL J. DIEBOLD, MD

Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, 1 Jarrett White Road, Tripler Army Medical Center, Honolulu, 

Hawaii 96859

THOMAS F. DITZLER, PhD

Director of Research, Department of Psychiatry, Tripler Army 

Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859

MICHAEL E. DOYLE, MD

Lieutenant Colonel, Medical Corps, US Army; Deputy Commander for Clinical Services, USAMEDDAC West Point, 900 Washington Road, West Point, New York 10996; formerly, Commander, US 

Army Health Clinic, Wiesbaden, Germany

GARY J. DROUILLARD, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Chemical Addiction Treatment Service, Department of Psychiatry 1 

Jarrett White Road, Tripler Army Medical Center, Hawaii 96859; 

formerly, Chief, Consultation Liaison Psychiatry, Tripler Army 

Medical Center, Honolulu, Hawaii

JASON E. DUCKWORTH, DMin, MDiv

Lieutenant Colonel, Chaplain Corps, US Army; Garrison Chaplain, Religious Support Office, US Army Garrison, Heidelberg, 

Germany, CMR 419 Box 1876, APO AE 09102; formerly, Training 

Developer, Chaplain Basic Officer Leader Course, US Army Chaplain Center and School, Fort Jackson, South Carolina 

MARK EARNSHAW, BA(Hons), MSc

Lieutenant Colonel, QARANC, Ministry of Defence, St Georges 

Court, Bloomsbury Way, London, WC1A 2SH, United Kingdom; 

formerly, Research Fellow, Academic Centre for Defence Mental 

Health, London, United Kingdom

MARY W. ERICKSON, MAOL, OTR/L 

Colonel, US Army (Retired); formerly, Reintegration Branch Chief, 

Proponency Office for Rehabilitation and Reintegeration, The Office of The Surgeon General, US Army, 5109 Leesburg Pike, Suite 

684, Falls Church, Virginia

MICHAEL E. FARAN, MD, PhD

Colonel, US Army (Retired); Director, Child, Adolescent, and 

Family Behavior Health Proponency, Madigan Army Medical 

Center, Madigan Annex Building 9913A, Ramp 2, McKinnley 

Road, Tacoma, Washington 98431; Director, School Based Mental 

Health, Child and Adolescent Psychiatry Service, Department of 

Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii

CHARLES M. FLORA, MSW

Associate Director, Readjustment Counseling Service, Department 

of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 

20420

ROBERT D. FORSTEN, DO

Colonel, Medical Corps, US Army; Command Psychiatrist, US 

Army Special Operations Command (AOMD), 2929 Desert Storm 

Drive (Stop A), Fort Bragg, North Carolina 28310-9110; formerly, 

Staff Psychiatrist, Department of Psychiatry, Walter Reed Army 

Medical Center, Washington, DC

KELLY FORYS, PhD

Psychologist, Department of Outpatient Behavioral Health, 

Landstuhl Regional Medical Center, CMR 402, Box 1045, APO 

AE 09180; formerly, Psychologist, US Army Center for Health 

Promotion and Preventive Medicine, Aberdeen Proving Ground, 

Maryland

PETER FREDERICH, MDiv

Lieutenant Colonel, Chaplain Corps, US Army; Family Ministries Officer, Directorate of Ministry Initiatives, US Army Chief 

of Chaplains Office, 1421 Jefferson Davis Highway, Suite 10600, 

Arlington, Virginia 22202; formerly, Director, US Army Family 

Life Chaplain Training Center, Fort Benning, Georgia

LOUIS M. FRENCH, PsyD

Director, Traumatic Brain Injury Service, Defense and Veterans Brain Injury Center and Department of Orthopaedics and 

Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307; Department of Neurology, 

Uniformed Services University of the Health Sciences, Bethesda, 

Maryland 

GREGORY A. GAHM, PhD

Colonel, Medical Service Corps, US Army; Chief, Department of 

Psychology, Madigan Army Medical Center, 9933C West Hayes 

Street, Fort Lewis, Washington 98431

THOMAS A. GASKIN, PhD

Commander, US Navy (Retired); Director of Combat Operational 

Stress Control, US Marine Corps, Manpower and Reserve Affairs, 

Personal and Family Readiness Division, 3280 Russell Road, 

Quantico, Virginia 22134; formerly, Head, Combat and Operational Stress Control Program, Headquarters, US Marine Corps, 

Quantico, Virginia
xvi

MARSHALL J. GOBY, PhD

Colonel, US Army (Retired); Team Leader/Supervisory Psychologist, Veterans Affairs Readjustment Counseling Service, Palm 

Beach Veterans Center, 2311 10th Avenue North, #13, Lake Worth, 

Florida 33461; formerly, Reserve Psychology Consultant, Office of 

The Surgeon General, US Army, Falls Church, Virginia

EILEEN U. GODINEZ, PhD

Inspector General Chief, Inspections and Outreach Branch, 

US European Command, CMR 480, Box 1865, APO AE 09128; 

formerly, Chief, Plans Analysis and Integration Office, US Army 

Garrison, Hawaii

GEOFFREY GRAMMER, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient 

Psychiatry, Department of Psychiatry, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington, DC 20307 

SHARETTE KIRSTEN GRAY, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Hospital and 

Administrative Psychiatry Services, Department of Behavioral 

Health, Carl R. Darnell Army Medical Center, Building 36000, 

Darnell Loop, Fort Hood, Texas 76544; formerly, Division Psychiatrist, 4th Infantry Division, Fort Hood, Texas 

NEIL GREENBERG, MD

Commander, Medical Corps, United Kingdom Armed Forces; Defence Professor of Mental Health, King’s College, London, Weston 

Education Centre, Cutcombe Road, London SE5 9RJ; formerly, Senior Lecturer in Military Psychiatry, Academic Center for Defence 

Mental Health, King’s College, London

THOMAS GRIEGER, MD

Captain, US Navy (Retired); Associate Professor, Department of 

Psychiatry, Uniformed Services University of the Health Sciences, 

4301 Jones Bridge Road, Bethesda, Maryland 20814

PAUL HAMMER, MD

Captain, Medical Corps, US Navy; Director, Naval Center for 

Combat and Operational Stress Control, 34960 Bob Wilson Drive, 

Suite 400, San Diego, California 92134-6400

DARYL HAWKINS, PhD

Alcohol and Drug Control Officer, Army Substance Abuse Program, Building 6, Room 2066, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307-5001

KATHY HELMICK, MS, CNRN, CRNP 

Senior Executive Director, Traumatic Brain Injury, Defense Center 

of Excellence for Psychological Health and Traumatic Brain Injury, 

1335 East-West Highway, 9th Floor, Suite 700, Silver Spring, MD 

20910; formerly, Deputy Director, Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center, Washington, DC

JEFFREY V. HILL, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Child and 

Adolescent Psychiatry, Landstuhl Regional Medical Center, CMR 

402 Box 1356, APO AE 09180; formerly, Chief, Outpatient Psychiatry, Landstuhl Regional Medical Center, Landstuhl, Germany

CHARLES W. HOGE, MD

Colonel, US Army (Retired); formerly, Director, Division of 

Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910

EDMUND G. HOWE, MD, JD

Professor of Psychiatry, Associate Professor of Medicine, and 

Director, Programs in Medical Ethics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, 

Maryland 20814; and Senior Scientist, Center for the Study of 

Traumatic Stress, Bethesda, Maryland; formerly, Major, Medical 

Corps, US Army

JAMIE HACKER HUGHES, PsychD

Head of Defence Clinical Psychology, Ministry of Defence, Joint 

Medical Command, Coltman House, Whittington Barracks, Lichfield, United Kingdom WS14 9PY; formerly, Senior Lecturer in 

Military Psychology, Academic Center for Defence Mental Health, 

London, United Kingdom

ROBIN A. HURLEY, MD

Associate Director, Education, WG Hefner Veterans Affairs Medical Center (Mailcode 11F), 1601 Brenner Avenue, Salisbury, North 

Carolina 28144; formerly, Associate Director, Mental Health, WG 

Hefner Veterans Affairs Medical Center, Salisbury, North Carolina

CHRISTOPHER G. IVANY, MD

Major, Medical Corps, US Army; Psychiatrist, Department of 

Behavioral Health, Evans Army Community Hospital, Building 

7500, 1650 Cochrane Circle, Fort Carson, Colorado 80913; formerly, Division Psychiatrist, 4th Infantry Division, Fort Hood, Texas

DAVID E. JOHNSON, MD

Major, Medical Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, US Army MEDDAC Bavaria, IMEU-SFTDHR, ATTN: OMDC Schweinfurt, Unit 25850, APO AE 09033

AILEEN KIM, MD

Lieutenant Commander, Medical Corps, US Navy; Staff Psychiatrist, Department of Behavioral Health, Building 7, 3rd 

Floor, National Naval Medical Center, 8901 Wisconsin Avenue, 

Bethesda, Maryland 20889; formerly, Chief Resident, Department 

of Psychiatry, Naval Medical Center Portsmouth, Portsmouth, 

Virginia

ROBERT L. KOFFMAN, MD, MPH

Captain, Medical Corps, US Navy; Director of Deployment 

Health, Department of the Navy, Bureau of Medicine and Surgery, 

Deployment Health, 2300 E Street NW, Washington, DC, 20372

HAROLD KUDLER, MD

Associate Clinical Professor, Department of Psychiatry, Duke 

University Medical Center, Durham, North Carolina; Associate 

Director, Mental Illness Research, Education and Clinical Center, 

Mid-Atlantic Veterans Integrated Service Network (VISN 6), VA 

Medical Center, 508 Fulton Street, #166A, Durham, North Carolina 27705 

R. GREGORY LANDE, DO 

Chief, Psychiatry Continuity Service, Department of Psychiatry, 

Walter Reed Army Medical Center, 6900 Georgia Avenue NW, 

Building 2, Room 5343, Washington, DC 20307; Clinical Consultant, Walter Reed Army Medical Center Substance Abuse 

Program, Washington, DC 

LISA LANDRY, PhD

Instructor/Writer, Department of Behavioral Health Sciences, 

Army Medical Department Center and School, 3151 Scott Road, 

Building 2840, Office 32, Fort Sam Houston, Texas 78234
xvii

CHRISTOPHER L. LANGE, MD

Lieutenant Colonel, Medical Corps, US Army; Program Director, National Capital Consortium Forsenic Psychiatry Fellowship 

Program, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 6, Room 3038, 

Washington, DC 20307; formerly, Staff Psychiatrist, Psychiatry 

Consultation Liaison Service, Walter Reed Army Medical Center, 

Washington, DC

JENNIFER T. LANGE, MD

Lieutenant Colonel, Medical Corps, US Army; Medical Director, 

Behavioral Health Clinic, Department of Psychiatry, Walter Reed 

Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 

20307-5001

DOUGLAS H. LEHMAN, MSW, LCSW

Treatment Provider, Department of Behavioral Health and Family 

Advocacy, Evans Army Community Hospital, 7500 Cochrane 

Circle, Fort Carson, Colorado 80913

LAURENT S. LEHMANN, MD

Associate Chief Consultant in Mental Health, Office of Mental 

Health Services, Department of Veterans Affairs, 810 Vermont 

Avenue NW, Room 966, Washington, DC 20420

BARBARA LEINER, MSW, LCSW-C 

Psychiatric Social Worker, Department of Child Psychiatry, 

Walter Reed Army Medical Center, Borden Pavilion, 6900 Georgia 

Avenue NW, Washington, DC 20307-5001; formerly, Clinical Case 

Manager, Department of Child Psychiatry, Kaiser Permanente 

Mid-Atlantic States, Rockville, Maryland

STEVEN LINDLEY, MD, PhD

Director of Outpatient Mental Health, Department of Veterans 

Affairs Palo Alto Health Care System, 795 Willow Road, 116R/

MHC, Menlo Park, California 94025; and, Associate Professor, Department of Psychiatry, Stanford University, Palo Alto, California

BRETT LITZ, PhD

Professor, Department of Psychiatry, Boston University School of 

Medicine, 77 East Concord Street, Boston, Massachusetts 02118; 

Associate Director, Behavioral Sciences Division, Department 

of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont

GAIL H. MANOS, MD

Captain, Medical Corps, US Navy; Navy Psychiatry Specialty 

Leader and Senior Medical Officer, Director of Mental Health, 

Naval Medical Center Portsmouth, 620 John Paul Jones Road, 

Portsmouth, Virginia 23708; formerly, Psychiatry Residency Training Director, Department of Psychiatry, Naval Medical Center 

Portsmouth, Portsmouth, Virginia 

BARBARA A. MARIN, PhD

Integrated Chief, Department of Addictions Treatment and 

Clinical Director, Army Substance Abuse Program, Walter Reed 

Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 

20307-5001

JEEVENDRA MARTYN, MD

Professor/Chief, Department of Anesthesiology and Critical Care, 

Harvard Medical School/Shriners Hospital for Children, 51 Blossom Street, Room 206, Boston, Massachusetts 02114

AMY M. MATTILA, MS, MBA

Captain, Medical Specialist Corps, US Army; Chief, Department 

of Occupational Therapy, Reynolds Army Community Hospital, 

4301 Wilson Street, Fort Sill, Oklahoma 73503; formerly, Chief, 

Occupational Therapy, 254th Medical Detachment (Combat Operational Stress Control), Germany

JAMES E. McCARROLL, PhD, MPH

Colonel, US Army (Retired); Psychologist, Center for the Study 

of Traumatic Stress and Department of Psychiatry, Room B3068, 

Uniformed Services University of the Health Sciences, 4301 Jones 

Bridge Road, Bethesda, Maryland 20814; formerly, Psychologist, 

Walter Reed Army Institute of Research, Silver Spring, Maryland

KELLY R. McCARTHY, MA

Captain, Nurse Corps, US Air Force; Historian, Peterson Air 

Force Base, 150 Vandenberg, Suite 110S, Peterson Air Force Base, 

Colorado 80914; formerly, Chief, Behavioral Health Nursing 

Management, Life Skills Center, United States Air Force Academy, 

Colorado Springs, Colorado

KEVIN M. McGUINNESS, PhD

Captain, Scientist Corps, US Public Health Service; Director and 

Medical Psychologist, HRSA/BCRS National Health Service 

Corps, Ready Responder Program, Department of Health and 

Human Services, c/o La Clinica de Familia, 510 East Lisa Drive, 

Chaparral, New Mexico 88081; formerly, Senior Clinical Scientist, 

Health and Human Services, US Department of Justice, Bureau of 

Prisons, Federal Correctional Institution La Tuna, New Mexico

DENNIS McGURK, PhD

Major, Medical Service Corps, US Army; Commander, US Army 

Medical Research Unit—Europe, Walter Reed Army Institute of 

Research, CMR 442, Box 777, APO AE 09042

ROBERT C. McKENZIE, DO 

Lieutenant Colonel, Medical Corps, US Army; Department of Behavioral Health, US Army Health Clinic-Vicenza, Caserma Ederle, 

Italy, Unit 31401, Box 13, APO AE 09042

MARGARET A. McNULTY, DrPH

Captain, US Navy (Retired); Assistant Professor, Department of 

Nursing, Kapiolani Community College, 4303 Diamond Head 

Road, Honolulu, Hawaii 96816

CORINA MILLER, MSW 

Clinical Social Worker, Department of Psychiatry, Walter Reed 

Army Medical Center, Building 2, Office #6317, 6900 Georgia 

Avenue NW, Washington, DC 20307-5001; formerly, Clinical Social 

Worker, National Naval Medical Center, Bethesda, Maryland

CHARLES MILLIKEN, MD

Colonel, Medical Corps, US Army; Program Director, National 

Capital Consortium Psychosomatic Medicine/Geriatric Psychiatry Fellowship, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC; formerly, Principal Investigator, 

Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Grant Avenue, Silver Spring, Maryland

ANGELA MOBBS, PsyD

Captain, Medical Service Corps, US Army; Special Forces Assignment and Selection Psychologist, Special Warfare Center 

and School, Rowe Training Facility, Building T-5167, 1500 Camp 

Mackall Place, Marston, North Carolina 28363; formerly, Brigade 

Psychologist, 3rd Brigade Combat Team, 3rd Infantry Division, 

Fort Benning, Georgia
xviii

WALTER MORALES, MSA

Sergeant Major, US Army (Retired); Program Manager, Army Suicide Prevention Program, Army G-1, Headquarters, Department 

of the Army, 300 Army Pentagon, ATTN: Army G-1 (DAPE-HR), 

Washington, DC 20310-0300

SCOTT C. MORAN, MD

Major (P), Medical Corps, US Army; Psychiatry Residency Training Program Director, Psychiatry Consultation Liaison Service, 

Department of Psychiatry, Building 6, Room 2060, Walter Reed 

Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 

20307-5100

ANTHONY J. MORTON, MD

Major, Medical Corps, US Army; Medical Director, Department 

of Behavioral Health, Moncrief Army Community Hospital, 4500 

Stuart Street, Fort Jackson, South Carolina 29207-5720; formerly, 

Division Psychiatrist, 1st Armored Division, Wiesbaden, Germany

WILLIAM P. NASH, MD

Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego, 6326 

Timarron Cove Lane, Burke, Virginia 22015; formerly, Senior Consultant, Defense Centers of Excellence for Psychological Health 

and Traumatic Brain Injury, Rosslyn, Virginia

SHARON M. NEWTON, OTR/L, MHS 

Lieutenant Colonel, Medical Specialist Corps, US Army; Command Inspector General, 30th Medical Command, CMR 442, APO 

AE 09042; formerly, Theater Consultant for Combat and Operational Stress Control, Iraq

MARVIN OLESHANSKY, MD

Colonel, US Army (Retired); Staff Psychiatrist, Psychiatric Outpatient Service, Department of Psychiatry, Tripler Army Medical 

Center, 1 Jarrett White Road, Honolulu, Hawaii 96822; formerly, 

Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC

VICTORIA W. OLSON, MBA

Executive Director, Hawai’i Army Museum Society, Post Office 

Box 8064, Honolulu, Hawaii 96830-0064

JESSICA PARKER, PsyD

Captain, Medical Service Corps, US Army; Chief, Warrior Restoration Center, Department of Behavioral Medicine, Winn Army 

Community Hospital, 541 East 9th Street, Building 359, Fort Stewart, Georgia 31314-5674; formerly, Psychology Resident, Traumatic 

Brain Injury, Brooke Army Medical Center, San Antonio, Texas

ROSS H. PASTEL, PhD

Lieutenant Colonel, Medical Service Corps, US Army; Chief, 

Division of Traumatic Brain Injury, Research Directorate, Defense 

Centers of Excellence for Psychological Health and Traumatic 

Brain Injury, 1335 East-West Highway, Suite 900, Silver Spring, 

Maryland 20910; formerly, Assistant Professor, Department of 

Medical and Clinical Psychology, Uniformed Services University 

of the Health Sciences, Bethesda, Maryland

SAMUEL E. PAYNE, MD

Colonel, Medical Corps, US Army; Chief, Outpatient Behavioral 

Health Services, Dwight D. Eisenhower Army Medical Center, 

Building 300, Room 13A-15, 300 South Hospital Road, Fort Gordon, Georgia 30905 

MARY ANN PECHACEK, PsyD, LMFT 

Psychologist and Instructor/Writer, Department of Behavioral 

Health Sciences, Special Subjects Branch, Army Medical Department Center and School, 3151 Scott Road, Building 2840, Office 

#033-B9, Fort Sam Houston, Texas 78234; formerly, Psychologist 

and Instructor/Writer, Soldier and Family Support Branch/Special Subjects, Fort Sam Houston, Texas

JON T. PEREZ, PhD

Captain, Scientist Corps, US Public Health Service; Team Leader, 

US Public Health Service Disaster Mental Health Team II, Department of Health and Human Services, Indian Health Service Headquarters, 801 Thompson Avenue, Suite 300, Rockville, Maryland 

20852

ALAN L. PETERSON, PhD, ABPP 

Professor, Department of Psychiatry, Mail Code 7792, University 

of Texas Health Science Center at San Antonio, 7703 Floyd Curl 

Drive, San Antonio, Texas 78229; formerly, Chair, Department of 

Psychology, Wilford Hall Medical Center, San Antonio, Texas

KRIS A. PETERSON, MD

Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, Madigan Army Medical Center, Building 9040, Fitzsimmons 

Drive, Tacoma, Washington 98431; formerly, Child and Adolescent Psychiatry Consultant to The Surgeon General, US Army

SIMON PINCUS, MD

Colonel, US Army (Retired); Clinical Director, Department of 

Mental Health, McChord Medical Clinic, 690 Barnes Boulevard, 

Joint Base Lewis-McChord (McChord Field), Washington 98438; 

formerly, Chief, Inpatient Psychiatry, Madigan Army Medical 

Center, Tacoma, Washington

CHRISTINE M. PIPER, APRN, BC

Colonel, US Army (Retired); Coaching Trainer/Instructor, LivingWorks, Inc.; formerly, Chief, Soldier and Family Assistance 

Center, Schofield Barracks, Hawaii

JOHN RALPH, PhD

Commander, Medical Service Corps, US Navy; Director, Department of Mental Health, National Naval Medical Center, 8901 

Wisconsin Avenue, Bethesda, Maryland 20889; formerly, Officerin-Command, Presidential Support Program, Marine Barracks, 

Washington, DC

MARK A. REGER, PhD

Research Psychologist, Department of Psychology, Madigan 

Army Medical Center, 9933C West Hayes Street, Fort Lewis, 

Washington 98431; and Affiliate Assistant Professor, Department 

of Psychiatry and Behavioral Sciences, University of Washington 

School of Medicine, 1925 NE Pacific Street, Seattle, Washington 

98195-6340

DAVID REYNOLDS, PhD

Major, Biomedical Sciences Corps, US Air Force; Mental Health 

Element Leader, Department of Psychology, Malcolm Grow 

Medical Center, 1050 West Perimeter Road, 779 MDOS/SGOH, 

Andrews Air Force Base, Maryland 20762; formerly, Chief, 

Department of Health Psychology, Landstuhl Regional Medical 

Center, Landstuhl, Germany
xix

ELSPETH CAMERON RITCHIE, MD, MPH

Colonel, US Army (Retired); formerly, Psychiatry Consultant 

to The Surgeon General, US Army, and Director, Behavioral 

Health Proponency, Office of The Surgeon General, Falls Church, 

Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York Avenue NE, 4th Floor, 

Washington, DC 20002

AMANDA ROBBINS, PsyD

Captain, Medical Service Corps, US Army; Brigade Combat Team 

Behavioral Health Officer, 4th Brigade Combat Team, 10th Mountain Division, Fort Polk, Louisiana 71459

RENÉ J. ROBICHAUX, PhD, LCSW 

Colonel, US Army (Retired); Social Work Programs Manager, 

Behavioral Health Division, US Army Medical Command, 2050 

Worth Road, Suite 10, Fort Sam Houston, Texas 78234; formerly, 

Chief, Department of Social Work, Brooke Army Medical Center, 

Fort Sam Houston, Texas

MICHAEL RUSSELL, PhD

Lieutenant Colonel, Medical Service Corps, US Army; Army 

Medical Department Neuropsychology Consultant, Warrior Resiliency Program, Lincoln Center, Suite 300, 7800 Interstate 10 West, 

San Antonio, Texas 78230 

JOSEF I. RUZEK, PhD

Director, Dissemination and Training Division, National Center 

for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto 

Health Care System, 795 Willow Road, Menlo Park, California 

94025

ALBERT Y. SAITO, MD

Clinical Director, Child and Adolescent Psychiatry Service, 

Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett 

White Road, Honolulu, Hawaii 96859-5000; formerly, Staff Psychiatrist, Department of Child Psychiatry, Tripler Army Medical 

Center, Honolulu, Hawaii

BRETT J. SCHNEIDER, MD

Lieutenant Colonel, Medical Corps, US Army; Deputy Chief, 

Department of Psychiatry, Building 61, Child and Adolescent Psychiatry Clinic, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307

MERRITT SCHREIBER, PhD

Captain, Scientist Corps, US Public Health Service (Inactive Reserve Corps); Senior Program Manager, Center for Public Health 

and Disasters, University of California at Los Angeles Center for 

the Health Sciences, 1145 Gayley Avenue, Suite 304, Los Angeles, 

California 90024; and Operations Lead, USPHS Mental Health 

Team II

ROBERT L. SHERIDAN, MD

Associate Director, Department of Surgery, Harvard Medical 

School at the Massachusetts General Hospital; Assistant Chief of 

Staff, Shriners Burn Hospital, 51 Blossom Street, Boston, Massachusetts 02114; formerly, Lieutenant Colonel, Medical Corps, 

US Army; US Army Institute of Surgical Research, Brooke Army 

Medical Center, San Antonio, Texas

EDWARD SIMMER, MD, MPH

Captain, Medical Corps, US Navy; Executive Officer, Naval Hospital, 1 Pinckney, Beaufort, South Carolina 29902; formerly, Senior 

Executive Director for Psychological Health, Defense Centers of 

Excellence for Psychological Health and Traumatic Brain Injury, 

Silver Spring, Maryland

TANGENEARE WARD SINGH, MD

Major, Medical Corps, US Army; Chief, Department of Behavioral 

Health, Blanchfield Army Community Hospital, 650 Joel Drive, 

Fort Campbell, Kentucky 42223

MARSHALL SMITH, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Behavioral 

Health, Landstuhl Regional Medical Center, CMR 402, Box 1357, 

APO AE 09180; formerly, Chief, Outpatient Behavioral Health, 

Landstuhl Regional Medical Center, Landstuhl, Germany

STEVEN SOUTHWICK, MD

Professor, Department of Psychiatry, Yale University School of 

Medicine and Yale Child Study Center, 333 Cedar Street, New 

Haven, Connecticut 06510; Adjunct Professor, Department of 

Psychiatry, Mount Sinai School of Medicine, One Gustave L. 

Levy Place, New York, New York 10029; Deputy Director, Clinical 

Neurosciences Division, Department of Veterans Affairs National 

Center for Posttraumatic Stress Disorder, White River Junction, 

Vermont 

JAMES J. STAUDENMEIER, MD, MPH

Colonel, Medical Corps, US Army; Consultant, Army Substance 

Abuse Program, Department of Psychiatry, USAMEDDAC, 11050 

Mount Belvedere Boulevard, BMD (Wilcox), Fort Drum, New 

York 13602; formerly, Fellow in Geriatric Psychiatry, Walter Reed 

Army Medical Center, Washington, DC

FREDERICK J. STODDARD Jr, MD

Associate Clinical Professor, Department of Psychiatry, Harvard 

Medical School at the Massachusetts General Hospital; and Chief 

of Psychiatry, Shriners Burn Hospital, 51 Blossom Street, Boston, 

Massachusetts 02114; formerly, Senior Surgeon, US Public Health 

Service 

KATHERINE H. TABER, PhD

Research Health Scientist, Department of Research and Education, WG Hefner Veterans Affairs Medical Center, Mailstation 

11M, 1601 Brenner Avenue, Salisbury, North Carolina 28144; 

formerly, Research Fellow, School of Health Information Sciences, 

University of Texas at Houston

ARTIN TERHAKOPIAN, MD, MPH

Major, Medical Corps, US Army; Chief, Inpatient Psychiatry, Department of Behavioral Health, William Beaumont Army Medical 

Center, 5005 North Piedras Street, El Paso, Texas 79920; formerly, 

Chief, Behavioral Health, 10th Combat Support Hospital, Baghdad, Iraq

RICHARD TOYE, PhD

Lieutenant Colonel, Medical Service Corps, US Army Reserve; 

Company Commander, 883rd Medical Company (Combat Stress 

Control), 495 Summer Street, Boston, Massachusetts 02210; 

formerly, Brigade Behavioral Health Consultant, 804th Medical 

Brigade, Fort Devens, Massachusetts

TINA TRUDEL, PhD

Site Director, Defense and Veterans Brain Injury Center at Virginia 

NeuroCare, 1101-B East High Street, Charlottesville, Virginia 

22902; Assistant Clinical Professor of Psychiatry and Behavioral 

Neurobehavioral Sciences, University of Virginia Medical School, 

Charlottesville, Virginia 22902; formerly, Executive Director, 

Lakeview NeuroRehabilitation Center, Effingham Falls, New 

Hampshire 
xx

ROBERT J. URSANO, MD

Colonel, US Air Force (Retired); Director, Center for the Study 

of Traumatic Stress, and Chair, Department of Psychiatry, Room 

B3068, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814 

JEFFREY L. VOYLES, MDiv

Lieutenant Colonel, Chaplain Corps, US Army; Director and 

Clinical Supervisor, Chaplain Family Life Training Program, 

Building 2606 Collins Loop, Fort Benning, Georgia 31905

HAROLD J. WAIN, PhD

Chief, Psychiatry Consultation Liaison Service, Department of 

Psychiatry, Building 2, Room 6238, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington, DC 20307-5100

WENDI M. WAITS, MD

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient 

Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Room 4B106, Honolulu, Hawaii 

96859-5000; formerly, Child and Adolescent Psychiatry Fellow, 

Tripler Army Medical Center, Honolulu, Hawaii

DEBORAH L. WARDEN, MD

Formerly, National Director, Defense and Veterans Brain Injury 

Center Headquarters; Departments of Neurology and Psychiatry, 

Walter Reed Army Medical Center, 6900 Georgia Avenue NW, 

Washington, DC 20307; Departments of Neurology and Psychiatry, Walter Reed Army Medical Center, 6900 Georgia

Avenue NW, Washington, DC 20307-5001

CHRISTOPHER H. WARNER, MD

Major, Medical Corps, US Army; Chief, Department of Behavioral 

Medicine, Winn Army Community Hospital, Building 9242, Room 

20, 1083 Worcester Drive, Fort Stewart, Georgia 31324; formerly, 

Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

TERRY C. WASHAM, MSSA, LISW 

Colonel, Medical Service Corps, US Army Reserve; Military 

Liaison Coordinator, Office of Seamless Transition, Department 

of Veterans Affairs, VA Medical Center, 10000 Brecksville Road, 

Brecksville, Ohio 44141

PATRICIA WATSON, PhD

Assistant Professor, Dartmouth Medical School, 1 Rope Ferry 

Road, Hanover, New Hampshire 03755-1404; Senior Educational 

Specialist, Executive Division, Department of Veterans Affairs 

National Center for Posttraumatic Stress Disorder, White River 

Junction, Vermont

THOMAS C. WAYNICK, MDiv

Lieutenant Colonel, Chaplain Corps, US Army; Command 

Chaplain, Family, Morale, Welfare, and Recreation Command, 

4700 King Street, Alexandria, Virginia 22301; formerly, Director 

and Clinical Supervisor, US Army Family Life Chaplain Training 

Program, Fort Benning, Georgia

SIMON WESSELY, MD

Department Head, Department of Psychological Medicine, King’s 

Centre for Military Health Research, King’s College, Weston 

Education Centre, 10 Cutcombe Road, London SE5 9RJ United 

Kingdom; formerly, Honorary Lecturer in Forensic Psychiatry, 

Institute of Psychiatry, London, United Kingdom

RICHARD J. WESTPHAL, PhD, RN

Captain, Nurse Corps, US Navy; Psychological Health Promotion Programs, Department of the Navy, Bureau of Medicine and 

Surgery, Deployment Health, 2300 E Street NW, Washington, DC 

20372

KATHLEEN M. WRIGHT, PhD

Research Psychologist, US Army Medical Research-Europe, Walter Reed Army Institute of Research, CMR 442, Box 94, APO AE 

09042; formerly, Deputy Chief, Department of Military Psychiatry, 

Walter Reed Army Institute of Research, Silver Spring, Maryland

JEFFREY S. YARVIS, MSW, PhD

Lieutenant Colonel, Medical Service Corps, US Army; Chief, 

Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical Center, 6900 Georgia Avenue 

NW, Washington, DC 20307; formerly, Director of Social Work, 

Uniformed Services University of the Health Sciences, Bethesda, 

Maryland

TODD YOSICK, LISW 

Major, Medical Service Corps, US Army; Deputy Director, Resilience and Prevention Directorate, Office of the Assistant Secretary 

of Defense for Health Affairs, Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury, 1335 EastWest Highway, Silver Spring, Maryland 20910; formerly, Chief, 

Battlemind Training Office/Chief, Combat and Operational Stress 

Control, Army Medical Department Center and School, Fort Sam 

Houston, Texas
xxi

Foreword

Military healthcare has the unique opportunity of truly addressing the full continuum of illness, injury, disease, 

and health. Just as military healthcare professionals have made significant contributions to the improvement of 

physical health and lessening of injury and disease over the history of the United States, we are now a leading 

proponent of changes in prevention, recognition, and treatment in multiple areas of behavioral health.

Essential to progress in this arena is developing awareness of behavioral health needs and educating our 

beneficiaries about the appropriateness of receiving care for what are often “invisible” diseases or injuries. The 

need for this education and developing a toolkit of successful skills, techniques, and strategies for resilience have 

never been more apparent than during what has become a persistent state of conflict. We are committed to leading the Nation in eliminating the stigma of behavioral health problems. Men and women within our militaries 

and across America must learn that it is just as acceptable and appropriate to seek behavioral healthcare as it is 

to seek treatment for a broken bone.

Since the publication of the two Textbooks of Military Medicine psychiatry volumes—Military Psychiatry: Preparing in Peace for War (1994) and War Psychiatry (1995)—we have made tremendous strides. This volume, Combat 

and Operational Behavioral Health, expands on these previous two volumes, covering the full breadth of the 

psychological and behavioral health continuum. Important contributions include preparation for deployment 

and resiliency training; the provision of services in theater; recovery after physical or emotional injury due to 

combat; reunion and reintegration; military children and families; operational psychiatry; and the daunting 

challenge to prevent suicide.

I see our effect on social attitudes toward behavioral and/or psychological health as potentially substantial. 

Our prospects are good for a better understanding of the neurochemistry and basic pathophysiology of many 

common stress-related problems, and our grasp and management of millennia-old problems of armed conflict are 

much improved. However, major challenges remain. One may think the diagnosis of posttraumatic stress disorder 

(PTSD), for example, would be straightforward. On the contrary, it varies widely among different stakeholders. 

The more complex issues of the etiology of PTSD and traumatic brain injury, and effective treatments for these 

conditions, as well as their interaction with age, gender, and other medical issues, are far more daunting. 

This new textbook is an excellent resource for all healthcare professionals as they strive to provide the finest 

quality and most compassionate care of the men and women in uniform and their spouses, significant others, 

and children. Every person who is in contact with a military member struggling to cope with the emotional 

trauma of war, disease, or injury needs our support and best efforts. 

The contributions of the exceptional civilian and military professionals in this outstanding text can raise the 

quality of behavioral healthcare across our land and help eliminate the stigma of requesting this care. Although 

we talk a lot about the reduction of stigma, to actually reduce it and improve Soldiers’ willingness to seek treatment is a Herculean task. Therefore, let us all participate in this essential step forward for the health and wellbeing of those who have often suffered in silence and alone.

 Lieutenant General Eric B. Schoomaker, MD, PhD

The Surgeon General and

Commanding General, US Army Medical Command

Washington, DC

February 2010
xxii
xxiii

Preface

This book was begun in 2005 when it became apparent that an update to the previous volumes on military 

psychiatry—Military Psychiatry: Preparing in Peace for War (1994) and War Psychiatry (1995)—was needed. In the 

almost 20 years since the chapters in those two volumes were drafted, enormous changes and advancements 

in classification, diagnosis, and treatment of combat stress have occurred. The pace of change has accelerated 

with the wars in Afghanistan and Iraq. These wars have become known by many names: Operations Enduring 

Freedom and Iraqi Freedom, the Long War, and continuous overseas contingency operations, among others. 

In the early years of the operations in Afghanistan (2001) and Iraq (2003), changes in operational tempo and 

resulting extended deployments were extremely taxing for military families. What was problematic in these 

early years (tempo and deployment) because of the change from past experience has now become problematic 

because it is the norm. The murders and murder/suicides at Fort Bragg, North Carolina, in 2002 highlighted 

the perils of soldiers’ rapid return from Afghanistan battlefields to civilian life. The investigations at Fort Bragg 

and other installations revealed continuing problems with access to care, as well as reluctance of career-minded 

soldiers to seek treatment. 

In response to these and other events, training and systems were put into place to prepare soldiers for “redeployment” (return to garrison). One of the earlier approaches, “Battlemind,” was designed to help reintegrate 

service members and families. Battlemind recently evolved into the Comprehensive Soldier Fitness program, 

which is focused on enhancing resiliency. Despite these various new programs, many soldiers remain reluctant 

to seek behavioral healthcare for many reasons, perhaps the greatest of which is worry about its effects on 

their careers. Stigma is a persistent problem, despite numerous efforts to reduce its prevalence. Often it is the 

soldiers’ families who try to get these service members in for treatment. To improve access to care, the Army 

and other services have dramatically increased their number of mental health providers, up about 70% between 

2007 and 2010. 

To assist this growing population of service members, the military behavioral health community has added 

many new systems of evaluation and care. The Post-Deployment Health Assessment (PDHA), which screens 

soldiers on return from theater, was implemented after the Persian Gulf War (1990–1991). However, soldiers 

often did not admit to symptoms after deployment because they wanted to get home as soon as possible. Beginning in 2005, the PDHA was joined by the Post-Deployment Health Re-Assessment (PDHRA), administered at 

3 to 6 months after return. It was designed to connect with service members after “the honeymoon” of returning 

home was over. 

Family programs have been expanded to help with issues that arise during both deployment and redeployment. There are specialized programs at Walter Reed Army Medical Center and other facilities for families of 

the wounded that attempt to prepare children to see parents missing a limb or disfigured from a blast. Another 

difficult area has been support to families of the deceased. US military families have not faced these numbers 

of service-connected fatalities since the Vietnam War. In the past, spouses and children were required to leave 

base housing and service-centered support systems relatively soon after their loved one’s death. This policy has 

changed over time, with longer access to housing and healthcare afforded these families. 

Traumatic brain injury (TBI) is another major concern and affects families as well as service members. The 

sources of these injuries are varied: blasts, gunshot wounds, accidents. TBI can present with many symptoms, 

some similar to posttraumatic stress disorder, including irritability, impulsiveness, and personality changes.

The rising suicide rate has been a major concern for all in the Army. The combination of unit and individual 

risk factors include high operations tempo, feelings of disconnectedness on return home, problems at work 

or home, pain and disability, alcohol, and easy access to weapons. Consistent and high-profile attempts have 

been made to reduce suicide with numerous training programs for service members, focusing on buddy aid 

and gatekeepers. However, thus far these efforts have been only partially successful. The prolonged effects of 

exposure to violence and death are not easy to change.

New efforts to assist service members continue. The Defense Center of Excellence was stood up in November 2007, with a focus on best practices and reducing stigma. Other programs are the Comprehensive Behavioral Health Campaign Plan, the Department of Defense–Department of Veterans Affairs Integrated Mental 

Health Plan, and the National Intrepid Center of Excellence. 

An ongoing concern is the long-term effects of the Long War, for the next 20, 30, or 50 years. After the Viet-
xxiv

nam War, far too many veterans ended up on the streets—unemployed, homeless, and addicted. By examining 

the potential causes of combat stress and emotional trauma, the various approaches to diagnosis and treatment, 

the roles of providers (and their own resiliency), and the many programs available to help, this volume seeks to 

reduce the difficulties faced by veterans as they reenter civilian life. However, success in this area will require 

a concerted effort by all on the home front, including the Army, other branches of the military, the Department 

of Veterans Affairs, other federal agencies, and state and local agencies, as well as civilian and private organizations. It is hoped that the interventions described in this volume will contribute to that effort by informing 

and guiding military and civilian healthcare providers, the public, and both active duty service members and 

veterans of these most recent conflicts.

Elspeth Cameron Ritchie, MD, MPH, Colonel, US Army (Retired) 

Chief Clinical Officer, District of Columbia Department of Mental Health 

Formerly, Psychiatry Consultant to The Army Surgeon General, and Director, Behavioral Health Proponency, 

Office of The Surgeon General

Washington, DC

December 2010
xxv

Abbreviations and Acronyms

AbBreviations and Acronyms

25th ID: 25th Infantry Division Light

5-HT1a: serotonin 

A

AA 77: American Airlines Flight 77 

AAA: animal-assisted activity 

AAR: after-action review 

AAS: American Association of Suicidology 

AAT: animal-assisted therapy 

ACE: Ask, Care, and Escort 

ACGME: American Council of Graduate Medical Education 

ACPHP: Army Campaign Plan for Health Promotion, Risk Reduction and Suicide Prevention 

ACR: Army Central Registry 

ACRM: American Congress of Rehabilitative Medicine 

ACS: Army Community Service 

ACU: Army combat uniform 

ADAPT: Alcohol and other Drug Abuse Prevention Training 

ADCO: Alcohol and Drug Control Officer 

ADHD: attention deficit hyperactivity disorder 

AFB: Air Force Base 

AFHSC: Armed Forces Health Surveillance Center 

AFIP: Armed Forces Institute of Pathology 

AFMAC: Adult Family Member Assistance Center 

AFME: Armed Forces Medical Examiner’s Office 

AHEC: Area Health Education Center 

AIT: advanced individual training 

AKO: Army Knowledge Online 

AMEDD: Army Medical Department 

AMEDDC&S: Army Medical Department Center and School 

AN: anorexia nervosa 

AO: area of operations 

AOC: alteration of consciousness 

APA: American Psychiatric Association 

APA: American Psychological Association 

APOE/APOD: aerial point of embarkation/debarkation 

AR: Army Regulation 

ARNG: Army National Guard 

ARS: acute radiation sickness 

ARVN: Army of the Republic of Vietnam 

ASAM: American Society of Addiction Medicine 

ASAP: Army Substance Abuse Program 

ASD: acute stress disorder 

ASER: Army Suicide Event Report 

ASF: aeromedical staging facility 

ASIST: Applied Suicide Intervention Skills Training 

ASMB: area support medical battalion

ASMC: area support medical company 

ASPP: Army Suicide Prevention Program 

ASPTF: Army Suicide Prevention Task Force 

AST: aspartate aminotransferase 

ASVAB: Armed Services Vocational Aptitude Battery 

ATM: automated teller machine 

AusAID: Australian Agency for International Development 

AW2: Army Wounded Warrior 

AWOL: absent without leave

B

BAC: blood alcohol concentration 

BAMC: Brooke Army Medical Center 

BCT: brigade combat team 

BDE: brigade 

BDU: battle dress uniform 

BED: binge-eating disorder 

BFG: British Forces Germany 

BH: behavioral health 

BHL: behavioral health liaison 

BHO: behavioral health officer 

BICEPS: brevity, immediacy, centrality, expectancy, proximity, and 

simplicity 

BKA: below-the-knee amputation 

BMI: body mass index 

BN: bulimia nervosa 

BRAC: Base Realignment and Closure 

BSC: behavioral science consultants 

BSHOP: Behavioral and Social Health Outcomes Program

C

CAAC: Child and Adolescent Assistance Center 

CACO: casualty assistance call officer 

CanMEDS: Canadian Medical Education Directions for Specialists 

CAO: casualty assistance officer 

CAPS: Child and Adolescent Psychiatry Service 

CASF: contingency aeromedical staging facility 

CAST: Chaplain Annual Sustainment Training 

CBRN: chemical, biological, radiological, and nuclear 

CBRNE: chemical, biological, radiological, nuclear, and explosive 

CBT: cognitive-behavioral therapy 

CDC: Centers for Disease Control and Prevention 

CDT: carbohydrate deficient transferrin 

CED: critical event debriefing 

CENTCOM: Central Command

CG/USARV: Commanding General, United States Army Republic 

of Vietnam

CHCS: Composite Health Care System 

CHCS-ITT: Composite Health Care System–Interactive Training 

Tool 

CHE: complex humanitarian emergency 

CHPC: Community Health Promotion Council 

CHPPM: Center for Health Promotion and Preventive Medicine 

CID: Criminal Investigation Division 

CIP: command interest profile 

CIR: critical incident report 

CISD: critical incident stress debriefing 

CISM: critical incident stress management 

Civ: civilian 

CMAOC: Casualty and Mortuary Affairs Operation Center

CMO: civil-military operations 

CMOC: civil-military operations center 

CNN: Cable News Network 

CO: Company 

COMT: catechol-o-methyltransferase 

COMUSMACV: Commander US Military Assistance Command, 

Vietnam 

CONUS: continental United States 

COSB: combat and operational stress behavior 

COSC: combat and operational stress control 

COSC-WARS: Combat/Operational Stress Control Workload 

Activity Reporting System 

COSFA: combat and operational stress first aid 

COSR: combat and operational stress reaction 

COSR/SR: combat and operational stress/staff resiliency 

COTA: certified occupational therapy assistant 

COX-2: cyclooxygenase-2 

CPIP: Clinical Psychology Internship Program 

CPT: cognitive processing therapy 

CQ: charge of quarters 

CRH: corticotropin-releasing hormone 
xxvi

Combat and Operational Behavioral Health 

CSC: combat stress control 

CSC: combat stress casualty 

CSCT: combat stress control team 

CSF: cerebrospinal fluid 

CSF: Comprehensive Soldier Fitness 

CSH: combat support hospital 

CSR: combat stress reaction

CT: cognitive therapy 

CT: computed tomography 

CY: calendar year 

CYP2D6: cytochrome p450 enzyme 

D

DA: Department of the Army 

DAI: diffuse axonal injury 

DAMIS: Drug and Alcohol Management Information System 

DCCS: deputy chief of clinical services 

DCMH: Department of Community Mental Health 

DCOE: Defense Centers of Excellence 

DCS: Deployment Cycle Support 

DCSP: Deployment Cycle Support Program 

DEROS: date of expected return from overseas 

DHC: Deployment Health Clinic 

DHEA: dehydroepiandrosterone 

DHHS: Department of Health and Human Services 

DIF: division internment facility 

DISCOM: Division Support Command 

DMH: division mental health 

DMHA: division mental health activity 

DMHS: defense mental health services 

DMHS: division mental health section 

DNA: deoxyribonucleic acid 

DNBI: disease nonbattle injury

DoD: Department of Defense 

DoDSER: Department of Defense Suicide Event Report 

DoE: Department of Education 

DRRI: Deployment Risk and Resilience Inventory 

DSB: division support battalion 

DSCOT: doctorate of science in occupational therapy 

DSM: Diagnostic and Statistical Manual of Mental Disorders

DSM-III: Diagnostic and Statistical Manual of Mental Disorders, 3rd 

edition 

DSM-III-R: Diagnostic and Statistical Manual of Mental Disorders, 

3rd edition, revised 

DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th 

edition 

DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 

4th edition, text revision 

DSN: Defense Satellite Network 

DTI: diffusion tensor imaging 

DUI: driving under the influence 

DVA: Department of Veterans Affairs 

DVBIC: Defense and Veterans Brain Injury Center 

DWI: driving while intoxicated 

DWMMC: Deployed Warrior Medical Management Center 

E

ECT: electroconvulsant therapy 

EDNOS: eating disorder not otherwise specified 

EEG: electroencephalography 

EFMP: Exceptional Family Member Program 

EMDR: eye movement desensitization and reprocessing 

EMF: expeditionary medical facility 

EPA: Environmental Protection Agency 

EPICON: epidemiological consultation 

EPS: extrapyramidal symptom 

ER: emergency room 

EtG: ethyl glucuronide 

ETOh: ethanol

F

FAP: Family Advocacy Program 

FDA: Food and Drug Administration 

FEMA: Federal Emergency Management Agency 

FLAIR: fluid attenuated inversion recovery 

FM: Field Manual 

FMHT: field mental health team 

FOB: forward operating base 

FORSCOM: Forces Command 

FRAGO: fragmentary order 

FRG: family readiness group 

FSB: forward support battalion 

FSMC: forward support medical company

G

G-3: operations

G-5: civil-military operations officer 

GABA: gamma-amino butyric acid 

GAO: Government Accountability Office 

GCS: Glasgow Coma Scale 

GDP: gross domestic product 

GE: gradient echo 

GERD: gastroesophageal reflux disease 

GGT: gamma glutamyl transferase 

GI: government issue

GKO: Guard Knowledge Online 

GME: graduate medical education

GOAT: Galveston Orientation and Amnesia Test 

GPMRC: Global Patient Movement Requirements Center 

GSA: GWOT Support Assignment 

GTA: graphic training aid 

GTO: girls’ time out

GTP: guanine triphosphate 

GWOT: global war on terror 

H

HA: humanitarian assistance 

hemcon: hemorrhage control 

HI: homicidal ideation 

HIPAA: Health Insurance Portability and Accountability Act 

HIV/AIDS: human immunodeficiency virus/acquired immunodeficiency syndrome 

HMMWV: high mobility multipurpose wheeled vehicle 

HOPE: Health Opportunities for People Everywhere 

HOSP: hospital 

HPA: hypothalamic-pituitary-adrenocortical 

HPI: history of present illness 

HRA: Health Risk Appraisal 

HS: hour of sleep (at bedtime) 

I

IA: individual augmentation 

IBTC: installation biochemical testing coordinator 

ICD-10: International Classification of Diseases, 10th edition 

ICD-9: International Classification of Diseases, 9th edition 

ICD-9-CM: International Classification of Diseases, 9th edition, clinical modification 

ICP: intracranial pressure 

ICRC: International Committee of the Red Cross 

ICU: intensive care unit 

ICW: intermediate care ward 
Abbreviations and Acronyms

xxvii

ID: Infantry Division 

IDF: Israeli Defence Forces 

IDP: internally displaced person 

IED: improvised explosive device 

IMA: installation management activity 

IMCOM: Installation Management Command 

IOM: Institute of Medicine 

IPT: interpersonal therapy 

IRT: imagery rehearsal therapy 

ISAF: International Security Assistance Force 

ISP: inpatient service provider 

ITO: in the theater of operations 

J

JAG: Judge Advocate General 

JFHQ: Joint Forces Headquarters 

JIDC: Joint Interrogation Debriefing Center 

JLIST: Joint Service Integrated Suit Technology 

JPTA: Joint Patient Tracking Application

K

KCMHR: King’s Centre for Military Health Research 

KIA: killed in action 

KO teams: hospital augmentation detachments 

L

LINN: Living in the New Normal 

LMF: lack of moral fiber

LO: liaison office 

LOC: loss of consciousness 

LOD: line-of-duty 

LRMC: Landstuhl Regional Medical Center 

LSA: logistic support area 

LSD: lysergic acid diethylamide

M

MACE: Military Acute Concussion Evaluation 

MATC: Military Advanced Training Center 

MCEC: Military Child Education Coalition 

MCE: mass casualty event 

MCV: mean corpuscular volume 

MDNOS: mood disorder not otherwise specified 

MEB: medical evaluation board 

MED: medical 

MEDCAP: medical civic action program 

MEDCMO: medical civil-military operations

MEDCOM: Medical Command 

MEDDAC: Medical Department Activity 

MEDEVAC: medical evacuation 

MEF: marine expeditionary force 

MEPS: Military Entrance Processing Station 

METT-TC: mission, enemy, terrain and weather, troops and support available, time available, and civil considerations 

MFLC: Military Family Life Consultant 

MHAT: Mental Health Advisory Team 

MHCS: Mental Health Consultation Service 

MHCTO: Mental Health Casualty Tracker for OIF 

Mil: military 

MIRECC: Mental Illness Research, Education, and Clinic Center 

MMB: multifunctional medical brigade 

MNC-I: Multi-National Corps–Iraq 

MNF-I: Multi-National Force–Iraq 

MOA: memorandum of agreement 

MOD: Ministry of Defence 

MOPP: mission-oriented protective posture 

MOS: military occupational specialty 

MP: military police 

MRE: meal, ready-to-eat 

MRE: military rules of evidence 

MRI: medical reengineering initiative 

MRI: magnetic resonance imaging 

MRO: medical review officer 

MS: multiple sclerosis 

MSB: main support battalion 

MSE: mental status evaluation 

mTBI: mild traumatic brain injury 

MTD: Medical Transient Detachment 

MTF: medical treatment facility 

MTOE: modified Table of Organization and Equipment 

MUPS: medically unexplained physical symptoms 

MWR: Morale, Welfare and Recreation 

N

NATO: North Atlantic Treaty Organization 

NBC: nuclear, biological, and chemical 

NBCOT: National Board for Certification in Occupational Therapy 

NCA: National Capital Area 

NCO: noncommissioned officer 

NCOER: noncommissioned officer evaluation report 

NCOIC: noncommissioned officer in charge 

NCPTSD: National Center for PTSD 

NE: norepinephrine 

NES: night-eating syndrome 

NGB: National Guard Bureau 

NGFβ: nerve growth factor β

NGO: nongovernmental organization 

NMDA: N-methyl-d-aspartic acid 

NNMC: National Naval Medical Center 

NPDB: National Practitioner Data Bank 

NPSP: New Parent Support Program 

NPY: neuropeptide Y 

NSAID: nonsteroidal antiinflammatory drug 

NVA: North Vietnamese Army 

NVVRS: National Vietnam Veterans Readjustment Study 

NYDN: not yet diagnosed neurological 

O

OCCH: Office of the Chief of Chaplains 

OCD: obsessive-compulsive disorder 

OCONUS: outside the continental United States 

ODS/S: Operation Desert Shield/Storm 

OEF: Operation Enduring Freedom 

OER: officer evaluation report 

OIF: Operation Iraqi Freedom 

OIF 05-07: Operation Iraqi Freedom 05-07 

OIF I: Operation Iraqi Freedom One 

OIF-II: Operation Iraqi Freedom Two 

OIH: opioid-induced hyperalgesia 

OMUS: outbreak of multiple unexplained symptoms 

ONE: Operation Noble Eagle 

OPNAVIST: Operational Navy Instruction 

OPTEMPO: operations tempo 

OR: operating room 

OSCAR: Operational Stress Control and Readiness 

OT: occupational therapy 

OTA: occupational therapy assistant 

OTSG: Office of The Surgeon General 

OUA: Operation Unified Assistance 

P

P-U-L-H-E-S: profile serial system 
xxviii

Combat and Operational Behavioral Health 

PAM: Pamphlet 

PAO: public affairs office/officer 

PA: physician assistant 

PASBA: Patient Administration Systems and Biostatistics Activity 

PC: psychological casualty 

PCA: patient-controlled analgesia 

PCLS: Psychiatry Consultation Liaison Service 

PCM: primary care management 

PCOS: postcombat and operational stress 

PDHA: Post-Deployment Health Assessment 

PDHA: predeployment health assessment 

PDHRA: Post-Deployment Health Re-Assessment 

PDPA: People’s Democratic Party of Afghanistan 

PE: prolonged exposure 

PET: positron emission tomography 

PFA: psychological first aid 

PFA: personal fitness assessment 

PGA-CI: Parent Guidance Assessment–Combat Injured 

PGD: prolonged grief disorder 

PH: psychological health 

PHC(P): Public Health Command (Provisional) 

PHI : protected health information 

PICK: Premarital Interpersonal Choices and Knowledge 

PKC: protein kinase C 

PMCS: Preventative Maintenance Checks and Services 

PMD: psychiatric mental disorder 

PMDD: premenstrual dysphoric disorder 

PMP: Preventive Medical Psychiatry 

PMR: Patient Movement Record, Patient Movement Requirement, 

or Patient Movement Request

po: per os (by mouth, orally) 

POC: point of contact 

POPM: Proponency of Preventive Medicine 

POW: prisoner of war 

PROFIS: Professional Officer Filler Information System 

ProQOL: Professional Quality of Life Scale 

PRT: provider resiliency training 

PSA: prostate-specific antigen 

PSP: patient support pallet 

PsySTART: psychological simple triage and rapid treatment 

PT: physical training 

PTA: posttraumatic amnesia 

PTE: potentially traumatic event 

PTG: posttraumatic growth 

PTSD: posttraumatic stress disorder 

PTSS: posttraumatic stress symptoms 

Q

q: quodque (every) 

QPR: Question, Persuade, Refer 

R

R&R: rest and recuperation 

RAF: Royal Air Force

RANKL: receptor activator of nuclear factor-κB ligand 

RASS: Richmond Agitation-Sedation Score 

RCS: Readjustment Counseling Service 

RCT: randomized controlled trial 

REM: rapid eye movement 

RFO: request for orders 

RGA: retrograde amnesia 

RMC: regional medical center 

RNAi: antisense ribonucleic acid 

ROE: rules of engagement 

RRC: Regional Readiness Command 

RRC: residency review committee 

RTD: return to duty 

RTU: return to unit 

S

S-3: operations officer 

SA: substance abuse 

SAC: Soldier Assistance Center 

SAC: Standardized Assessment of Concussion 

SAFAC: Soldier and Family Assistance Center 

SAMHSA: Substance Abuse and Mental Health Services Administration 

SARS: severe acute respiratory syndrome 

SAV: staff assistance visit 

SDH: subdural hemorrhage 

SDQ: Strengths and Difficulties Questionnaire 

SERE: Survival, Evasion, Resistance, and Escape 

SeRV-MH: Services for Returning Veterans-Mental Health 

SFLC: Soldier and Family Life Consultants 

SI: suicidal ideation 

SIC: stress injury continuum 

SIR: serious incident report 

SIT: stress inoculation training 

SITREP: situation report 

SME: subject matter expert 

SM: service member 

SNP: single-nucleotide polymorphism 

SNRI: serotonin-norepinephrine reuptake inhibitor 

SNS: sympathetic nervous system 

SOP: standard operating procedure 

SPPM: suicide prevention program manager 

SPRINT: Special Psychiatric Rapid Intervention Team 

SPSS: Statistical Package for the Social Sciences (version 16, SPSS 

Inc, Chicago, IL) 

SRMSO: Suicide Risk Management and Surveillance Office 

sRNA: small ribonucleic acid molecules 

SRP: Soldier Readiness Program 

SSRI: selective serotonin reuptake inhibitor 

STOAL: short take off and landing 

SWAPP: Soldier Wellness Assessment Pilot Program 

SWEP: Solomon Wellness Educational Program 

SWET: sewer, water, electricity, and trash 

T

TAI: traumatic axonal injury

TAMC: Tripler Army Medical Center 

TAPS: Tragedy Assistance Program for Survivors 

TBI: traumatic brain injury 

TCA: tricyclic antidepressant 

TEM: traumatic event management 

TF 30 Med: Task Force 30th Medical Brigade 

THR: target heart rate 

TIF: tertiary internment facility or theater internment facility 

TIPPS: Therapeutic Intervention for the Prevention of Psychiatric 

Stress 

TMD: temporomandibular dysfunction 

TMI: Three Mile Island 

TMIP: theater medical information program 

TOE: Table of Organization and Equipment 

TRAC2ES: TRANSCOM Regulating and Command and Control 

Evacuation System 

TRANSCOM: Transportation Command 

TRiM: Trauma Risk Management 

TSG: The Surgeon General 

TSH: thyroid-stimulating hormone 

TTY: text telephone 

TWA: Trans World Airlines 
Abbreviations and Acronyms

xxix

U

UBHNA: Unit Behavioral Health Needs Assessment 

UCMJ: Uniform Code of Military Justice 

UK: United Kingdom 

UMT: unit ministry team 

UN: United Nations 

UNHCR: UN High Commissioner for Refugees 

UNICEF: United Nations Children’s Fund 

USAID: US Agency for International Development 

USAMEDCOMV: US Army Medical Command Vietnam 

USAR: US Army Reserves 

USAREUR: US Army, Europe 

USARV: US Army Republic of Vietnam 

USDOT: US Department of Transportation 

USMACV: United States Military Assistance Command, Vietnam 

USPHS: US Public Health Service 

USUHS: Uniformed Services University of the Health Sciences

V

VA: Veterans Affairs 

VA: Veterans’ Administration (pre-1980 name) 

VAS: verbal or visual (or both) analogue scales 

VBA: Veterans Benefits Administration

VBIED: vehicle-borne improvised explosive device 

VCSA: vice chief of staff for the Army 

VHA: Veterans Health Administration

VTC: video teleconference 

W

w/: with 

w/o: without 

WHO: World Health Organization 

WHO-EURO: World Health Organization Regional Office for 

Europe 

WIA: wounded in action 

WICS: wisdom, intelligence, and creativity, synthesized 

WRAIR: Walter Reed Army Institute of Research 

WRAMC: Walter Reed Army Medical Center 

WTC: World Trade Center 

WTP: Warrior Transition Program 

WTRP: Warrior Training and Rehabilitation Program 

WTU: warrior transition unit
xxx

Combat and Operational Behavioral Health 
3

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

Chapter 1

COMBAT AND OPERATIONAL 

BEHAVIORAL HEALTH: AN UPDATE TO 

AN OLD HISTORY 

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

INTRODUCTION

BEHAVIORAL HEALTH CHALLENGES FOR THE US MILITARY

HISTORY OF THE PSYCHIATRY VOLUMES OF THE TEXTBOOKS OF MILITARY 

MEDICINE

SUMMARY

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

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

Avenue NE, 4th Floor, Washington, DC 20002

†

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

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

Combat and Operational Behavioral Health

INTRODUCTION

In the years since the attacks of September 11, 2001 

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

been at war in both Iraq and Afghanistan, and has 

responded to myriad natural disasters and terrorist 

incidents. Although all wars produce stress casualties, 

during and after different wars these casualties have 

manifested in many ways, both with physical and 

psychological symptoms. With the notable exceptions 

of the data collected by the Walter Reed Institute of 

Research and the Mental Health Assessment Teams (to 

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

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

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

seeks to consolidate, in real time, the information that 

is emerging, both to guide current policy and practice, 

and for the future.

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

(b) care of the physical and psychological needs 

of the wounded; (c) reintegration of soldiers with 

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

troops into humanitarian and disaster situations, 

such as the 2004 tsunami and Hurricane Katrina in 

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

members, including the families of the wounded 

and deceased.

The disaster literature, which draws heavily on the 

combat literature, tends to focus on a single traumatic 

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

It may start as unexpectedly as disasters do, but then 

persist for years. Unlike victims of disaster, service 

members are generally prepared for battle. They 

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

sounds, and smells of starving populations as seen in 

Somalia or mass graves, such as in Bosnia.

BEHAVIORAL HEALTH CHALLENGES FOR THE US MILITARY

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

These include service members home on leave brought 

to a civilian emergency room by a concerned family 

member; demobilized National Guard and reservists 

who may be remote from a military treatment facility 

or Veterans Affairs (VA) facility; and family members 

distraught over the frequent deployments of their 

soldier kin. 

A recurrent issue is that of stigma and barriers to 

care. Numerous programs, which will be described 

in this volume, exist to encourage military personnel 

to seek help. But there are also considerable potential 

consequences of seeking mental healthcare. These 

include: leadership ignorance of psychological issues; 

the requirement to report to command if a soldier 

enrolls in the Alcohol and Substance Abuse Program; 

security clearances; and other potential impacts on the 

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

addressed by the leadership.

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

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

access to free healthcare—all factors that reduce the 

incidence of suicide. The Army continues to strive to 

reduce these rates further. However, the rate of suicide 

in the Army has continued to rise every year since 

2004. The rate has just surpassed that in the civilian 

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

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

training has been revised to reflect the motivations 

of soldiers who kill themselves. Suicide prevention, 

therefore, is a topic of enormous significance to the 

Army.

Over the next few years, based on historical data, 

many service members will leave the Army or other 

military services. Traditionally, about 10% of former 

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

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

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

Thus it is critically important that civilian providers 

know about the psychological issues facing soldiers 

and families. 

The signature weapon of today’ wars, both in Iraq 

and Afghanistan, is the blast. The clinicians’ experience 

of caring for victims of these weapons is the result 

of years of technological, medical, and psychiatric 

advancements. But the history of military psychiatry 

is replete with attempts to answer many questions 

similar to the ones that the US military now faces. 

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

for contemporary application. 

Many questions remain. How can the responses of 

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

risks facing today’s soldiers and their families? How 

can practitioners engage returning soldiers, and what 
5

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

are likely pitfalls they may encounter? These dilemmas 

apply to all services, but the Army and Marines have 

been most heavily involved in the ground conflict and 

therefore constitute the focus of the text. 

HISTORY OF THE PSYCHIATRY VOLUMES OF THE TEXTBOOKS OF MILITARY MEDICINE 

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

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

pioneering clinicians developed potent strategies in 

the war against mental illness. For decades, however, 

despite numerous therapeutic advances, only a small 

number published their findings, leaving invaluable 

lessons vulnerable to the passage of time.

The disparate preservation and distribution of 

these “lessons learned” hindered future generations 

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

II psychiatrist Frederick Hanson had to rediscover 

the principles of forward treatment of combat stress 

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

their effectiveness 25 years earlier during World War 

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

conflict, US Army physicians, unaware of the benefit 

of quickly treating combat stress cases close to their 

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

 Fortunately, 

Colonel Albert Glass, well-versed in the practice of 

combat psychiatry in the course of his World War II 

tour under Hanson, sharply reduced combat stress 

casualties by implementing principles now known 

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

simplicity.

It was not until 20 years after the conclusion of 

World War II that the preeminent Army psychiatrists of 

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

of Neuropsychiatry in World War II appeared in print 

in 19664 and the second in 1973.5 These two volumes 

became the foundation of modern combat psychiatry. 

Although valuable for their historical preservation 

of the failures and ultimate successes of psychiatry 

in World War II, the delay in publication prevented 

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

the sizable cultural shifts of the 1960s, which would 

heavily influence the presentation of combat stress in 

the Vietnam War.

The Vietnam War and its social aftermath further 

demonstrated the effectiveness of forward treatment of 

combat stress and introduced new principles, such as 

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

era, these essential tenets, hard won through decades 

of painful experience, were preserved only as an oral 

tradition and in scattered literary sources. 

Even before the end of the Vietnam War, several 

luminaries of the military psychiatric community 

realized that a comprehensively compiled, refined, 

and codified source of military psychiatric experience 

from this era was required to preserve the accumulated 

data and perpetuate its application in future conflicts. 

Lieutenant Colonel Kenneth Artiss took an interest in 

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

War, Colonel Franklin Del Jones emerged as the lead 

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

career military psychiatrists who had completed a tour 

in Vietnam, also distinguished himself as a pragmatic 

clinician, expert pharmacotherapist, knowledgeable 

military historian, and master teacher. 

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

mentored by Albert Glass, well-known throughout 

the military for his implementation of the forward 

treatment of combat stress casualties in Korea. Jones 

also shared Glass’ steadfast commitment to preserve 

and develop the psychiatric lessons learned in past 

armed conflicts.9

 Throughout his Army career, Jones 

had held numerous prominent clinical, academic, and 

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

and the Consultant to the Surgeon General, US Army, 

but his greatest passion remained writing. As the 

leader of the textbook project, Jones invited authors 

from all armed services, multiple backgrounds, and 

various disciplines, but imbued the work with his 

own belief that practical experience takes precedence 

over speculation and theory. Jones retired from active 

military service in 1988 with the rank of colonel. He 

battled a severe autoimmune disorder, but nonetheless 

poured himself into the textbook project by personally 

authoring or coauthoring 18 of the 38 chapters, and 

researching and editing the remaining 20. During the 

first Gulf War (Operations Desert Shield and Desert 

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

relevant draft chapters to the psychiatry consultants 

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

in turn, distributed these to psychiatrists throughout 

the theater of operations to enable them to use the 

lessons learned from previous wars in this rapidly 

evolving conflict. Through collaboration with the 
6

Combat and Operational Behavioral Health

Borden Institute, the endeavor blossomed into two 

volumes, one published in 1994 (Military Psychiatry: 

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

Psychiatry10) in the Textbooks of Military Medicine series. 

Jones died in 2005, remembered as an epic contributor 

in the annals of military psychiatry.

With the publication of Military Psychiatry and War 

Psychiatry, members of the military mental health 

community could for the first time quickly reference 

a central repository of military-specific psychiatric 

knowledge from Napoleonic times through the 

Persian Gulf War. Faculty at the Army’s teaching 

hospitals integrated the texts into the curriculum for 

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

US Army War College, which educates the Army’s 

most promising combat arms leaders. Behavioral 

health clinicians based much of their intervention at 

the Pentagon on September 11, 2001, on the principles 

of forward treatment.8,11 Perhaps most significantly, 

the generation of mental heath officers deployed 

as part of Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) avoided mistakes 

made by their predecessors in the opening stages of 

previous wars. Instead, they rapidly adapted and 

implemented time-tested psychiatric treatment of 

US military fighters.

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

that improve on those of the past. The importance of 

an efficient transition of care for soldiers from active 

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

of posttraumatic stress disorder (PTSD) in OIF and 

OEF soldiers is presaged by Jones’ description of the 

evolution of the syndrome from World War I through 

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

the benefit of systematic emphasis on education and 

rehabilitation in recovery from PTSD. The textbooks 

present historical insights into many contemporary 

mental health issues.

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

researchers, and administrators have made countless 

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

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

will be described further in this volume. 

Today’s military mission also differs greatly from 

that of Jones’ era. Combat doctrine now emphasizes 

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

without clearly defined front lines. An expanding body 

of research and clinical experience is illuminating the 

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

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

of debate and documentation. 

SUMMARY

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

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

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

and many others, this newest version of the behavioral 

health volumes of the Textbooks of Military Medicine

provides clinicians with an indispensable weapon in 

the battle against the psychiatric illnesses that affect the 

men and women in uniform and their families.

There has been considerable discussion about the 

title of this book, which will be briefly summarized 

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

discipline specific. However, the question was what 

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

health” to “behavioral health.” The Department of 

Defense is beginning to use “psychological health.” 

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

Parallel discussions ensued about whether to use 

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

Health Service plays a central role in responding to 

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

out the responses to natural disasters. Thus the title, 

“Combat and Operational Behavioral Health,” was 

chosen to cast the widest net possible. 

There are some caveats. Inevitably, this is not the 

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

book, there have been multiple new efforts. Rather 

than hold off publication to have time to judge their 

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

as many sources and military services as possible, 

many practitioners are too busy during these times 

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

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

included as appendices, as they are more first-person 

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

like to be a practitioner in an immature and dangerous 

theater. There is also an account of media coverage of 

soldiers’ behavioral health in Iraq during Operation 
7

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

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

appendix. Finally it is hoped that this volume is a 

valuable addition to the literature, and a timely guide 

for practitioners and leaders.

 REFERENCES

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

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

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

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

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

General, Borden Institute; 1994.

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

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

Government Printing Office; 1966. 

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

Government Printing Office; 1973. 

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

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

65.

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

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

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

2007;35:1–12.

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

1995.

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

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

suppl):48–57.
8

Combat and Operational Behavioral Health
9

US Army Psychiatry Legacies of the Vietnam War

Chapter 2

US ARMY PSYCHIATRY LEGACIES OF 

THE VIETNAM WAR

NORMAN M. CAMP, MD*

INTRODUCTION

THE INCOMPLETE HISTORY OF ARMY PSYCHIATRY IN THE VIETNAM WAR

THE WAR’S RATIONALE AND PROVOCATION

THE SCOPE OF AMERICA’S WAR IN VIETNAM

AMERICA’S TWO VIETNAM WARS: PRE-TET ‘68 AND POST-TET ‘68

The Buildup Phase (1965–1967): Lyndon Johnson’s War 

The Transition From Buildup to Drawdown (1968–1969)

The Drawdown Phase (1969–1973): Richard Nixon’s War 

POSTWAR FEATURES

Vietnam Veterans and the High Prevalence of Readjustment Problems

Survey of Veteran Army Psychiatrists Who Served in Vietnam

LINGERING QUESTIONS AND CONSIDERATIONS

The Larger Army During the War

The Soldiers Who Served in Vietnam

The Army Psychiatric Component in Vietnam

A Social Stress and “Disease” Model

Veteran Postwar Adjustment Problems

Final Considerations

SUMMARY

*Colonel, US Army (Retired); 3105-D Stony Point Road, Richmond, Virginia 23235; Clinical Professor of Psychiatry, Department of Psychiatry, Medical 

College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298
10

Combat and Operational Behavioral Health

INTRODUCTION

The US ground war in Vietnam (1965–1972) began 

on March 8, 1965, when over 3,500 men of the 9th 

Marine Expeditionary Brigade made an unopposed 

amphibious landing on the northern coast of the 

Republic of South Vietnam. This was in response 

to intensification in the fighting between South 

Vietnam—an ally of the United States—and indigenous communist forces (Viet Cong guerrillas) and 

those from South Vietnam’s neighbor to the north, 

the Democratic Republic of Vietnam (North Vietnam). 

In early May, the first US Army troops (the 173rd 

Airborne Brigade) arrived in South Vietnam, landing 

at the mouth of the Saigon River at Vung Tau. Thus 

began an enormous military effort by the United 

States and other allies who sought to block the spread 

of communism in Southeast Asia. 

Considering the limited resources of the enemy and 

the superior military might of the United States, it was 

anticipated that the threat could be quickly contained. 

Only belatedly was it discovered that the resolve of 

the communists had been underestimated. The war 

became a drawn out, mostly “low intensity,” “irregular,” counterinsurgency/guerrilla conflict, which 

was far more challenging than expected. The United 

States and its allies had become intractably ensnared in 

Vietnam’s simultaneous and protracted social revolution, civil war, and nationalistic opposition to foreign 

domination. In time, the cost of the war far exceeded 

the tolerance of the American people (over 58,000 

Americans died and over 300,000 were wounded) 

and produced great national agony and incalculable 

cultural aftereffects. Finally, just over 2 years after the 

last US military personnel were withdrawn (March 

29, 1973) under a negotiated truce, North Vietnam 

violated the truce and overran South Vietnam, which 

surrendered on April 30, 1975. 

The war effort also assumed a central role in a 

decade of social and political upheaval in the United 

States—a nightmare that threatened its most basic 

institutions, including the US military. Through the 

second half of the war (1969–1972), an increasing proportion of US troops in Vietnam came to question their 

purpose there. They expressed, in every way except for 

collective mutiny (including psychiatric conditions), 

their inability or unwillingness to accept the risks of 

combat, acknowledge the authority of military leaders, 

or tolerate the hardships of an assignment in Vietnam. 

This all occurred in a setting where combat objectives 

were still in effect, weapons were ubiquitous, violence 

was adaptive, and illicit drugs were effectively marketed and widely used by US troops. The attitudes 

of these young replacement soldiers, most of whom 

were draftees or reluctant volunteers, were strongly 

resonant with the growing opposition to the war in the 

United States. A radicalized, liberal, “counterculture” 

youth movement emerged, along with antagonism 

toward American institutions and, especially, military 

service among younger, black Americans. Facilitative, 

but also emblematic, this dissenting subculture especially rallied around the burgeoning drug culture of 

the times. 

The severe breakdown in soldier morale and 

discipline suffered by the US Army during the drawdown years in Vietnam struck at the heart of military 

leadership. It also overlapped with the mission of 

Army psychiatry. From the outset, the organization 

of psychiatric services in Vietnam was especially 

weighted in favor of the treatment and rehabilitation 

of combat stress casualties. These did not materialize 

in the numbers envisioned, however, and instead 

an unprecedented flood of psychosocial casualties 

emerged. These consisted of disciplinary problems, 

racial disturbances, attacks on superiors, drug abuse, 

and the rising prevalence of soldiers diagnosed with 

character disorders, especially for those in noncombat units and with assignments relatively unrelated 

to combat risks.1

 Military leaders, as well as law enforcement, administrative, and medical/psychiatric 

elements, were all severely tested until the remaining 

US ground forces were withdrawn. 

Following the war, the Army Medical Department 

did not commit to developing a historical summary 

of psychiatry in Vietnam or study these problems for 

“lessons learned.” Furthermore, the Army evidently 

lost, abandoned, or destroyed documentation at the 

conclusion of hostilities that could serve as primary 

source material.2 Vietnam has been referred to as 

America’s first computerized war. Ironically, however, 

the Army apparently emerged from this experience 

with far fewer records pertaining to the provision of 

military psychiatric services than in earlier and less 

“sophisticated” times. In lieu of a more systematic 

approach, this chapter will draw upon the extant 

literature from the war to provide a composite of 

the stressors affecting soldiers sent to Vietnam. It 

will provide an overview of the emergent trends 

in psychiatric conditions and behavioral problems 

faced by Army leaders and the deployed psychiatric 

specialists and their mental health colleagues. It also 

will raise important questions that seem to linger 

despite the three-and-a-half decades since US troops 

left Vietnam—questions for which the answers may 

have considerable bearing for such troops in similar 

wars in the future. 
11

US Army Psychiatry Legacies of the Vietnam War

THE INCOMPLETE HISTORY OF ARMY PSYCHIATRY IN THE VIETNAM WAR

Spanning approximately a decade, from late 1962 

through early 1972, an estimated 135 psychiatrists 

served with the US Army in Vietnam in successive 

cohorts, typically for 1-year assignments.3

 Roughly 

one third of these psychiatrists were trained in Army 

residency programs; the other two thirds received 

their psychiatric education in civilian settings. The 

number of psychiatrists who served in Vietnam was 

considerably fewer than the more than 2,400 psychiatrists who served in World War II. However, those who 

served in Vietnam participated in a war that became 

surrounded with unparalleled social and political 

discord. The associated polarization and tensions of 

the period, especially later in the war, clearly affected 

attitudes within psychiatry and particularly challenged the role and ethics of psychiatry in support 

of the military.

A few publications summarize Army psychiatry 

experience in Vietnam. They primarily focus, however, on observations from the advisor period and 

the buildup phase of the war (1962–1969)3–6 and fail 

to draw sufficient attention to the rampant psychiatric 

and behavioral problems that subsequently developed 

there. Also misleading is the commonly published 

Army psychiatric admission rate for the Vietnam War 

of 12–16/1,000 soldiers per year,7–10 which appears 

quite favorable compared to Korea (28/1,000/y)10 and 

World War II (28–101/1,000/y).11 Utilizing a single 

outcome measure and averaging all 7 years of experience in Vietnam effectively dilutes the 4-fold increase 

in the last few years and minimizes both the breadth 

and the depth of the intersecting morale and psychiatric problems in Vietnam.

In 1975, Jones and Johnson published a preliminary overview of Army psychiatry in Vietnam when 

Johnson was serving as the psychiatric consultant to 

the Office of The Surgeon General, US Army.7

 They 

described common clinical entities and provided gross 

prevalence data, which they associated with changing 

theater circumstances and policy features of the war. 

They left greater detail and synthesis for other accounts 

that, regrettably, failed to materialize. 

Other circumstances also help explain the absence of 

a more complete Vietnam military psychiatry history. 

Until it was forced to study heroin use among soldiers 

late in the war,12–14 the Army undertook relatively 

little formal psychiatric field research in Vietnam after 

regular forces were committed in 1965. Notable exceptions are the study of physiological, psychological, 

and social correlates of stress by Major Peter Bourne, 

Medical Corps, and his colleagues from Walter Reed 

Army Institute of Research (WRAIR), conducted in 

1965 and 1966,15 and the surveys of illegal drug use in 

1967 by RA Roffman and E Sapol,16 and in 1969 by MD 

Stanton.17 Also helpful are publications regarding the 

theater drug abuse epidemic derived from investigative visits to Vietnam late in the war by senior military 

psychiatrists—Colonel Stewart L Baker Jr, Medical 

Corps,18 Colonel Harry C Holloway, Medical Corps,19

and Norman Zinberg, MD, a civilian psychiatrist.20

Anecdotal accounts published by psychiatrists 

who served in the war are also a useful source of 

information.21 Regrettably, some measure of skew is 

introduced because, of the 27 psychiatrists who served 

with the Army and who published accounts, 82% (22) 

were assigned there during the first half of the war 

(1965–1968). Also, of 46 publications from the entire 

group of 24 individuals, half appeared in the US Army 

Vietnam Medical Journal—a nonjuried publication that 

was circulated primarily in Vietnam and ceased publication in 1970. The few articles by psychiatrists who 

served during the drawdown phase of the war when 

psychiatric attrition rates were highest are primarily 

limited to descriptions of local patterns of drug abuse 

or drug treatment programs. 

Besides being generally spotty, the available 

research and historical literature specifically lacks 

validation of the field psychiatric practices and results 

in Vietnam,22 especially the adaptation of the classic 

combat psychiatry “doctrine” (informal) to the irregular, counterinsurgency war that was mostly fought in 

Vietnam and under increasingly controversial circumstances. This chapter will make additional references to 

this doctrine, but it can be summarized as the provision 

of brief, simple, mostly field treatments (eg, safety, rest, 

and physical replenishment); peer support; sedation, if 

necessary; and opportunities for emotional catharsis of 

the soldier’s traumatic events—applied as close to the 

affected soldier’s unit as practical and accompanied by 

expectations that the individual quickly recover, rejoin 

comrades, and reenter the combat situation.23,24

Similar uncertainties surround the use in theater 

of recently developed pharmacologic agents. Vietnam provided military medicine with its first set 

of physicians—especially psychiatrists—routinely 

trained in the use of neuroleptic (antipsychotic), 

anxiolytic (antianxiety), and tricyclic (antidepressant) 

medications. The discovery of these medications 

revolutionized the practice of psychiatry generally; 

they had considerable promise in the management of 

combat stress reactions (CSRs) and other conditions 

in Vietnam. Anecdotal reports indicate that they were 

commonly prescribed throughout the theater for a full 

range of symptoms related to combat stress. A limited 
12

Combat and Operational Behavioral Health

survey in 1967 confirmed their high use by Army 

physicians, including psychiatrists.25 However, there 

were no associated clinical or research studies, and, in 

the aftermath of the war, some have raised questions 

as to whether prescribing psychoactive medications 

for combat-exposed soldiers represented unethical 

medical practice by coercing participation among 

dissenting soldiers.

It is also critical to try to reconstruct the military psychiatry experience in Vietnam to consider the impact 

of the reversal in American approval of the war on the 

clinical decisions of the deployed psychiatrists. Ethical 

and moral reactions to a war and its politics can influence military psychiatrists regarding the diagnosis and 

management of their cases (eg, encourage sympathetic 

overdiagnosis and overevacuation—decisions proven 

in past wars to prolong morbidity in combat-affected 

soldiers).26

In 1982, in an attempt to fill in this missing information, WRAIR queried all veteran Army psychiatrists 

who could be located about their professional experiences in the war. Of the estimated 135 psychiatrists 

who served in Vietnam (133 were men, two were women), 115 were located. Of those, 85 (74%) responded to 

a structured questionnaire exploring patterns of psychiatric problems encountered, types and effectiveness 

of clinical approaches, and personal reactions to the 

associated professional challenges and dilemmas.2,27

Selected study findings will be summarized later in 

this chapter. 

THE WAR’S RATIONALE AND PROVOCATION

To understand how the US government could reach 

a point where it would expend American lives and 

resources to fight a counterinsurgency in Vietnam, 

one must remember that following the end of World 

War II (1945), the United States and its allies soon 

found themselves again in an epic struggle against 

the menace of totalitarianism—this time, Sovietsponsored Marxist communism (the “Cold War”). 

Relations between the two ideological camps were 

typically strained, and a catastrophic nuclear war 

seemed frighteningly possible. For example, between 

1950 and 1953, the United States waged a costly war 

in support of South Korea’s defense against a communist takeover by North Korea. Even closer to home, 

in 1961 the United States came perilously close to 

nuclear war with the former Soviet Union when it 

was discovered that the communist regime of Fidel 

Castro in Cuba had permitted the Soviet placement of 

nuclear missiles on that Caribbean island. The growing perception among Americans was that without 

vigorous opposition by the United States and its allies, 

democracy could be obliterated by a cascade of communist revolutions (the “domino theory”) throughout 

the developing nations of the world, such as those 

in Southeast Asia. Because the United States was a 

signatory of the 1954 Southeast Asia Treaty Organization (with France, the United Kingdom, Thailand, 

Pakistan, Australia, New Zealand, and the Philippines),28 South Vietnam’s struggle to defend itself 

against armed aggression from North Vietnam (in 

violation of the 1954 Geneva Agreement that brought 

an end to the First Indochina War)28 presented a compelling opportunity to draw the line with respect to 

the perceived threat. 

THE SCOPE OF AMERICA’S WAR IN VIETNAM

America’s enemies in Southeast Asia were 2-fold: 

(1) the indigenous Viet Cong guerrilla forces who operated in South Vietnam and who used harassment, 

terrorism, and sabotage as tactics to destabilize the 

government of South Vietnam, and (2) their allies—the 

regular units of North Vietnamese Army, who likewise 

sought a takeover of South Vietnam. 

The pursuit of US military objectives in Vietnam 

became a huge undertaking. The ground war spanned 

over 8 years and by the time the remaining military 

personnel were withdrawn in 1973, 3.4 million American military men and women had served in the theater (typically a single, 1-year assignment), as well as 

offshore with the US Navy and at US Air Force bases 

in Thailand and Guam. When it ended, more than 

58,000 Americans had died (over 47,000 due to enemy 

action or missing in action),29 and more than 300,000 

had been wounded. 

The majority of those who were sent to Vietnam 

served in the Army (60%–80%), thus the majority of 

the casualties also were from the ranks of the Army 

(over 30,000 killed in action [KIA] and over 200,000 

wounded in action [WIA]). Roughly 20% of troops 

actually served in first echelon combat arms, and the 

remainder served in combat support and service support roles. For the most part, Reserve and National 

Guard units were not called up, and the US military, 

especially the Army, resorted to increased conscription 

rates to meet its needs. Although only 25% of the total 

American forces deployed were technically draftees 

(vs 66% in World War II), many more were “draftmotivated” (ie, they enlisted in anticipation of being 
13

US Army Psychiatry Legacies of the Vietnam War

drafted because enlisting improved their chances of 

obtaining a noncombat assignment30(p32)). The average 

age of the Vietnam War soldier was younger (19 years 

old) than those who served in World War II (26 years 

old). They were also better educated than their fathers’ 

generation of soldiers. 

The war in Vietnam is classified as a “limited conventional war” because there were units larger than 

4,000 soldiers operating in the field. However, it became mostly a counterinsurgency war. The war in Vietnam is also referred to as “low intensity” because of the 

low ratio of KIA and WIA to the numbers of personnel 

deployed compared to previous American wars. For 

example, a comparison of the peak years of US Army 

WIA rates during Vietnam (1968 = 120/1,000 troops) 

and Korea (1950 = 460/1,000 troops) suggests a lower 

combat intensity in Vietnam.31 This can be misleading 

because of the smaller proportion of combat personnel compared to those in combat support and service 

support positions in Vietnam (a “tooth-to-tail” ratio 

of 1:5) and the availability of improved medical care. 

According to Ronald Spector, a military historian, 

Men in “maneuver battalions,” the units that actually did the fighting, continued to run about the same 

chance of death or injury as their older relatives who 

had fought in Korea or in the Pacific [in World War 

II]. Indeed, during the first half of 1968, the overall

[author’s italics] Vietnam casualty rate exceeded the 

overall rate for all theatres in World War II, while the 

casualty rates for Army and Marine maneuver battalions were more than four times as high.30(p55)

The data accumulated on the types of wounds sustained in Vietnam are also revealing of the nature of 

combat there. Many more American casualties were 

caused by small arms fire or by booby traps and mines 

than in previous wars, and many fewer were caused by 

artillery and other explosive projectile fragments. 

 At home, an estimated quarter of a million Americans lost an immediate family member to the war. 

South Vietnam’s military casualties numbered 220,357, 

with almost a half million becoming wounded. The 

United States spent $189 billion prosecuting the war 

and supporting the South Vietnamese government. In 

one 12-month period alone—mid-1968 through mid1969, the peak year of US combat activities—America 

and its allies had over 1.5 million military personnel 

deployed (543,000 Americans, 819,200 South Vietnamese, and 231,100 from South Korea, Australia, New 

Zealand, Thailand, and the Philippines combined); 

US forces staged 1,100 ground attacks of battalion size 

or larger (compared to only 126 by the communist 

forces); and there were 400,000 American air attacks 

that dropped 1.2 million tons of bombs, costing $14 

billion.32

AMERICA’S TWO VIETNAM WARS: PRE-TET ’68 AND POST-TET ’68

The American story of the ground war in Vietnam 

should be considered as two Vietnam War stories—

starkly different, sequential stories that pivot on the 

events occurring in 1968. Taken together, these two 

stories portray a dramatic reversal of fortune for 

the United States, a reversal that powerfully shaped 

American culture. 

The Buildup Phase (1965–1967): Lyndon Johnson’s 

War 

Lyndon Johnson was sworn into his first full term 

as President in January 1965, riding the crest of a 

national political consensus and overall prosperity. It 

was only, in the words of Newsweek, that “[n]agging 

little war in Vietnam,”33(p58) that cast a shadow on his 

ambition to create a “Great Society” of social reforms 

as his legacy. Nonetheless, the administration was 

determined to pursue those political agendas as well 

as ensure that South Vietnam did not fall into the communist sphere. 

Preceded by over 10 years of US financial assistance 

and military advisors, US military presence expanded 

rapidly in South Vietnam after the Marine landing 

in 1965. By June 1966, American troops numbered 

285,000, and another 100,000 would be pouring in by 

the end of the year. The number of inductions into the 

US military in 1966 alone was almost 320,000 men, a 

250% increase over the previous year.30

The US Army, Marine Corps, and, in the Mekong 

River Delta, Navy units committed in South Vietnam 

typically found themselves operating in a rugged, 

tropical environment with formidable impediments 

to movement over the ground, extraordinary heat and 

humidity, and monsoonal rains for months at a time. 

Furthermore, combat operations conducted 10,000 

miles from the United States required a very long 

logistical network. These troops also operated among 

an indigenous population of an exotic, Asian culture 

who spoke an exceptionally difficult language for 

Americans to learn. The local Vietnamese appeared to 

tolerate the presence of US troops, but it was common 

for them to be ambivalent about the government of 

South Vietnam and to harbor Viet Cong guerrillas. The 

relationships between US forces and the South Vietnamese were generally strained; US troops regarded 
14

Combat and Operational Behavioral Health

them warily at best.34 US combat units sponsored public relations programs designed to “win the hearts and 

minds” (ie, recruit the loyalty of villagers by providing 

for their welfare and security), but these brought only 

qualified success. 

The combat strategy employed by the US Army 

in the buildup phase in Vietnam was one of attrition 

(body counts and kill ratios),35 primarily through 

search-and-destroy missions initiated from welldefended enclaves. Guerrilla and terrorist operations 

by Viet Cong forces and periodic attacks by North 

Vietnamese regular units were the principle tactics 

of the communist forces. As a consequence, military 

engagements more often involved clashes between 

highly mobile, small tactical units as opposed to battles 

between major military formations. Furthermore, US 

successes were limited because the Viet Cong guerrillas were elusive, dictated the tempo of the fighting, 

and too often were content to snipe, set booby traps, 

and stage ambushes. Their hit-and-run tactics allowed 

them to fade safely into the jungle or into the local 

populace if the fight turned against them—tactics 

ingrained in their culture from centuries of guerrilla warfare against foreign invaders. US forces were 

more likely to find themselves in conventional war 

engagements against regular North Vietnamese divisions in the northern provinces. However, even these 

main force units more often than not staged combat 

initiatives from behind the safety of the 17th parallel 

demilitarized zone that separated North Vietnam from 

South Vietnam, thereby eluding pursuit by US units 

and their allies. Consequently, most combat activity for 

US forces involved brief encounters between isolated, 

small units—a war of no fronts. A Joint Chiefs of Staff 

study reported that of all the US patrols conducted in 

1967 and 1968, less than 1% resulted in contact with 

the enemy.35 Still, when there was contact, the fighting 

was as bloody and intense as any that had occurred 

during World War II. US forces did periodically stage 

larger scale operations during this phase of the war, 

and some elements of these engagements exacted 

heavy tolls on the enemy. 

The US military in the late 1960s enjoyed remarkable technological advantages in Vietnam. Weaponry 

was a prime example. Whether carried with them 

into the field, or employed as tactical support from air 

strikes or artillery, field commanders could bring to 

bear formidable firepower on the enemy. If the enemy 

began to outnumber an allied force in an engagement, 

close support from the air or from artillery quickly reversed the equation. Another element of US technical 

superiority in Vietnam was that of air mobility—the 

ubiquitous helicopter. This was unprecedented in US 

warfare and allowed reconnaissance and ordnance 

delivery from the air, heliborne movement of troops for 

tactical advantage, timely evacuation of the wounded, 

and frequent resupply. In fact, the first full US Army 

combat division to be sent to Vietnam was the 1st 

Cavalry Division (Airmobile).

US Army Medical and Psychiatric Support

A third element in the Vietnam theater that greatly 

enhanced life for the US combat soldier in Vietnam was 

the outstanding medical support available. From the 

outset of the war, the US military made every effort to 

ensure that troops received timely, sophisticated medical attention, including psychiatric care, despite the 

hostile physical environment and Vietnam’s geographical remoteness. The build up of Army medical units 

was completed in 1968 when 11 evacuation, 5 field, and 

7 surgical hospitals were in place. These facilities, plus 

the 6th Convalescent Center in Cam Ranh Bay, brought 

the total bed capacity in South Vietnam to 5,283.31 Most 

importantly, the new helicopter ambulance capability 

also permitted rapid evacuation of the wounded to 

the most appropriate level of medical care. As far as 

physical casualties, these efforts achieved remarkable 

success throughout the war. Comparing the ratio of 

KIA to WIA across wars attests to the superiority of 

medical care provided in Vietnam (World War II, 1:3.1; 

Korea, 1:4.1; and Vietnam, 1:5.6).31

The Organization and Preparation of Army Psychiatrists for Vietnam 

Once the mobilization was under way in 1965, 

Army psychiatrists and allied mental health personnel were rapidly assigned and widely distributed 

throughout the theater. This peaked during the 4 fullstrength years (1967–1970) when approximately 23 

Army psychiatrist positions per year were available. 

In planning to fight in Vietnam, the Army Medical 

Department assumed that the greatest psychological 

threat to the force would be the “breaking point” of 

soldiers exposed to sustained enemy fire (eg, “combat 

exhaustion”—now labeled “combat stress reaction”). 

In anticipating large numbers of these casualties, 

they not only promulgated the treatment philosophy 

developed and refined in World War II and Korea 

(doctrine described earlier),8 they also established 

policies and organizational structures36 borrowed from 

those earlier engagements—a system that weighted 

the psychiatric assets in favor of combat units, even 

though combat-exposed troops would represent less 

than 20% of the Army deployed in South Vietnam.30

Military planners were not only confident that this 

system would promote the conservation of military 
15

US Army Psychiatry Legacies of the Vietnam War

strength, they also believed that it would reduce 

morbidity in affected soldiers. This system centered 

upon assignment of psychiatrists to either a combat 

unit, typically as a division psychiatrist, or to a combat 

service support medical unit, typically a hospital (or 

specialized psychiatric detachment). 

Assignment as a Division Psychiatrist. Throughout the war only the combat divisions (composed of 

15,000–20,000 soldiers), that is, their medical battalions, 

had their own, directly assigned (eg, “organic”) psychiatrists (along with allied mental health personnel). 

The rationale was to embed mental health personnel 

within combat units to provide psychiatric treatment 

capability as far forward as could practically be accomplished.7

 It also permitted the psychiatrist to serve as a 

staff officer of the command of the division and thereby 

provide timely advice on matters affecting morale and 

mental health (eg, “command consultation”).

Assignment as a Hospital Psychiatrist. Alternatively, psychiatrists (along with allied mental health 

personnel) were assigned to Army-level hospitals or to 

the two specialized medical/psychiatric detachments 

(98th and 935th) in Vietnam. They functioned more 

often in a clinical role, and their command authority 

was from higher levels of Army medical command in 

Vietnam (ultimately the US Army Medical Command, 

Vietnam, or USAMEDCOMV, as it came to be called). 

The first priority for these psychiatric elements was 

to provide inpatient treatment for referrals from the 

combat divisions or other primary care facilities. In 

the case of the specialized psychiatric detachments 

(“KO teams” [the “KO” arbitrarily indicated that 

these were hospital augmentation detachments]), 

they offered more extended hospitalized care (up to 

30 days) as well as serving as staging centers for outof-country evacuations for soldiers needing additional 

care. The mission for hospital psychiatrists and their 

mental health colleagues also included the provision 

of outpatient care (eg, the Mental Health Consultation 

Service) for the soldiers from nondivisional (primarily noncombat) units on a regional basis. However, 

because these mental health assets were not part of 

the command structure of these units, mental health 

“command consultation” was far less predictable than 

would be the case in the combat divisions. 

One psychiatrist slot was allocated to each of the 

seven full combat divisions deployed in Vietnam, as 

well as one each to the evacuation and field hospitals. 

These were filled depending on anticipated need and 

psychiatrist availability. In addition, throughout most 

of the war, the two Army neuropsychiatric specialty 

centers were operational and each was to be staffed 

with three psychiatrists. Furthermore, each year of 

the war a senior psychiatrist was to serve in a staff 

position with US Army Vietnam Headquarters as the 

Neuropsychiatric Consultant to the Commanding 

General, United States Army Republic of Vietnam 

(CG/USARV) Surgeon. The central task of the Consultant was to direct the coordination of psychiatric 

facilities and program planning, which required extensive travel throughout Vietnam to visit psychiatrists 

and programs, to provide clinical leadership, and to 

serve as consultant to senior military leaders about 

psychiatric issues. 

The training and indoctrination provided for physicians, including psychiatrists, who would be assigned 

in Vietnam also centered on the limits of soldiers in 

combat, the causes of breakdown under sustained fire 

(social, physical, and emotional), and the prevention 

or management of large numbers of combat-generated 

psychiatric casualties as were encountered in the wars 

preceding Vietnam. This was the case in the Army’s 

two psychiatric residency-training programs (Walter 

Reed General Hospital, Washington, DC, and Letterman General Hospital, San Francisco, California) 

where the principles of prevention and treatment of 

combat breakdown were emphasized in the curricula. 

It was also the case regarding newly commissioned, 

civilian-trained psychiatrists who would be assigned 

in Vietnam. They received their primary orientation to 

military psychiatry at the Army’s Medical Field Service 

School, which was located at Fort Sam Houston in San 

Antonio, Texas. This preparation included only a few 

hours of didactic instruction in military psychiatry, 

and this was primarily regarding the pathogenesis, 

symptoms, and management of combat exhaustion37

and the organization of psychiatric services within the 

combat division.38

The Relative Infrequency of Classic Combat Exhaustion Casualties in Vietnam

In time it became evident that the large numbers of 

combat exhaustion casualties that were predicted and 

planned for in Vietnam never materialized. The only 

overview of the psychiatric problems in the Vietnam 

War, published by Jones and Johnson, did not report 

theater-wide incidence statistics for combat exhaustion 

specifically,7

 although they were apparently collected 

by USAMEDCOMV.9 Although these authors attested 

to the fact that the incidence throughout the war was 

“extremely low,”7(p53) Jones and Johnson added some 

confusion by referring to all hospitalized psychiatric 

patients in Vietnam as “combat psychiatric casualties.” 

They also acknowledged that disagreements as to 

diagnostic criteria produced major problems in collecting and comparing incidence statistics for combat 

exhaustion in Vietnam, or even between wars. Boman, 
16

Combat and Operational Behavioral Health

an Australian psychiatrist, provided corroboration in 

his postwar analysis of military psychiatry practices in 

Vietnam. He illustrated significant diagnostic confusion in the literature, and he posited that US military 

psychiatrists systematically, if inadvertently, mislabeled combat-generated psychological problems as 

character disorders, resulting in inappropriate administrative or disciplinary dispositions as well as spuriously lowering apparent incidence rates.39 Finally, the 

only official summary of US Army medical experience 

in Vietnam (covering the war up through May 1970, 

two thirds into the war), which was authored by Major General Spurgeon Neel, does not mention combat 

exhaustion or any other forms of combat-generated 

psycholopathology.31

Also hampering the collection of data regarding 

combat exhaustion casualties in Vietnam was the fact 

that, by definition, it is a reversible, stress-generated, 

psychosomatic regression that, when treated early and 

effectively, typically remits within a couple of days. As 

a consequence, many cases would have been treated 

at lower echelons of medical care and thus not be included in hospitalization rates.40,41

Approximations of CSR incidence measures in 

Vietnam came in the form of comparisons of the 

number of hospitalized CSR cases with those for other 

psychiatric conditions. The overview by Colbach and 

Parrish of US Army mental health activities in Vietnam 

through the first two thirds of the war reported 7% 

of all psychiatric admissions were diagnosed as CSR, 

but unfortunately they did not include data sources.6

A smaller window, but one with more specific data, 

is provided by Major Peter Bourne, Medical Corps, 

Chief, Neuropsychiatry, WRAIR Medical Research 

Team in Vietnam (1965–1966). While comparing US 

Army psychiatric hospitalization rates in Vietnam 

with those of the Army of the Republic of Vietnam 

during the first 6 months of 1966, Bourne found 6% 

of US Army psychiatric admissions were diagnosed 

as combat exhaustion.9

 Captain HSR Byrdy, Medical 

Corps, division psychiatrist (1965–1966) with the 1st 

Cavalry Division (Airmobile) reported a true CSR rate 

for his division of 1.6/1,000 troops per year; however, 

he also comments, “What gets referred [to the division 

psychiatrist] depends on the tactical situation of the 

unit [and] one is hard-pressed to know what a real 

incidence is.”41(p50) Still, these figures are consistent 

with an unusually low incidence, at least for the first 

half to two thirds of the war. In addition, in a postwar 

survey of psychiatrists who served with the Army in 

Vietnam, 32% reported that they had only rare exposure to combat-induced psychiatric casualties.27

All this is not to say that the specialized treatment 

of combat exhaustion was not an important challenge in Vietnam; just that it was never at the level 

(numbers) that had been anticipated, and that in time 

it was greatly overshadowed by other unanticipated 

psychiatric conditions and behavior problems.

Morale in the Buildup Phase: Consensus at Home 

and Esprit in Vietnam

During the war’s first 3 years, opposition at home 

was only gradually building, whereas draft call-ups 

quickly gathered momentum to meet the huge personnel needs in Southeast Asia. Because reserve units and 

the National Guard were, for all practical purposes, 

exempted from deployment in Vietnam throughout 

the war, the ground forces were composed of a mix 

of career soldiers, draftees, and volunteers (including many draft-motivated volunteers). Although the 

combat could at times be very intense during these 

initial years, and the cities and countryside were not 

secure, morale and sense of purpose remained high 

among the troops fighting in Vietnam. Furthermore, 

attrition due to psychiatric or behavioral problems was 

exceptionally low compared to previous conflicts. This 

was somewhat surprising considering the psychologically depleting nature of the remote, exotic, hostile, 

tropical setting and the enemy’s guerrilla tactics and 

resolute tenacity.42

Throughout the war, soldiers fighting in Vietnam 

encountered certain novel features that distinguished 

the theater from those of previous wars and invariably 

affected morale. For example, the battlefield ecology 

was powerfully affected by the helicopter mobility of 

US ground forces; the enemy’s elusiveness but lack 

of a capacity to deliver sustained, precision-guided 

indirect fire (as with artillery and combat aircraft); and, 

especially, the overall US strategy of fighting a war of 

attrition as opposed to one for territorial control. The 

psychosocial complexion of the “rear” was unique. 

US troops typically staged combat activities from geographically isolated, fixed, relatively secure enclaves 

that were easily resupplied by helicopter. The high 

ratio of combat support and service support troops 

to combat troops (5:1) was also unusual compared to 

earlier wars. 

Efforts to understand soldier stress and resilience in 

Vietnam also have to take into account the influence 

of the draft (stress inducing) as well as the effect of 

the military’s replacement policy of individualized, 

1-year tours. The 1-year tour was intended to be stress 

reducing because these soldiers would perceive their 

obligation and risk as limited.9,31 However, over time 

the resultant churning and ultimate depletion of experienced military personnel in the theater (including 

officers and noncommissioned officers [NCOs]) also 
17

US Army Psychiatry Legacies of the Vietnam War

had a hugely negative effect on commitment and cohesion, and consequently morale.29,30

Still, according to General Westmoreland, Commander, US Military Assistance Command, Vietnam 

(COMUSMACV), the troops operating in Vietnam during the buildup years were “the toughest, best trained, 

most dedicated American servicemen in history.”43(p34)

More specific to the Army in Vietnam, Retired Brigadier General SLA Marshall, combat veteran of World 

War I and front-line observer in World War II and 

Korea, commented after his extended visit in 1966: 

My overall estimate was that the morale of the troops 

and the level of discipline of the Army were higher 

than I had ever known them in any of our wars. 

There was no lack of will to fight and the average soldier withstood the stress of engagement better than 

ever before.43(p34)

The observations and interpretations by military 

sociologist Charles Moskos from his time in Vietnam 

as a war correspondent between 1965 and 1967 are 

especially useful in understanding the morale, stress, 

and psychosocial adaptations of the soldiers serving 

in those initial years. Moskos reported high morale 

and combat motivation despite the rigors of the counterinsurgency warfare and the extremely inhospitable 

setting. He believed this arose out of the linkage between the soldiers’ individual self-concern (heightened 

because of the 1-year, individual rotation system) and 

devotion to the other soldiers in the immediate combat 

group (eg, instrumental interdependencies motivated 

by the functional goal of survival). He also observed 

their shared belief in an exaggerated masculine ethic 

as well as a “latent ideology” of devotion to US ideals, which stemmed from their conviction regarding 

the supremacy of the US way of life. Furthermore, 

the soldiers he studied were notably apolitical and 

antagonistic toward peace demonstrators (“privileged 

anarchists”) at home.44

Psychiatric investigator Bourne’s comments from 

his year in Vietnam are also illuminating. He reported 

that soldiers in these early years maintained a positive 

motivation in part through what he labeled “combat 

provincialism.” 

They are not only unconcerned about the political 

and strategic aspects of the war; they are also disinterested in the outcome of any battle that is not in 

their own immediate vicinity. . . . [The soldier] retains 

certain deep allegiances and beliefs in an . . . amorphous positive entity, “Americanism,” which allow 

him to justify his being sent to Vietnam.9(p44)

Bourne especially credited the fixed, 1-year tour for 

soldiers for the continued high morale, but he also 

expressed concern for its consequent disturbance to 

the “solidarity of the small unit”—the traditional stress 

protection system for combat soldiers.

Buildup Phase Psychiatric Overview

Correlating with the observations of high esprit 

and commitment, troop attrition due to psychiatric or 

behavioral dysfunction was exceptionally low as well 

during those first few years. The proportion of medevacs out of Vietnam for psychiatric reasons (3%–4%) 

compared quite favorably with that for the Korean 

conflict (6%) and for World War II (23%).23 Rates for deviant behaviors for the same period were also low (eg, 

the annual stockade confinement rate was 1.15/1,000, 

compared to the expected overseas rate of 2.2).4 Some 

senior Army psychiatric observers attributed this to 

an array of operational and preventive factors that 

appeared to protect the soldiers from psychiatric and 

behavioral difficulties: (a) technological superiority 

and the professionalism of the troops; (b) fixed, 1-year 

assignments; (c) high-quality leadership; and (d) adequate supplies, equipment, and support—especially 

medical support.7,23,45,46 Others also credited the application of the aforementioned doctrine of combat 

psychiatry.47,48

Although alcohol use and abuse was predictably 

a common stress outlet for these soldiers,7 military 

leaders and the psychiatric contingent were primarily concerned with the use of illegal drugs by troops, 

especially the locally grown marijuana, which was 

readily available and highly potent. In their survey 

regarding drug use patterns of 584 lower ranking 

enlisted soldiers departing Vietnam in 1967, Roffman 

and Sapol reported that of the 32% who acknowledged 

ever smoking marijuana, 61% began in Vietnam and 

one quarter were considered heavy users (greater 

than 20 times during their 1-year tour in Vietnam). 

The authors concluded that the extent of marijuana 

use in Vietnam was very similar to that among civilian peers.16 Furthermore, in the opinion of Bourne, 

marijuana use created almost no psychiatric problems.9

Use of opiates was also reported in Vietnam, but it was 

not as pure as that sold after 1970 and was not used by 

soldiers in sufficient numbers to constitute a serious 

problem for command.17

One psychological phenomenon that did attract a 

fair amount of attention from military psychiatrists 

was the phasic nature of moods and attitudes affecting soldiers during the course of their 12-month tour 

of duty in Vietnam: (a) “immersion shock” and fearfulness; (b) then mastery and reduced preoccupation 

with home, but with some depression, resignation, 
18

Combat and Operational Behavioral Health

and flight into a “hedonistic psuedocommunity”; 

(c) followed by growing combat apprehension and 

a “short-timers syndrome.”7,49,50 The latter refers to a 

low-grade form of disability often exhibited in combat 

soldiers who were within 4 to 6 weeks of their date of 

expected return from overseas (DEROS). Symptoms 

consisted of reduced combat tolerance and efficiency; 

increasing fear about being killed or wounded; and 

sullen, irritable, or withdrawn behavior. This had also 

been noted among troops serving in the Korean War 

after fixed, individualized tours were first introduced 

there in mid-1951.51

Overall, the incidence of psychiatric and behavioral difficulties among the deployed Army troops 

in Vietnam in these initial years was held to levels no 

greater than if they were still stateside. Satisfaction 

was expressed that adequate psychiatric resources had 

been deployed from the start in contrast to previous 

wars.3,8 To that effect, Bourne confidently, if prematurely, declared the end of the military-medical problem of combat psychiatric casualties: “The Vietnam 

experience has shown that we have now successfully 

identified most of the major correlates of psychiatric 

attrition in the combat zone.”47(p487)

Buildup Phase Psychiatrist Reports

The morale and confidence of the deployed Army 

psychiatrists during these early years also appeared to 

be high. This is suggested both in the large numbers 

who were inspired to publish professional accounts 

and the role satisfaction that these reports reveal. 

Taken together, these psychiatrists reflect optimism 

and tout the effectiveness of the traditional doctrine of 

combat psychiatry in Vietnam, the utilization of newly 

developed pharmacologic agents (anxiolytics and 

neuroleptics), and the extension of principles of social 

psychiatry to military leaders (command consultation). 

Simply scanning selected titles provides an impression 

as to the predominant psychiatric challenges faced 

through these early years in the war (Exhibit 2-1).

More specific to the growing antiwar sentiment in 

the United States, two Army psychiatrists who served 

in the buildup phase and published accounts, Captain 

AS Blank Jr and Captain HS Bloch, commented specifically that they did not believe the growing opposition 

to the war was significantly affecting their patients. 

Blank, who served early in this phase (1965–1966), 

commented, 

Do the ambiguities of the war seem to be a problem 

for the soldiers? The answer is very simply, “No.” I 

did not see a single patient in whom I felt that any 

kind of conflict about the war on any level was primary in precipitating his visits to me.41(p58)

Bloch, who served 2 years later (1967–1968) in the 

same area as Blank, asserted that in his experience, 

soldiers who struggled with concerns regarding the 

morality of the conflict typically were driven by preVietnam psychological conflicts.40 Nonetheless, considering what followed, it is apparent that time was 

running out on positive morale in Vietnam. 

The Transition From Buildup to Drawdown 

(1968–1969)

1968 Surprise “Tet” Offensives and Perceptions of a 

Lost War

The year 1968 was the bloodiest year in Vietnam 

for US forces (16,592 KIA), and events both at home 

and in Southeast Asia served as the tipping point in 

US sentiment for pursuing military objectives there. 

During the month of May alone, 2,000 Americans 

were killed—the highest monthly death toll of the 

war.52 June 13th marked the day that Americans had 

been fighting in Vietnam longer than any prior war. 

However, the greatest negative effect arose from the 

enemy’s “Tet” offensives. 

On the morning of January 31st, communist guerillas broke the Tet (or Lunar New Year) truce and 

launched coordinated attacks on cities and towns 

throughout South Vietnam. Although they were 

ultimately extremely costly to the communist forces 

and achieved little militarily, their political yield was 

enormous. Many held the US media accountable for 

misinterpreting these events as signaling a US defeat 

and provoking a reversal in public and political support for war.53 Nonetheless, these attacks, as well as 

the month-long, bloody battle to retake Hue and the 

prolonged siege of the Marine base of Khe Sanh, created the indelible perception in the United States that 

the war could not be won. The enemy appeared to defy 

the Johnson administration’s assurances of imminent 

defeat, and nowhere in the country seemed secure 

despite great expenditures of lives and money. As a 

consequence, calls for the war to end became urgent 

and trumped most other considerations. 

On March 31, 1968, President Johnson announced 

that he would halt the bombing over North Vietnam 

as a prelude to peace negotiations. He also declared 

that he would not seek reelection in service of that end. 

Ten days later he announced that General Creighton 

Abrams would relieve General William Westmoreland, the original commander, United States Military 

Assistance Command, Vietnam (USMACV). Still, it 

wasn’t until a year later, mid-1969, that the first Army 

units pulled out of South Vietnam. America had begun to disengage, yet the fighting continued amid 

tortuous peace negotiations, continued assignment 
19

US Army Psychiatry Legacies of the Vietnam War

EXHIBIT 2-1

SELECTED PUBLICATIONS BY BUILDUP-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1965 1/7 (14.2%) Huffman RE. Which soldiers break down: a survey of 610 psychiatric patients in Vietnam. Bull Menninger Clin. 1970;34:343–351.

Bourne PG. Urinary 17-OHCS levels in two combat situations. In: Bourne 

PG, ed. The Psychology and Physiology of Stress: With Reference To Special 

Studies of the Viet Nam War. New York, NY: Academic Press; 1969: 95–116. 

Research report. 

1966 6/16 (37.5%) Conte LR. A neuropsychiatric team in Vietnam 1966–1967: an overview. In: 

Parker RS, ed. The Emotional Stress of War, Violence, and Peace. Pittsburgh, 

Penn: Stanwix House; 1972: 163–168.

Johnson AW. Psychiatric treatment in the combat situation. US Army Vietnam 

Med Bull. 1967;January/February:38–45. 

Jones FD. Experiences of a division psychiatrist in Vietnam. Mil Med. 

1967;132:1003–1008.

Dowling JJ. Psychological aspects of the year in Vietnam. US Army Vietnam 

Med Bull. 1967;May/June:45–48.

Tischler GL. Patterns of psychiatric attrition and of behavior in a combat 

zone. In: Bourne PG, ed. The Psychology and Physiology of Stress: With Reference to Special Studies of the Viet Nam War. New York: Academic Press; 1969: 

19–44. 

Kenny WF. Psychiatric disorders among support personnel. US Army Vietnam Med Bull. 1967;January/February:34–37.

1967 12/22 (54.6%) Roffman RA, Sapol E. Marijuana in Vietnam: a survey of use among Army 

enlisted men in two southern corps. Int J Addict. 1970;5:1–42. Research 

report.

Anderson JR. Psychiatric support of the 3rd and 4th Corps tactical zone. US 

Army Vietnam Med Bull. 1968;January/February:37–39.

Baker WL. Division psychiatry in the 9th Infantry Division. US Army Vietnam 

Med Bull. 1967;November/December:5–9.

Bloch HS. Brief sleep treatment with chlorpromazine. Comp Psychiatry. 

1970;11:346–355.

Bostrom JA. Management of combat reactions. US Army Vietnam Med Bull. 

1967;July/August:6–8.

Casper E, Janacek J, Martinelli H. Marijuana in Vietnam. US Army Vietnam 

Med Bull. 1968;September/October:60–72.

Evans ON. Army aviation psychiatry in Vietnam. US Army Vietnam Med Bull. 

1968;May/June:54–58.

Fidaleo RA Marijuana: social and clinical observations. US Army Vietnam Med 

Bull. 1968;March/April:58–59.

Gordon EL. Division psychiatry: documents of a tour. US Army Vietnam Med 

Bull. 1968;November/December:62–69.

Motis G. Psychiatry at the battle of Dak To. US Army Vietnam Med Bull. 

1968;March/April:57.

Pettera RL, Johnson BM, Zimmer R. Psychiatric management of combat reactions with emphasis on a reaction unique to Vietnam. Mil Med. 

1969;134:673–678.

Talbott JA. The Saigon warriors during Tet. US Army Vietnam Med Bull. 

1968;March/April:60–61.

*These numbers do not count research reports, although they are listed in the Publications column.
20

Combat and Operational Behavioral Health

of replacement troops (albeit in decreasing numbers 

after mid-1969), and a progressively confrontational 

antiwar/antimilitary faction stateside. The war took on 

characteristics of a tedious, agonizing stalemate, and 

the lack of tangible measures of progress contributed 

to the widespread feelings of futility and frustration 

about the war.

Emerging Demoralization and Dissent

The contentious and protracted counterinsurgency 

war soon started to have corrosive effects on successive 

cohorts of replacements sent to fight there. Budding 

demoralization and dissent during these pivotal years 

began to reveal itself especially in racial incidents and 

widening drug use (particularly marijuana, but also 

commercially marketed stimulants and barbiturates) 

by soldiers. Law enforcement figures demonstrated 

an increase of over 260% in the number of soldiers 

involved with possession or use of marijuana during 

1968 as compared to the previous year.30 Also, excessive combat aggression (atrocities) seemed to become 

more prevalent.54–57 According to Ronald Spector, 

who served as a Marine field historian in Vietnam 

(1968–1969), 

as the war ground on through its third and fourth 

year, the prestige of performing a mission well proved 

increasingly inadequate to men who more and more 

could see no larger purpose in that mission, and no 

end to the incessant patrols, sweeps, and ambushes 

which appeared to result only in more danger, discomfort, and casualties.30(p61)

Spector also noted that the evolving stalemate in 

Vietnam came to resemble the bloody trench warfare 

of World War I, a battle in which both sides grossly 

underestimated the other.30(p314)

Journalist Donald Kirk reported from the field in 

1969 that 

[t]he attitudes of GIs [slang for “government issue”] 

did not turn seriously until Fall of 1968 when President Johnson stopped the bombing of North Vietnam and agreed to enter into peace talks . . . .The 

change in [soldier] attitudes was so sudden . . . [as 

compared to earlier] they by and large applauded the 

[antiwar] demonstrators . . . the senselessness of the 

struggle.58(p61)

Correspondent JP Sterba provides observations 

on the shifting demographics and particularly the attitudes of the soldiers who went to fight in Vietnam 

in 1969. He demonstrated how the rapidly unfolding political events in the United States caused the 

romance and idealism of the early war to be replaced 

by a “hated, dreary struggle” in which the soldier’s 

overriding preoccupation was that of self-protection: 

These were the grunts of the class of 1968—they had 

come out of that America some of their commanders had seen only from the windows of the Pentagon. 

They were the graduates of an American nightmare 

in 1968 that stemmed mostly from the war they had 

now come to fight—the year of riots and dissention, 

of assassinations and Chicago, the year America’s ulcer burst.59(p447)

Transition Phase Psychiatric Overview

The official summary of US Army medical experience in Vietnam through May 1970 made note of rising 

annual incidence rates for psychiatric conditions beginning in 1969 (from 13.3/1,000 for 1968, to 25.1/1,000 

through first quarter of 1970). It also underscored that 

this increase did not covary with the dropping rates 

for WIA, the traditional measure of combat intensity—

a correlation that had been true in previous wars.31

The principle author of this report, Major General 

Spurgeon Neel, attributed this uncharacteristic rise in 

psychiatric disorders to dissenting soldier subgroups 

who were motivated by racial, political, or drug culture 

priorities, and to the widening use of illegal drugs by 

soldiers in Vietnam. However, because this review only 

encompassed the first two thirds of the war and was 

not published until 1973, after the troops were withdrawn, it failed to illuminate the fuller, more ominous 

picture in a timely fashion. 

Published more contemporarily in 1970, the Army 

Psychiatry Consultant to the Surgeon General, Colonel 

Matthew Parrish, and the Assistant Consultant, Major 

Edward Colbach, both of whom had served in Vietnam, did broadcast their concern about the rise in the 

psychiatric casualty rate in Vietnam up through mid1970. In their opinion this was a consequence of the 

increase in racial tensions and the general decrement 

in perception of military purpose within the soldier. 

They correctly predicted that the intent to disengage 

from Vietnam would likely produce accelerating 

psychiatric problems among those newly assigned 

there.6

 However, despite this warning, there were no 

structural changes in the organization of mental health 

assets in Vietnam nor modifications in the selection, 

preparation, or deployment of mental health personnel 

sent as replacements to the theater. 

MD Stanton17 reported sizable increases in the use of 

most drugs from a survey of drug use patterns among 

soldiers entering or departing Vietnam in late 1969, 

which he compared with results from the 1967 survey 

by Roffman and Sapol. Stanton speculated, however, 

that marijuana and some other drugs might actually 
21

US Army Psychiatry Legacies of the Vietnam War

allow certain types of individuals to function under 

the stresses of a combat environment and separation 

from home. 

As far as comparisons with the US Marines fighting 

in Vietnam, Lieutenant Commander JA Renner Jr, a 

Navy psychiatrist who served in the Vietnam theater 

in 1969, noted a similar rise regarding disciplinary 

problems, including racial disturbances, attacks on 

superiors, drug abuse, and the number of men diagnosed with character disorders (“hidden casualties”). 

He expressed his concern that military psychiatrists 

were premature in touting the low rate for psychiatric 

difficulties in the war.60 (He did not publish until 1973, 

after the Marines had left Vietnam.)

Transition Phase Psychiatrist Reports

Army psychiatrists serving in these years were 

mostly not inspired to publish accounts of their professional experience in Vietnam compared to those 

who served in the buildup phase. Indeed, the titles 

suggest increasing attention to challenges surrounding 

GI drug use and other morale issues and away from 

combat-related problems. Still, dissent within the ranks 

appears not to be a subject of major concern by these 

psychiatrists (Exhibit 2-2).

The Drawdown Phase (1969–1972): Richard Nixon’s 

War 

The second half of the war took on a starkly different character from the first half. By January 1969, 

when President Nixon succeeded President Johnson, 

the United States had been at war in Vietnam for 4 

years. Nixon promised “peace with honor,” negotiations with the enemy, and a gradual withdrawal of 

troops, while confronting extreme impatience and 

often violent protest in America.61 With the change of 

command in Vietnam, the military strategy of attrition 

shifted to a defensive one that sought area security 

and “Vietnamization” of the fighting. Enemy offensive 

activity also slackened. Overall US troop strength in 

Vietnam peaked at 543,400 in mid-1969 and declined 

through the next 3 years until all combat forces were 

EXHIBIT 2-2

SELECTED PUBLICATIONS BY transition-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1968 3/22 (13.6%) Colbach EM, Crowe RR. Marijuana associated psychosis in Vietnam. Mil 

Med. 1970;135:571–573.

Colbach EM, Willson SM. The binoctal craze. US Army Vietnam Med Bull. 

1969;March/April:40–44. 

Forest DV, Bey DR, Bourne PG. The American soldier and Vietnamese 

women. Sex Behav. 1972;2:8–15.

Postel WB. Marijuana use in Vietnam: a preliminary report. US Army Vietnam 

Med Bull. 1968;September/October:56–59. 

1969 2/22 (9.1%) Bey DR. Change in command in combat: a locus of stress. Am J Psychiatry. 

1972;129:698–702.

Bey DR, Smith WE. Organizational consultant in a combat unit. Am J Psychiatry. 1970;128:401–406.

Bey DR, Zecchinelli VA. Marijuana as a coping device in Vietnam. Mil Med. 

1971;136:448–450. 

Master FD. Some clinical observations of drug abuse among GIs in Vietnam. 

J Kentucky Med Assn. 1971;69:193–195.

Stanton MD. Drug use in Vietnam. Arch Gen Psychiatry. 1972;26:279–286. 

Research report.

*These numbers do not count research reports, although they are listed in the Publications column.
22

Combat and Operational Behavioral Health

withdrawn. US operations of battalion size or larger 

slowly began to decline beginning in mid-1968.62 Still, 

despite the reduction of combat operations and the 

peace negotiations, which proceeded erratically, US 

service personnel continued to die there (15,316 from 

1969–1972). 

In 1969, the US public was horrified to learn that 

in 1968 several hundred Vietnamese civilians of the 

hamlet of My Lai had been massacred by a US Army 

unit.63 Although there had been previous reports of 

atrocities by US troops, this incident seemed to verify 

the public’s worst fears about the war being senseless 

and destructive.

“America’s war” had become prolonged, stalemated, 

and costly; the sense of national purpose and resolve 

was dropping fast. Furthermore, the abandonment of 

hopes for military victory in Vietnam had a powerfully 

negative effect on the country, the institution of the US 

Army,64–66 and especially those whose fate it would be 

to serve during the drawdown in Vietnam and who 

would be required to fight battles of disengagement 

amid pressures from home to oppose the war and the 

military.62 Simultaneously waging war and pursuing a 

peace with the enemy undermined the commitment of 

these soldiers compared to those deployed in the first 

few years of the war. This commitment was replaced 

with alienation, disaffection, and sagging morale. In 

retrospect, gradually rising rates for psychiatric conditions and behavior problems during 1968 and 1969 

signaled a brewing discontent and dissent within the 

ground forces deployed on a massive scale. 

Cultural Polarization in America and the Vietnam 

War

To fully understand the psychosocial forces affecting the soldiers sent to Vietnam, one must appreciate 

the powerful and often clashing cultural crosscurrents 

in the United States that surrounded them in the late 

1960s and early 1970s. This history must be viewed 

against the backdrop not only of the nation’s post–

World-War-II experience and subsequent Cold War 

tensions between the United States and the former 

Soviet Union, but also of the advent of television coverage of the war, the assassination of President John 

Kennedy in 1963, and the coming of age of the post–

World-War-II “baby boom” generation. 

The years surrounding the Vietnam War (1965–

1975) represented an excruciatingly volatile period in 

American life. Intense and often militant challenges to 

government institutions, especially the military and 

the war in Vietnam, were increasingly made by: (a) a 

progressively disapproving American public, (b) the 

rising civil rights and black pride movements, and (c) 

the emerging New Left and a dissenting youth counterculture (the “generation gap”). They, in turn, were opposed by an equally fervent and reactive conservative 

sector. The prolonged, costly war in Vietnam served as 

a rallying point, both pro and con, for their passions 

and ambitions. These three movements, fostered by 

an expanding drug culture, variously fed and were 

fed by a widening crisis within the military overall 

(unprecedented demoralization and alienation), and in 

Vietnam especially. As they synergistically intersected, 

they generated a groundswell of opposition to military 

service among draft-eligible men.

Public Opposition to the War and Political Activism. Over the course of the war larger and louder 

antiwar protest rallies, marches, and demonstrations 

took place in the United States, with some reaching the 

level of riots. The new television coverage of the war 

brought the costs and the political turmoil in Vietnam 

straight into the living rooms of US citizens and most 

likely accelerated the public’s perception that the war’s 

justification was questionable, despite reassurances 

from both the Johnson and Nixon administrations. 

The steadily growing public disapproval of the 

war in Vietnam can be traced through a series of nationwide Gallup opinion polls conducted during the 

war years in which respondents were asked: “In view 

of the developments since we entered the fighting in 

Vietnam, do you think the US made a mistake sending troops to fight in Vietnam?” In 1965, only 25% 

thought US military involvement was a mistake (vs 

60% who said “No”), but by 1971 these factions had 

almost completely reversed (60% saying “yes,” it was 

a mistake, and only 30% disagreeing).67

Following the insertion of ground troops in March 

1965, the growing personnel requirements in Vietnam 

resulted in dramatically accelerated draft calls. For 

example, total inductions in 1965 were about 120,000; 

those for 1966 and 1967 were two-and-a-half times 

the 1965 figure. As opposition to the war mounted, 

the draft became the epicenter of the antiwar protest 

until the military switched to an all-volunteer force in 

1973.30 With each passing year, as the need for more 

troops became evident, additional criteria for draft 

exemption were removed to increase the pool of eligible draftees. In 1968, in an effort to blunt the public’s 

growing concern for unevenness and inconsistency in 

the Selective Service System, the draft was modified 

to a lottery system, based on birthdays. On December 

1, 1969, the first drawing was held. Men then knew 

the likelihood of being drafted based on where their 

birthdays fell; however, for those selected and sent to 

Vietnam under this new, random system, their sense 

of injustice was compounded.68 Ultimately 4 million 

young men were exempted by high lottery numbers; 
23

US Army Psychiatry Legacies of the Vietnam War

more than 200,000 young men were accused of draft 

offenses.68

The Counterculture and Youth/Student Opposition to the Vietnam War. Opposition to US involvement in Vietnam began slowly in 1964 on various college campuses as part of a more general rising spirit of 

student activism. In addition to various liberal causes, 

“free speech,” “free love,” “peace,” and “do your 

own thing” were also popular. The means employed 

to indicate opposition included political advocacy, 

civil disobedience, “sit-ins,” “teach-ins,” and generally 

nonviolent resistance to the status quo. 

A succession of tremendous shocks ushered in a 

more fervent antiestablishment spirit: the assassination of President Kennedy in the autumn of 1963; 

the first ghetto uprisings in the summer of 1964; the 

escalation of the war in Vietnam beginning in 1965 

and the impact of the draft; the 1968 assassinations 

of presidential candidate Robert Kennedy and civil 

rights leader Reverend Martin Luther King; and, also 

in 1968, the enemy’s surprise Tet offensives and other 

seeming military setbacks in Vietnam. The result was 

widespread impatience with the prospects for orderly 

change through more peaceful, passive means, and 

deep cynicism and mistrust of American institutions 

and “anyone over 30.” The “Woodstock generation,” 

named after the huge rock festival held in upstate New 

York in August 1969, and it’s “summer of peace and 

love” were quickly fading memories as the movement 

took on a more radical perspective and accepted a more 

open, and at times violent, revolutionary approach.

As one measure, surveys of student attitudes in 

1969 revealed that although only 2% of college youth 

were highly visible activists, roughly 40% of their 

peers held similar views (“protest prone”), signifying 

a true generation gap. Among this larger group, approximately half endorsed the belief that the United 

States was a sick society and acknowledged a loss of 

faith in democratic institutions. Two thirds endorsed 

civil disobedience to promote their causes, especially 

antiwar protests and draft resistance.69

Emergent Black Pride Movement and Racial 

Tensions. In 1948, President Harry Truman put forth 

an executive order directing the nation’s military 

services to eliminate all vestiges of racial segregation. 

Since then, many positive gains made in the status of 

black Americans can be directly attributed to the men 

and women who served in the military. However, 

the burgeoning civil rights movement in the 1960s 

heightened black soldiers’ awareness of disparities 

(with accusations of discrimination) in positions and 

roles for blacks in the military, especially among the 

younger soldiers and particularly regarding combat 

exposure and risk.62,70

For instance, during the initial years in Vietnam, 

questions were raised as to whether blacks represented 

an unfair proportion of the combat casualties. In fact, 

for the period 1965 to 1966 in each of the deployed 

combat divisions, the proportion of deaths of AfricanAmericans exceeded the proportion of African-American soldiers in the division. However, closer analysis 

revealed that, overall, blacks did not serve in Vietnam 

out of proportion to their numbers in the general 

population; and rather than racially-driven policies, 

various other social and cultural factors (eg, levels of 

education and socioeconomic status) served to select 

African-Americans for greater risk in Vietnam.30 Still, 

beginning in 1967, the military began to reduce the 

numbers of black soldiers assigned to infantry, armor, 

and cavalry units in Vietnam, and by mid-1969 the percentage of black casualties was close to the percentage 

of blacks serving in Vietnam.70

Racial tensions in America became explosive following the assassination of Reverend Martin Luther 

King in April 1968. Racial protests and riots erupted 

at numerous US military installations worldwide, 

including in Vietnam. The most notorious in Vietnam 

was in August 1968, when black confinees seized the 

Long Binh stockade and held it for almost a month. 

These sentiments coincided with the rapid evolution of a more radical “black power” faction, which 

advocated a black pride revolution and rejected assimilation in American culture as a central goal for 

African-Americans. Career military blacks were often 

caught between their loyalty to the military and the 

attitudes of the younger, black enlisted soldiers who 

were restive and expected solidarity from them regarding questions of discrimination. As the war wound on, 

younger blacks increasingly opposed sacrifices and 

risks in what they perceived as a racially inspired war 

(eg, against other people of color).71,72 They dismissed 

it as a “white man’s war” and asserted their intention 

to return home to take up the fight against repression 

and racism in America.73

Soldier Resistance and the “GI” Underground 

Movement. As opposition to the war mounted, public 

attitudes in the United States toward returning veterans reversed from acceptance to scorn. This left those 

who chose, or were directed, to serve in Vietnam as 

replacements conflicted as to what represented patriotic, morally justifiable behavior, as well as less certain 

regarding the inherent risks and hardships they faced 

there. Johnston and Bachman74 compared results of 

surveys of draft-eligible men conducted in spring 1969 

and again in summer 1970, regarding their plans and 

attitudes toward military service. In that short span 

of time the majority shifted from identifying with US 

political and military policies in Vietnam to feeling 
24

Combat and Operational Behavioral Health

alienated from the greater society, the government, and 

USinvolvement there.74 The roughly 4-fold Army-wide 

increase in rates for absent without leave (AWOL) and 

desertion during the period from 1964 to 1974 provides 

a measure of the growing opposition to serving over 

the course of the war.75

Organized dissent within the military did not 

emerge until 1967 and disappeared in 1973 once combat units were out of Vietnam. It apparently was slow 

in its development because its inspiration required 

the angst of returning veterans to be combined with 

draftee resistance. In time, a vicious cycle developed 

in which returning veterans publicly repudiated their 

Vietnam service record, including joining war protest 

organizations such as Vietnam Veterans Against the 

War, which in turn encouraged prospective Vietnam 

soldiers to oppose service there. In the United States 

this essentially first-term enlistee and draftee antiwar 

resistance movement was especially promulgated 

through “alternative culture” GI coffee houses, underground newspapers (estimated to exist on 300 posts 

and bases),51(p234) antiwar protest petitions, and support 

from civilian antiwar groups. 

As it turned out, most soldiers in Vietnam were not 

true antiwar protestors and, overall, the GI resistance 

movement had only limited success.76 Still, although 

the antiwar movement within the Vietnam-era military 

failed to reach revolutionary proportions for several 

reasons, especially the lack of sympathetic civilians 

in Vietnam, its emergence was unique in US history 

and some believed it accelerated withdrawal from the 

war.51 Others argued that it emboldened the enemy 

and thus dragged out the peace negotiations and prolonged the war. Nonetheless, military and government 

officials were quite concerned about its effects. 

The Spreading Drug Culture and Its Effects on 

Soldiers Sent to Vietnam. The incidence of illegal drug 

use among teens and young adults in the United States, 

especially psychedelics and marijuana, rose rapidly 

in the 1960s in tandem with the emerging dissidence 

of this group. Various studies were conducted during 

the Vietnam era comparing drug use among soldiers 

with their civilian peers. For example, a nationwide 

study of psychoactive drug use by young men at the 

close of the Vietnam War indicated that the peak of the 

drug epidemic was 1969 to 1973, and that veterans, 

regardless of where they served, showed no higher 

rates than nonveterans.77 Regarding measures among 

the military in the United States, a survey of drug use 

at a stateside military installation in 1970, 1971, and 

1972 showed the percentage of respondents reporting premilitary drug use increased as did the amount 

of use and the number of current users.78 A study of 

pattterns of drug use among 5,482 active duty enlisted 

men assigned to 56 separate Army units in the United 

States between January 1969 and April 1969 found 

one quarter of subjects acknowledged past use of 

marijuana, amphetamines, lysergic acid diethylamide 

(LSD), or heroin.79 Two years later a similar survey of 

19,948 new military inductees between January 1971 

and June 1971 found that almost one third acknowledged civilian drug use.80

Among soldiers sent to Vietnam, Sapol and Roffman 

surveyed 584 enlisted soldiers departing Vietnam in 

1967 (31.7% reported use of marijuana at least once) 

and concluded that the rates were comparable with 

those reported in published studies among university 

students.81 In a survey of soldiers entering or departing 

Vietnam 2 years later, Stanton found a sizable increase 

in the reported use of marijuana among those leaving 

Vietnam (28.9% vs 50.1% respectively compared to 

the 1967 survey). Most of this was accounted for by 

the increase reported by soldiers entering Vietnam. 

However, Stanton did find a shift toward heavier 

use among his sample of departing enlisted soldiers 

(29.6% compared to the 7.4% from the earlier study). 

Nonetheless, his impression was that the rise in casual 

marijuana use in Vietnam mostly mirrored rising use 

patterns among civilian peers.82

Regarding heroin use, a 1972 heroin use survey 

comparing 1,007 noncombat Army soldiers in Vietnam 

simultaneously with 856 counterparts assigned to a 

stateside post found that 13.5% of Vietnam soldiers 

and 14.5% of those stateside reported previous use 

of heroin. The authors compared their findings with 

published surveys, concluding that a heroin epidemic 

occurred in Vietnam earlier in the 1970s, but that any 

conclusion that “such an epidemic ‘[w]as unique’ . . . 

and ‘infected’ many average US soldiers appears inaccurate and misleading.”83 Taken together, these studies strongly verify that younger enlisted soldiers, not 

surprisingly, brought into the service and into Vietnam 

their drug use habits from civilian life. 

Disputes About the Ethics of Combat Psychiatry

The shifting social and political zeitgeist in the latter 

half of the war—particularly the accelerating antiwar 

and antimilitary sentiment—began to affect psychiatrists and psychiatry, and provoked concerns about 

cooperating with the military. Debates—typically quite 

passionate—that questioned the ethics of psychiatrists 

who performed draft evaluations84–88 or served with 

the military, especially in Vietnam39,89–93 appeared in the 

professional literature beginning in 1970. Denunciation 

of military psychiatry came both from psychiatrists 

and other physicians who had served in Vietnam, as 

well as from those who had not.26
25

US Army Psychiatry Legacies of the Vietnam War

Mental health organizations also sought to take 

official positions on the war. Even if not specifically 

questioning the ethics of their colleagues in uniform, 

they nevertheless questioned the morality of the US 

military and government. In March 1971, 67% of members responding to a poll of the American Psychiatric 

Association voted that the United States should terminate all military activity in Vietnam.94 In July 1972, 

the American Psychological Association joined seven 

other mental health associations in attacking the US 

role in the war. Their public statement included, “we 

find it morally repugnant for any government to exact such heavy costs in human suffering for the sake 

of abstract conceptions of national pride or honor.”95

Defense of professional support for the US forces was 

published by several psychiatrists, most of whom had 

served in Vietnam.5,6,96–99

Mounting Biopsychosocial Stressors in the Combat 

Theater Ecology

In the second half of the war, even though more 

troops were leaving than were sent as replacements, 

hostilities and dangers continued. The successive cohorts of replacement soldiers in Vietnam were deeply 

affected by the moral crisis at home, which included 

increasingly radical US politics, especially regarding the war, and a rapidly expanding drug culture. 

Furthermore, the annualized troop rotation schedules, rapid and wholesale transportation of soldiers 

and media representatives, and modern technology 

all promoted the accelerated infusion of a growing 

antiwar, antimilitary sentiment into the ranks of the 

military there. Unrelenting public opposition to the 

war may have accelerated the US pullout, but the 

process demoralized those who were sent there during 

the drawdown years. Understandably, many soldiers 

interpreted antiwar sentiment as criticism of them 

personally—not the war more generally. The uncertain 

combat results in the theater and vacillating—at times 

contradictory—government policies and military 

strategies regarding prosecuting the war and pursuing 

the peace were also demoralizing. 

This demoralization and alienation of soldiers in 

the Vietnam theater often took the form of psychiatric 

and behavioral problems, especially drug abuse, racial 

incidents, and misconduct, and presented problems 

for the Army and Army psychiatrists on an unprecedented scale. These were even more of a problem 

among soldiers in the “rear,” but even within combat 

units, troops covertly, and at times overtly, challenged 

authority (eg, combat refusal incidents, “search and 

avoid” missions, excess combat aggression). Matters 

became even more serious after a Vietnamese-based 

heroin market began to flourish in the spring of 1970 

and large numbers of US soldiers became users. It took 

9 months to institute an effective urine drug screening 

system that would permit the military to comprehend 

and react to this insidious and widespread problem 

of self-inflicted soldier dissent and disability. Equally 

disturbing to the Army in Vietnam were the incidents 

of soldiers attacking their superiors, typically with 

explosives (“fragging”—named after the fragmentation grenade). Like the widening use of heroin by 

soldiers, such attacks became increasingly common in 

the drawdown phase of the war.62,100 Although there 

are no official figures, data presented by Gabriel and 

Savage identified a total of 1,016 incidents (for all 

branches) for the years 1969 through 1972 (eg, “actual 

assaults” combined with incidents where “intent to 

kill, do bodily harm, or to intimidate” was suspected).65

Whereas assassination of officers and NCOs had been 

seen in earlier wars to a limited degree, typically under 

combat circumstances, the Vietnam theater is distinct 

in that not only was the prevalence of such incidents 

exceptionally high, but these attacks occurred more 

often in rear areas with the tacit approval of peers.101

Thus, despite the reduction in combat levels, Army 

leadership and the medical/psychiatric contingent in 

Vietnam became increasingly consumed with problems associated with the wholesale demoralization 

and alienation of soldiers—symptoms of a seriously 

compromised Army that were competing for attention 

with the challenge of preparing the South Vietnamese 

military to take over from the United States and its allies. Furthermore, by now the deployed psychiatrists 

were surrounded by a professional literature that was 

mostly critical of the military psychiatric structures and 

doctrine that were applied in Vietnam.26

An especially thorough historical series on the Vietnam War by the Boston Publishing Company included 

vivid descriptions of the various expressions of the 

contempt for the war and the South Vietnamese shared 

by US military forces in the last years of the war:

The daily round of random death and incapacitation from mines and booby traps, combined with 

short-timers fever and skepticism about the worth 

of “search and clear” steadily lowered American 

morale.62(p97)

The authors give ample witness to the pervasive 

demoralization in the theater and the brittle nature 

of race relations, primarily within noncombat units. 

They also document the associated weakening of the 

military legal system. According to these authors, 

combat refusals, drug problems, and racial strife often 

proved impossible to resolve in the last years in Viet-
26

Combat and Operational Behavioral Health

nam. While punishments tended to be increasingly 

lenient, commanders openly acknowledged that rather 

than hunt the enemy or carry out a tactical mission, 

they considered their primary responsibility to be to 

return their men safely home. “It sometimes seemed 

to be little more than a ragtag band of men wearing 

bandannas, peace symbols, and floppy bush hats, with 

little or no fight left in it.”43(p16)

Similarly, Balkin’s historical review of the severe 

breakdown in morale and effectiveness of the US 

military in Southeast Asia during this phase of the 

war provided thoroughly referenced data indicating 

an unprecedented increase in rates of combat refusals, combat atrocities, heroin use, assassinations (or 

threats) of military leaders, racial conflicts, desertion 

and AWOL, and the emergence of the GI antiwar 

movement.51 It also underscored the corrosive effects 

on morale and cohesion consequent to pervasive careerism among military leaders (“ticket punching,” 

an emphasis similarly brought to bear by Gabriel and 

Savage65).

Kirk, a journalist reporting from the last years of 

the war, noted that,

[i]t is, in reality, a desultory kind of struggle, punctuated by occasional explosions and tragedy, for the 

last Americans in combat in Vietnam. It is a limbo 

between victory and defeat, a period of lull before 

the North Vietnamese again seriously challenge allied control over the coastal plain, as they did for the 

last time in the Tet, May and September offensives 

of 1968. For the average “grunt,” or infantryman, 

the war is not so much a test of strength under pressure, as it often was a few years ago, as a daily hassle 

to avoid patrols, avoid the enemy, avoid contact—

to keep out of trouble and not be the last American 

killed in Vietnam.58(p65)

More ominous is the investigative report by Linden, another journalist, about his visit in 1971. Linden 

covered much of the same ground as those mentioned 

above, but he provided case examples and other observations. These included corroboration from Captain 

Robert Landeen, an Army psychiatrist assigned to the 

101st Airborne Division. Linden dynamically depicted 

the circumstances and meanings that combined to 

produce a class war between leaders and subordinates 

in Vietnam, often with fragging as its final result. He 

described how fraggings and other threats of violence 

were commonly used as a means of controlling officers 

and NCOs: “[fragging in Vietnam became] prevalent, 

passionless, and apparently unprovoked, representing the grisly game of psychological warfare that GIs 

use.”100(p12)

Not surprisingly, the Army’s pernicious morale and 

discipline problems were mirrored on a comparable 

scale among the Marines fighting in Vietnam. The official review of US Marine activities late in the war acknowledged rampant combat atrocities, “friendly fire” 

accidents, combat refusals, racial strife, drug abuse, 

fraggings, and dissent.102 William Corson, a retired 

Marine lieutenant colonel (expert on revolution and 

counterinsurgency warfare, and a veteran of World 

War II, Korea, and Vietnam), blamed the military’s 

demobilization problems in late Vietnam (drug use, 

dissent, and racial incidents) on both America’s failure 

in Vietnam and to an “erosion of moral principle within 

the military.”103(p100) He referred to the rise in fragging 

incidents as a new service-wide form of psychological 

warfare and an aspect of institutionalized mutinous 

behaviors (along with sabotage, evasion of leadership 

responsibilities, and internecine conflict). According 

to Corson, “[a]s with fragging, the potential for a mutinous refusal to carry out an order is so widespread 

[in Vietnam] that routine actions are being avoided by 

those in charge.”103(p99)

Drawdown Phase Psychiatric Overview

Traditional Military Psychiatry Indices. The summary of Army neuropsychiatry in the Vietnam War 

provided by Jones and Johnson illustrated a dramatic 

rise in the standard indices of psychiatric attrition 

during the last few years of the war.7 As noted previously, the inpatient hospitalization rate had hovered 

around 12–14/1,000 soldiers per year through the first 

3 years of the war7–9—favorable compared to figures 

for Korea (73/1,000) and World War II (28–101/1,000).11

However, the rate started to rise in 1968, doubled by 

April 1970, and doubled again by July 1971, reaching 

an annualized rate of 40/1,000. From there it dropped 

rapidly until the remaining troops were pulled out in 

March 1973, apparently primarily because the Army 

relaxed its medevac policies (in Vietnam only) for 

drug-dependent soldiers, which ordinarily would 

have excluded them104 (Figure 2-1).

Especially dramatic is the skyrocketing out-of-country psychiatric evacuation rate, which had remained 

below 4–5/1,000 troops per year throughout the war 

until 1971. By July 1971, it had risen to 42.3, and by 

the following year, July 1972, the rate had climbed to 

129.8. In other words, at that point in the war, one out 

of every eight soldiers was being medically evacuated 

from Vietnam for psychiatric reasons (primarily for 

heroin dependency). 

As a corollary, the percentage of neuropsychiatric 

evacuations among all medevacs from Vietnam also 

accelerated. It had remained below 5% but rose to 30% 

in late 1971, and by late 1972 it was at 61%. By 1971, 
27

US Army Psychiatry Legacies of the Vietnam War

Figure 2-1. US Army Vietnam rates per 1,000 troops for battle 

deaths,1

 psychiatric hospitalization,2 and psychosis.3

1

US Army Adjutant General, Casualty Services Division 

(DAAG-PEC). Active duty Army personnel battle casualties and nonbattle deaths Vietnam, 1961–1979, Office of The 

Adjutant General counts. February 3, 1981.

2

Datel WE. A Summary of Source Data in Military Psychiatric 

Epidemiology. Alexandria, Va: Defense Documentation Center; 1976. Document ADA 021-265.

3

Jones FD, Johnson AW, Jr. Medical and psychiatric treatment 

policy and practice in Vietnam. J Social Issues; 1975;31(4):49-

65.

DEROS: date of expected return overseas

more soldiers were being evacuated from Vietnam 

for drug use than for war wounds.82 However, taken 

alone this could overstate the case for spiraling neuropsychiatric rates because the WIA rate was declining 

simultaneously.

It is of special note that the doubling rate for psychosis in 1969 and 1970 in Vietnam (see Figure 2-1) from 

its rather historically predictable 2/1,000 troops per 

year presented a paradox for Army psychiatry. Because 

it coincided with an Army-wide rise in the psychosis 

rate, it was initially explained by Jones and Johnson 

as secondary to the influence of illegal drugs in confusing the diagnosis.7

 Subsequently, Jones noted that 

the psychosis rate reverted back to its historical levels 

only in the Vietnam theater and only after the Army 

allowed drug-dependent soldiers to utilize medevac 

channels.105 He speculated that the rising rates also 

reflected the tendency for Army psychiatrists and other 

physicians in Vietnam to mislabel soldiers “who did 

not belong overseas” as psychotic (eg, insinuating the 

physicians’ intent to manipulate the system).105

Behavior Problems and Misconduct. In themselves, these traditional measures of psychiatric 

morbidity are startling. Equally disturbing, however, 

during the drawdown years in Vietnam the Army 

also saw a concomitant rise in behavioral problems 

as measured by rates for: (a) judicial and nonjudicial 

(Article 15) disciplinary actions,106 (b) noncombat 

fatalities,107 (c) combat refusals,62 (d) corruption and 

profiteering,30,51 (e) racial incidents,30,51 (f) convictions 

for the specific crime of “fragging,”108,109 and, especially, 

(g) use of illegal drugs. Army mental health personnel 

often became involved with these types of problems 

and sought to apply traditional means and models but 

with uncertain results.

Heroin Epidemic. As already suggested, the exponential increase in heroin use by lower ranking soldiers 

from 1970 on—a problem that overlaps the realms of 

psychiatry and military leadership (discipline and 

morale)—greatly confounded the psychiatric picture 

in Vietnam in the latter third of the war. Jones and 

Johnson substantiate that the rapidly rising, late-war 

psychiatric admissions/evacuations were primarily 

for narcotic use once urine drug screening technology 

became available in June 1971. This greatly increased 

military detection capability, increased the jeopardy 

for drug-using soldiers, and consequently affected 

prevalence measures. DoD statistics estimate 60% of 

soldiers in Vietnam late in the war were using marijuana, and 25% to 30% were using heroin.62 Robins’ 

follow-up study of Vietnam veterans’ drug use in 1972 

found that 44% of the general sample reported having 

tried some narcotic while in Vietnam (compared to 7% 

who acknowledged using heroin before assignment 

there).110 Even more ominous, deaths (confirmed by 

autopsy) attributed to drug abuse rose to a peak of 

15 for the month of November 1970 before starting to 

slowly recede.111

Stanton’s review of the most credible drug use 

prevalence studies conducted through the course of the 

war underscores that although the rise in drug use in 

Vietnam between 1966 and 1970 is best explained with 

the rise in pre-Vietnam use, the meteoric rise in heroin 

use beginning in 1970 is not. Instead, the rise coincides 

with the deteriorating social and political features in 

the United States and the sudden availability of very 

inexpensive, almost pure heroin in Vietnam.82 Because 

the heroin was so cheap, pure, and accessible, soldiers 

in Vietnam most commonly mixed it with tobacco and 

smoked it in ordinary-looking cigarettes. Some soldiers 

preferred to snort heroin (insufflation), and a minority 

injected it intravenously. 

Some insight into the world of the heroin-using 

soldier in Vietnam comes from the sociological studies of Ingraham.112 He interviewed opiate-positive 

40

35

30

25

20

15

10

5

0 1965 1966 1967 1968 1969 1970 1971 1972

9.42 15.6 21.6 36.3 28.4 15.7 11.7 17.1

6.98 11.8 9.8 12.7 15.4 25.2 31.3 10.4

1.58 1.83 1.78 3.63 4.35 2.43 2.2

Army battle

death rates

Army psychosis

 rate

Army psychiatric

hospitalization rate

DEROS drug

screen begins

(June 1971)

Heroin

market

begins

(spring

1970)
28

Combat and Operational Behavioral Health

soldiers recently returned from Vietnam in late 1971 

and presented findings regarding drug-use patterns.

He noted the fraternal social network described by 

his respondents (that existed within the larger but 

basically approving body of soldiers) and the various 

status distinctions that existed within this “head” society. The soldiers rationalized heroin use as a necessary 

adaptation to the unique stressors in Vietnam (not 

typically combat stress), considered their use to be 

minor because they had not injected drugs, and denied 

any need for further treatment. Most contended that 

they were able to maintain their habits without loss 

of function. The jargon of these soldiers exalted the 

enlisted “heads” and denigrated the “lifers/juicers” 

(NCOs and officers). For Ingraham, heroin use was 

not especially representative of a political ideology 

(antiwar), but instead it reinforced the appreciation 

of an extended network of associates with whom a 

member could express antimilitary sentiments accompanied with an intense sense of acceptance and 

belonging.112

The “Amnesty Program.” As noted in Neel’s report, 

Army Medical Support in Vietnam, “Growing awareness of the nature and extent of the drug problem in 

Vietnam led to a search for a flexible, non-punitive 

response.”31(p48) Ultimately, the “Amnesty Program,” 

an adaptation of Army Regulation 600-32 (Drug Rehabilitation/Amnesty Program), became US Army Vietnam 

(USARV) policy.113 This policy outlined procedures and 

conditions regarding a one-time-only “amnesty,” as 

well as stipulated the elements that should comprise 

a unit’s rehabilitation program (“for restorable drug 

abusers, when appropriate, and consistent with the 

sensitivity of the mission”). Efforts at implementation 

saw major commands hastily improvise treatment/

rehabilitation programs and facilities that utilized resources at hand and reflected a diversity of approaches 

for soldiers voluntarily seeking drug abstinence. In 

time, however, it became evident these were mostly 

failed efforts. The only variable that predicted successful heroin abstinence was the soldier nearing his 

DEROS.20,114,115 Consequently, the military was forced 

to resort to a law enforcement approach wherein units 

were subjected to unannounced urine screening. Soldiers found to have morphine breakdown products in 

their urine were quarantined in detoxification centers 

and, when medically cleared, returned as medevac patients to one of 34 Army hospitals in the United States 

for further evaluation and treatment. As of September 

21, 1971, 92,096 soldiers had been screened and 5.2% 

(4,788) had tested positive.18 However, these numbers 

must considerably underrepresent actual prevalence 

in Vietnam because soldiers preparing to leave were 

highly motivated to discontinue their heroin use in 

order not to delay their departure. 

Effects of the Heroin Problem in the Theater and 

Postdeployment. The most serious concern arising 

from the heroin problem was the effect of soldier 

drug use on military preparedness and effectiveness. 

According to Spector, few if any soldiers used drugs 

in combat, although some believed that after a battle 

it helped calm them down.30 From another approach, 

Holloway and his research colleagues concluded that 

drug abuse among US military forces represented a 

“significant threat to combat readiness.”116

On the plus side, the great apprehension of government and military leaders that the military would 

release large numbers of addicted Vietnam returnees 

onto the streets of the United States proved baseless. 

Not only did a controlled research study of withdrawal 

patterns of heroin-dependent soldiers conducted in 

Vietnam demonstrate a surprisingly mild physiological withdrawal despite high levels of heroin tolerance,12

other studies in the United States revealed that these 

soldiers generally did not return to heroin use.117 From 

Stanton’s postwar perspective, given the remission rate 

of 95% for heroin-using soldiers once they returned 

stateside and the lack of data indicating that heroin 

use degraded individual or group performance in 

Vietnam, the question can be raised as to whether 

heroin use there really was more deleterious than 

the alcohol use of previous wars.82 In support of that 

perspective, Zinberg recalled from his 1971 inspection 

visit in Vietnam a military judge telling him that 80% 

of his heroin use cases received top efficiency ratings 

from their commanding officers.20

Drawdown Phase Psychiatrist Reports

As in the tranisition phase, few Army psychiatrists 

deployed during the drawdown phase of the war 

published accounts of their experiences. Those who 

did publish wrote about the epidemic of soldier heroin 

use and implied that their efforts to respond to this 

and related problems of soldier demoralization and 

dissent through traditional psychiatric models mostly 

failed (Exhibit 2-3).

Two accounts from this period seem especially 

illuminating. Major R Ratner served with the 935th 

Medical (psychiatric) Detachment on the Long Binh 

post near Saigon (August 1970–August 1971) and later 

documented his experience there (“Drugs and Despair 

in Vietnam”), which mostly addressed the challenge of 

the heroin epidemic.118 Ratner conveyed a dark picture 

of military life in Vietnam at that time. He considered 

his caseload to be only a fraction of the estimated 30% 

of all younger, lower-ranking soldiers who used heroin 

regularly; and that they in turn only partially reflected 
29

US Army Psychiatry Legacies of the Vietnam War

EXHIBIT 2-3

SELECTED PUBLICATIONS BY DRAWDOWN-PHASE ARMY PSYCHIATRISTS (INCLUDING 

RESEARCH REPORTS)

Year in 

Vietnam

No. Who Published 

Articles/Total No. Deployed Army Psychiatrists (as a percentage)* Publications

1970 2/20 (10%) Char J. Drug abuse in Vietnam. Am J Psychiatry. 1972;129:463–465.

Ratner RA. Drugs and despair in Vietnam. U Chicago Magazine. 1972;64:15–

23. 

1971 1/13 (7.7%) Joseph BS. Lessons on heroin abuse from treating users in Vietnam. Hosp 

Community Psychiatry. 1974;25:742–744.

Holloway HC. Epidemiology of heroin dependency among soldiers in Vietnam. Mil Med. 1974;139:108–113. Research report. 

1972 0/1 (0.0%) Holloway HC, Sodetz FJ, Elsmore TF, and the members of Work Unit 102. 

Heroin dependence and withdrawal in the military heroin user in the US 

Army, Vietnam. In: Annual Progress Report, 1973. Washington, DC: Walter 

Reed Army Institute of Research; 1973: 1244–1246. Research report.

*These numbers do not count research reports, although they are listed in the Publications column.

the pervasive demoralization within the larger military 

population in Vietnam. Although alluding to likely 

individual premorbidity factors in the drug-dependent 

soldier, Ratner credited more their universal despair, 

which he attributed to a combination of societal factors 

(eg, America’s motivation for waging war in Southeast 

Asia represented a displacement of its internal “racial 

hostilities”) and an “inhumane” Army. Furthermore, 

he acknowledged the sense of clinical impotence he 

shared with his colleagues (“there seems to be no place 

for a psychiatrist to begin”) and appeared to echo the 

cynicism of his soldier-patients.118

Equally troubling is the publication of Lieutenant 

Commander HW Fisher, a Navy psychiatrist who 

served with the 1st Marine Division during the same 

year as Ratner, only far to the north near Da Nang. 

According to Fisher, of 1,000 consecutive referrals, 

he diagnosed 960 Marines as personality disorders, 

usually antisocial.119 Furthermore, although he differs 

from Ratner in attributing their military dysfunction 

to predisposition (eg, he labels them with personality 

disorder diagnoses), Fisher especially faulted their 

officers and NCOs for encouraging indiscipline. He 

felt that this occurred through vacillations in enforcing regulations and argued that these problems were 

exacerbated by expectations that psychiatry provide 

medical evacuation out of Vietnam or recommend 

administrative separation from the service in lieu of 

punishment, thus serving as encouragement of the 

deviant Marine’s rebellion.119

Taken together, the record from this phase suggests 

the morale of some of these psychiatrists suffered a 

serious decrement parallel to that of the typical soldier 

of that period. More importantly, it also indicates that 

the psychiatric contingent, like the military leadership 

in Vietnam, was wholly unprepared to contend with 

the extensive proportion of US troops who would 

in time oppose serving under the post-Tet (1968) 

circumstances through antimilitary behaviors and 

psychological disability.

POSTWAR FEATURES

Vietnam Veterans and the High Prevalence of Readjustment Problems

A comprehensive review of postdeployment adjustment and psychiatric morbidity is outside the scope 

of this chapter. However, the data indicate that many 

who served in Vietnam subsequently experienced serious and sustained readjustment problems, including 

frank posttraumatic stress disorder (PTSD). Some suggest that the prevalence of debilitating psychological 

and social problems among Vietnam veterans greatly 

exceeds that for earlier US wars. Additionally, when 
30

Combat and Operational Behavioral Health

postdeployment adjustment difficulties are included 

with psychological problems that arose in the theater, 

the psychosocial cost for the Vietnam War appears 

unprecedented.

However, estimates as to the prevalence of sustained postwar adjustment and psychiatric problems 

for Vietnam veterans seem to vary as widely as the 

political reactions to the war itself.22,120–125 Furthermore, 

comparisons of the psychosocial effect of combat 

service across US wars is especially difficult because 

measures are inconsistent. Somewhat reassuring, a 

1980 Harris Poll of Vietnam veterans commissioned by 

the then Veterans Administration found 91% reporting they were glad they had served their country, 74% 

said they enjoyed their time in the service, and nearly 

two thirds said they would go to Vietnam again, even 

knowing how the war would end.29

Nonetheless, rising professional concern for the 

psychological injury of veterans secondary to service in 

Vietnam brought about a revolutionary change in the 

taxonomy of psychiatric disorders in civilian medicine. 

In the decade that followed the war, the International 

Classification of Disease, 9th edition, Clinical Modification (ICD-9-CM),126 and the Diagnostic and Statistical 

Manual of Mental Disorders, 3rd edition (DSM-III),127

both contained the new category “Post-Traumatic 

Stress Disorder or PTSD,” which had been originally 

called “post-Vietnam syndrome.” The inclusion of 

PTSD in DSM-III reflected the political efforts of the 

Vietnam veterans who were seeking greater recognition, as well as the efforts of Americans with residual 

antiwar sentiment and psychiatrists who believed that 

DSM-II had neglected the ordeal of combat veterans.128

In that DSM-III includes combat as an etiological factor 

for PTSD, it suggests that overwhelming combat stress 

and civilian catastrophes are identical—a proposition 

that seems arguable. 

The most definitive findings regarding PTSD prevalence and incidence following the Vietnam War come 

from the government-sponsored National Vietnam 

Veterans Readjustment Study (NVVRS). At the time of 

the study (mid-1980s), approximately 30% of male and 

27% of female study participants had evidenced PTSD 

at some point since serving in Vietnam, and for many 

PTSD had become persistent and incapacitating (15% 

and 9% of study participants respectively).129

However, divergence from the emphasis in the 

original PTSD model (the traumatic event is singularly 

explanatory) has occurred. Over the years since the 

war, disputes have arisen as to the relative weight to 

give various etiologic influences (eg, predisposition 

and personality, traumatic extent of combat theater 

circumstance, and post-Vietnam experience). These 

disputes have complicated the diagnosis and treatment of PTSD and related adjustment difficulties. 

Many behavioral science observers have commented 

on the considerable potential for postwar adjustment 

difficulties to be powerfully affected by psychological 

and social dynamics that are not the direct consequence of combat zone “trauma.”39,123,130–132 According to Arthur S Blank Jr, a former Army psychiatrist 

who was assigned in Vietnam and who subsequently 

served for many years as National Director for the 

Department of Veterans Affairs Readjustment Counseling Centers, 

[s]ince 1973 I have treated, evaluated, supervised the 

treatment of, or discussed the cases of approximately 1,400 veterans of Viet Nam with PTSD and have 

yet to hear a single case where the veteran’s symptoms were not accompanied by either (1) significant 

doubts or conflicts about the worthiness of the war, 

or (2) considerable anger about perceived lack of 

support for the war by the government or the nation. 

Furthermore, although researchers have been barred 

from exploring the relationship between the occurrence of PTSD and the overwhelmingly conflicted 

nature of the war, it is the observation of almost all 

clinicians who have treated substantial numbers of 

Viet Nam veterans with PTSD that the clinical condition is almost always accompanied by a deeply 

flawed sense of purpose concerning what happened 

in Viet Nam.133

Following the cessation of hostilities in Southeast 

Asia, the ethical challenges to military psychiatry, 

which were voiced during the war, shifted to retrospectively critical conclusions regarding negative 

long-term consequences of field psychiatric practices 

in Vietnam (the aforementioned doctrine). The perspective seems to be that the implementation of these 

practices may have been in the service of collective 

goals (eg, military objectives), but in the process it 

ignored the needs of the soldier and fostered the development of PTSD.39,134–136 Offsetting opinion came 

from Blank, who noted that acute CSRs usually do 

not meet the criteria for PTSD and do not generally 

evolve into diagnosable PTSD later.137 It also came 

from Jones, who argued vigorously that postwar 

sympathies for maligned Vietnam veterans may 

have led psychiatrists without military experience 

to misunderstand the unique aspects of a soldier’s 

state when psychological defenses become overwhelmed in combat. As a consequence they fail to 

appreciate the characteristically fluid and reversible 

nature of the resultant acute stress disorder and the 

increased risk for psychiatric morbidity (including 

PTSD) if treatments do not promote symptom suppression and rapid return to military function and 

comrades.138
31

US Army Psychiatry Legacies of the Vietnam War

Survey of Veteran Army Psychiatrists Who Served 

in Vietnam

As mentioned earlier, in 1982 WRAIR queried 

veteran Army psychiatrists who served in Vietnam 

about their experiences in the war.2,27 Of the estimated 

135 who served in Vietnam, 115 were located, and of 

those, 74% (85) completed a structured questionnaire 

exploring patterns of psychiatric problems encountered, types and effectiveness of clinical approaches, 

and personal reactions to the associated professional 

challenges and dilemmas. Study respondents were 

evenly distributed over the years of deployment in 

Vietnam so that the gleaned information can be considered representative. Also, in the theater, 21% (18) 

served exclusively in combat units (roughly one third 

of the slots each year), 49% (42) served exclusively 

in combat service support medical units (eg, with 

hospitals or the psychiatric specialty teams), and 25% 

(21) spent some time assigned to each. The remaining 

four served exclusively as the theater “Neuropsychiatric Consultant” to the CG/USARV Surgeon. The 

following summarizes the most salient findings from 

the study:

• Unprecedented levels of predeployment professional training. The degree of formal psychiatric training shared by these psychiatrists was 

unprecedented in contrast to World War I and 

World War II, as was the proportion of deployed psychiatrists who received residency 

training in Army programs (one third).139

• As theater problems progressively increased, predeployment military experience among replacement 

psychiatrists decreased. Although the psychiatrists who served in Vietnam averaged little 

postprofessional training experience in the 

military, greater numbers of civilian-trained 

psychiatrists with no practical military background, as well as an increasing proportion 

of military-trained psychiatrists with no field 

experience, were sent during the second half 

of the war. In the first half of the war these two 

groups constituted only one quarter of the assigned psychiatrist strength. In the second half 

they represented three quarters. This decline 

in practical experience, which characterized 

successive groups of psychiatrists sent to 

Vietnam, was mirrored in an equally salient 

reduction in relevant background experience, 

though not rank, of the Vietnam theater Neuropsychiatric Consultant to the CG/USARV 

Surgeon.

• Psychosocial disorders progressively outweighed 

combat-generated ones. Regarding the distribution of patients by standard psychiatric diagnoses, these veteran psychiatrists reported 

over one half of their clinical efforts were 

devoted to personality disorders, adjustment 

reactions, or substance abuse syndromes. 

Furthermore, 32% (24) of the study participants reported that they had only rare 

exposure to combat-induced psychiatric 

casualties during their tours. Similarly, the 

mean percentage of clinical caseload devoted 

to “combat reactions” for all psychiatrists in 

the study was only 12.6%. These findings 

appear to validate that Vietnam was a “lowintensity” war,31 at least by the measure of 

its potential to psychologically overwhelm 

soldiers committed to combat. Furthermore, 

the burden of treating various psychosocial 

problems rose dramatically as the war passed 

the halfway mark. In comparing ratings of 

16 behavioral problems by the study participants from the first half of the war with those 

of the second half, the exponential rise in the 

heroin problem was distinguishable from the 

steady, although not insignificant, problems 

associated with the use of other drugs such 

as alcohol and marijuana. This finding held 

true when comparing psychiatrists who 

served only with combat units with those 

who served only in hospital assignments. 

Also, like the jump in problems associated 

with heroin use in the latter third of the war, 

the study psychiatrists overall reported a 

significant rise in their involvement in group 

racial conflicts and with individuals responsible for violent incidents.

• Psychoactive medications were extensively prescribed, but risks and benefits were not monitored.

The descriptive and quantitative data from 

the 48% (41) of the study psychiatrists who 

acknowledged some exposure to combat 

reaction cases indicate that they extensively 

used and highly valued these medications 

(neuroleptics and anxiolytics) in the treatment and management of soldiers suffering 

from a wide variety of combat-generated 

symptoms. (The Army psychiatrists in 

Vietnam, however, had little or no way 

to measure the subsequent effects of such 

medications on the combat effectiveness, or 

vulnerability, of solders who were returned 

to duty following such treatment, or regarding their long-term effects including postwar 

adjustment.)
32

Combat and Operational Behavioral Health

• Many Vietnam psychiatrists still felt embittered, 

especially those who served in the latter half 

of the war. A large proportion of the study 

psychiatrists emphasized, often eloquently, 

that they still felt quite strongly—typically 

negatively—about the war and their role in it. 

This was primarily the case among those who 

served in the second half of the war. These 

psychiatrists’ responses indicate that in many 

respects they felt overwhelmed when trying 

to treat soldiers (and advise commanders) 

affected by a raging drug epidemic, eruptions of racial animosities, and outbreaks of 

violence, while using staffing and policies 

instead designed to manage large numbers 

of combat-generated casualties. Compared to 

their counterparts in the first half of the war, 

these psychiatrists tended to be more vocal, 

more divided (according to training differences), and, in some cases, quite defensive. 

The psychiatrists of this latter period also 

appeared more likely to perceive inequities 

and to be critical of their preparation and 

utilization by the Army.2,27

LINGERING QUESTIONS AND CONSIDERATIONS

This review indicates that during the drawdown 

years in Vietnam (1969–1973), Army psychiatrists 

faced a different and more challenging scenario than 

that encountered by those who preceded them—one 

that suggests a dangerous erosion of Army morale 

and discipline and an associated epidemic of psychiatric conditions and misconduct. It also raises 

important questions that might have been more 

easily answered at the conclusion of hostilities if a 

thorough and systematic study of the psychiatric 

and behavioral crisis there had been conducted—

questions for which the answers may be critical 

in preparing for a similar military engagement in 

America’s future. 

Should more have been done by military and 

medical/psychiatric leaders to preserve the mental 

health, psychosocial resiliency, and, by implication, the 

combat readiness of the replacement soldiers sent to 

fight in Vietnam? Did the military leadership and the 

psychiatric component in Vietnam ignore the mounting evidence and warnings by senior medical and 

psychiatric observers6,31 and fail to adjust psychiatric 

perspectives or modify the preparation, deployment, 

and organization of psychiatric assets in order to meet 

these challenges? By way of response, the following 

considerations are offered despite the late date and 

incomplete information.

The Larger Army During the War

Although the troops in Vietnam were more demonstrative, clearly the long and controversial war took a 

massive toll on the morale and mental health of the 

US Army generally.64–66,140 The troops in Vietnam were 

resonant with the restive, antiestablishment sentiments 

of their military peers outside the theater. More specific to mental health, epidemiological data provided 

by Datel regarding the larger US Army indicate that 

by mid-1973:

• the worldwide incidence of neuropsychiatric 

disease among Army personnel rose to near 

the peak level seen during the Korean War; 

• the psychosis rate for the worldwide active 

duty Army had never been higher; 

• character and behavior disorder diagnoses 

also peaked; and 

• the proportion of Army hospital beds in the 

United States occupied for all psychiatric 

causes was greater than it had ever been,25

including during the so-called “psychiatric 

disaster period”10 of World War II. 

The Soldiers Who Served in Vietnam

The reduction in combat activities and the perception of demobilization surely explains some of the rise 

in psychiatric conditions and behavioral problems 

from 1969 on. These kinds of problems were predictable based on data from World War II and Korea, 

where large numbers of soldiers were stationed far 

from home, living in confined and isolated groups, 

and serving primarily in service and support roles.141,142

Similar problems have been associated with constabulary forces and those in the process of demobilization 

in an overseas setting who resent being asked to 

sustain further sacrifices beyond the conclusion of 

hostilities.104,143 Even a dramatic increase in the use of 

narcotics by US soldiers was seen at the close of the 

Korean War, which was also attributed to service in 

the Asian theater.144 Should all of these problems be 

lumped under a concept like a collective “short-timer’s 

syndrome” (ie, impatient to complete their assignment 

and return to their stateside lives)? In the case of the 

skyrocketing evacuation rates in Vietnam for soldiers 

with opium breakdown products detected in their 

urine, Jones referred to these casualties as “evacuation syndromes” (eg, efforts by soldiers to manipulate 

the system to get relief from foreign deployment and, 
33

US Army Psychiatry Legacies of the Vietnam War

perhaps, combat risks).105

However, beyond these familiar stressors, the troops 

in the latter part of the war in Vietnam also exhibited 

intense opposition to military authority—an attitude 

that coincided with the virulent antiwar and antimilitary feelings of those at home. Should it be concluded 

that the pervasive psychiatric and behavioral problems 

in these individuals were primarily expressions of an 

embittered aggregate of soldiers who resented being 

asked to make sacrifices to salvage America’s lost 

cause there while surrounded by the moral outrage 

and blame of the US public? Some consider these 

soldier behaviors to have collectively represented a 

“macromutiny.”145 But was Vietnam so sociopolitically 

unique that the US experience there can be discounted 

as unlikely to repeat? Or does a closer look need to be 

taken at what happened there? What can it teach about 

the limitations of human nature, including among 

the civilian population at home, under these specific 

conditions of war and deployment, especially from 

the standpoint of the social psychology of military 

groups?

The Army Psychiatric Component in Vietnam

Certainly the overall record of psychiatric care 

provided through the course of the war in Vietnam 

was laudatory. But the traditional psychiatric models 

for the management and treatment of this avalanche 

of demoralization and alienation seem to have mostly 

been ineffective by the end of the war. It does appear 

that military psychiatry failed to extrapolate from 

drawdown and demobilization problems seen in earlier wars. A failure to anticipate the growing demoralization and dissent in Vietnam secondary to public 

repudiation of the war resulted in a failure to modify 

the system of mental health resources and the selection 

and preparation of replacement psychiatrists. 

A Social Stress and “Disease” Model

On the other hand, perhaps these problems were 

insoluble on any terms pertaining to clinical psychiatry. 

First, the overlap between matters bearing on morale 

and mental health ultimately became quite entangled 

as the war progressed, and yet those primarily responsible for the former (military commanders) and 

those responsible for the latter (military mental health 

personnel) did not typically maintain a running dialogue, especially in instances of divergent command 

structures, which was most usually the case. Second, 

considering the exceptionally high prevalence of 

problems that arose among previously functional 

soldiers, the pathogenesis is more suggestive of a 

social–psychiatric disorder of the collective (eg, Goffman’s pathogenic “total institution,”146 Fleming’s 

“sociosis,”131 or Rose’s “macromutiny”145), as opposed 

to one primarily centered on the individual soldier. In 

this regard, it should be noted that the psychiatric training of the times, including in the Army settings (and 

despite intents otherwise23) did not emphasize social 

pathology and interventions (including at the macro 

level) nor provide sufficient practical training. 

In other words, in that these problems were epidemic in the Vietnam theater and were not, for the 

most part, combat-related, a social stress model seems 

especially warranted because these seem to represent failures of adaptation at the group level. They 

evidently arose from complex interactions combining 

personal circumstance with powerful biological (often 

including drug-induced), psychological, and social 

stressors (in Vietnam as well as from home)—stressors 

that became progressively onerous for sequential cohorts of replacement soldiers as the war wound to its 

bitter conclusion. 

Veteran Postwar Adjustment Problems

As noted earlier, the important subject of the adjustment problems of veterans after the war is beyond the 

scope of this chapter, but it should be mentioned that 

the clash of values affecting soldiers in Vietnam also 

invariably complicated the reintegration of returning 

soldiers. For many, it may have contributed to chronic 

psychiatric conditions and serious adjustment difficulties because some symptom formation may have 

served to obtain, through the “sick role,”147 an honorable adaptation to impossibly contradictory public 

(moral) pressures (eg, “damned for going, blamed for 

losing”). Furthermore, in most cases the symptoms and 

difficulties of these veterans remained unaddressed 

because of the unavailability of the PTSD diagnosis 

prior to 1980. Following the promulgation of the PTSD 

diagnosis through the publication of DSM-III, the problems and conditions of this group of veterans began to 

be more systematically addressed by the Department 

of Veterans Affairs, which began the gradual implementation of the Vet Centers—a nationwide system of 

community-based, war veteran counseling centers133

(totaling 260 centers by 2009). More information on 

the Vet Centers is available at their Web site: http://

www.vetcenter.va.gov. 

Final Considerations

In his book, Psychiatry in a Troubled World,

148 Dr William C Menninger, the Army Surgeon General’s chief 

psychiatrist through most of World War II, described 
34

Combat and Operational Behavioral Health

military psychiatry as a “dirty job,” one in which the 

psychiatrist helps a normal individual adjust to the 

abnormal situation of combat. He was primarily referring to the moral weight inherent in expecting soldiers 

to return to combat duty and additional risks following 

the brief, simple measures associated with the classic 

combat psychiatry treatment regimen (the doctrine 

mentioned earlier). Following military psychiatry’s 

experience in Vietnam, it can surely be acknowledged 

that it is a “messy job” as well. As such, attention can 

be drawn to the multivariate social and environmental 

stressors that can also serve to corrupt soldier morale, 

commitment, and discipline, as well as mental health, 

under certain adverse combat theater circumstances, 

and psychiatry’s limited capabilities for making this 

bearable for them. 

SUMMARY

The commitment of US forces in Southeast Asia 

resulted in 7 exhausting years of combat activities. 

Ultimately, however, despite their material and 

technological inferiority, the enemy’s resolve and resilience outlasted the tolerance of the US public, and 

US involvement ended following mounting protest 

in the United States, withdrawal of US military forces 

and civilian advisors in 1973, and, finally, the defeat 

and surrender of the Saigon government to North 

Vietnam in April 1975—little more than 2 years after 

the negotiated truce in January 1973. More specific 

to military psychiatry, these remarkable events and 

circumstances—and the attendant social and political 

convulsion in America—adversely affected the mental 

health and psychological resilience of a large proportion of the military service members assigned in 

Vietnam, and the task for military psychiatrists there 

broadened and became more complex. 

Even if widely scattered, the various publications 

from psychiatrists and other professionals who served 

in Vietnam, visited the theater, or were in a position to 

review the circumstances there, do comprise a partial 

historical record. These reports and the WRAIR survey of veteran Army psychiatrists suggest a number 

of characteristics regarding the psychiatric challenge 

in Vietnam, some of which appear to be unique compared to the wars that preceded it. They also provoke 

additional important questions.

In the beginning, when US ground troops were first 

committed and throughout the buildup phase (1965–

1967), adequate psychiatric resources were deployed 

with the combat forces, and psychiatric and behavioral 

problems were manageable. Rates of psychiatric evacuations from Vietnam were exceptionally low, as were 

rates for disciplinary problems. Morale and commitment of Army troops, including psychiatrists, proved 

to be high. Of special note is that newly developed 

psychoactive medications, especially neuroleptics and 

anxiolytics, were enthusiastically used throughout the 

theater by psychiatrists and other medical officers, but 

their use and effects were never studied.

The US public’s attitude toward the war reversed 

dramatically following the enemy’s bold surprise attacks in 1968. These events heralded the withdrawal 

of US forces and demobilization from the war. Despite 

this, there continued the assignment of replacement 

soldiers (in decreasing numbers), including psychiatrists; killing and wounding of more US service members; and passionate antiwar, antimilitary sentiment 

within US society. These years also saw the beginning 

of a surge in psychiatric admissions and behavioral 

problems throughout the Army—and especially in 

Vietnam.

Over time, the reality in Vietnam proved to be far 

different than expected. The combat exhaustion casualties that were predicted never materialized and the 

replacement Army psychiatrists and allied personnel 

who served in Vietnam from 1969 on found themselves 

in a radically different war (and with a radically different Army) than was faced by those who served in previous wars (with their emphasis on psychiatric attrition 

among soldiers worn down by sustained combat) or 

those who preceded them in Vietnam. Furthermore, 

psychiatrists with appreciably less military experience, 

including those in leadership positions, were sent 

even as the problems in the theater were multiplying. 

Not only were they challenged with unprecedented 

levels of psychiatric and behavior problems, it was 

unprecedented for these rates to rise while the United 

States was reducing its military and political presence 

in South Vietnam, US forces were gradually turning 

the fighting over to the Army of the Republic of South 

Vietnam, and US casualty rates were declining.

What military psychiatry ultimately encountered 

in large numbers were young troops with severe 

demoralization, a progressive reluctance to soldier, 

antagonism—sometimes violent—toward military 

authority, and a variety of psychiatric conditions and 

behavioral disorders. Theater psychiatric hospitalization statistics indicate a 4-fold increase compared to 

the early war years. Related, and even more remarkable, was the common and casual use of heroin by a 

large proportion of US troops, although most were not 

addicted. At its worst point, one out of every eight enlisted soldiers was medically evacuated from Vietnam 

because of narcotic use.
35

US Army Psychiatry Legacies of the Vietnam War

These accelerating psychiatric conditions and behavior problems, which coincided with America’s repudiation of the war and the counterculture passions of their 

civilian peers, were certainly consequential to serving in 

the combat theater, but in most cases they had little or 

no direct connection to combat activity. It appears that 

many soldiers more or less disabled (or demobilized) 

themselves through mental disorders, drug use, and 

other symptoms and forms of misconduct. 

Regarding the response of the deployed mental 

health elements, because the rising theater and deployment demoralization and alienation-driven problems 

arose far more predictably among noncombat troops, 

the center of effort shifted to hospital-based mental 

health assets and gradually overtaxed the psychiatric 

and related medical resources. These problems mostly 

failed to yield to conventional psychiatric approaches, 

and increasingly drastic administrative and law 

enforcement measures were required. The late-war 

psychiatrists complained about being unprepared 

and may have become uncertain of their goals and 

structures. They may have also shared, to some degree, 

the demoralization and antimilitary passions of the 

soldiers with whom they served. Combat readiness 

went thankfully untested by the enemy. Nonetheless, 

it is striking that there were no structural changes in 

the organization of mental health assets in Vietnam or 

modifications in the selection, preparation, or deployment of mental health personnel sent as replacements 

to the theater. 

With the advantage of the relative objectivity offered 

by the passage of time, it can now be acknowledged 

that the models for understanding and anticipating 

casualties both from combat stress and from deployment stress are considerably more complex than was 

understood before—or even during—the Vietnam 

War. The earlier model was derived from observations of troops fighting in sustained, intense combat 

environments, and it primarily weighed combat stress 

against resiliency of the individual soldier (although 

the buffering effects of allegiance to combat buddies 

and other factors were considered to be vital). But in an 

extended, “low-intensity,” counterinsurgency conflict 

the model must be broadened to also take into account 

other critical, compounding, and often indirect influences of the combat theater. A list centered around 

“soldier variables” might include the usual ones, that 

is, (a) the nature and setting of the fighting; (b) training 

and expertise; (c) physical condition; (d) background 

and personality; (e) social circumstance (within the 

small combat unit as well as the soldier’s network of 

family and friends); (f) confidence in military leaders 

and equipment; and (g) commitment to the military 

goals. It might also, and surely not least, include the 

necessity to ensure that soldiers believe the country 

requires, as well as values, the inherent risks and sacrifices they undertake. 

Retrospective suggestions generated out of the 

Vietnam War especially include the need for the 

military to develop a multivariate concept of combat 

“theater” breakdown (as opposed to combat breakdown) that considers both the symptomatic soldier 

and the dysfunction arising in groups of soldiers, 

and to employ an epidemiological approach for 

early recognition of deteriorating psychosocial and 

psychiatric circumstances. For example, in Vietnam a 

psychiatric field research team could have been created for the sole purpose of collecting, analyzing, and 

disseminating information regarding a wide array of 

often initially innocuous indices of flagging morale 

(eg, rising malaria rates among soldiers subverting 

malaria prophylaxis as a means of avoiding service). 

This information could have then served for clinicians 

and commanders as a timely map of the psychosocial “terrain” of stressors, morale, performance, and 

symptom patterns of the troops, which would have 

permitted the development of early intervention 

measures. Such an epidemiologic approach could 

have been combined with systematic debriefing of 

returning psychiatrists to redirect some of the attention of replacement psychiatrists from a combat stress 

model toward a social stress model of psychiatric 

dysfunction. 

Other structural adaptations as the war in Vietnam lengthened might have included: (a) extending 

the tours of each of the theater Neuropsychiatry 

Consultants (as well as tours of other psychiatrists in 

leadership positions) to provide needed continuity; (b) 

increasing the level of seniority of the replacement military psychiatrists as the pool of experienced civilian 

psychiatrists unavoidably decreased; and (c) linking 

numbers of deployed psychiatrists to epidemiologically documented need, rather than to overall troop 

strength. Finally, a policy could have been established, 

presuming it met overall mobilization needs, requiring 

that each recently graduated psychiatrist serve some 

time with a stateside military unit before departing 

for Vietnam.

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Preparation for Deployment: Improving Resilience

Chapter 3

PREPARATION FOR DEPLOYMENT: 

IMPROVING RESILIENCE

PATRICIA WATSON, PhD*; BRETT LITZ, PhD†; STEVEN SOUTHWICK, MD‡; and ELSPETH CAMERON 

RITCHIE, MD, MPH§

INTRODUCTION

THEORETICAL MODELS OF STRESS, TRAUMA, AND RESILIENCE

Stress

Trauma

Resilience

EVALUATING RESILIENCE OUTCOMES

MEASUREMENT OF RESILIENCE FACTORS IN THE MILITARY

INTERVENTIONS FOR BUILDING RESILIENCE AND PREPAREDNESS

Toughening Responses to Stress

Building Strengths Through Training Programs 

Building Resilience Through Self-Help Programs 

Teaching Skills Commonly Utilized During Survival Situations 

Reinforcing Skills Through Military Training 

SUGGESTIONS FOR FUTURE RESEARCH ON RESILIENCE

SUMMARY

*Assistant Professor, Dartmouth Medical School, 1 Rope Ferry Road, Hanover, New Hampshire 03755-1404; Senior Educational Specialist, Executive 

Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont 

†

Professor, Department of Psychiatry, Boston University School of Medicine, 77 East Concord Street, Boston, Massachusetts 02118; Associate Director, 

Behavioral Sciences Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont

‡

Professor, Department of Psychiatry, Yale University School of Medicine and Yale Child Study Center, 333 Cedar Street, New Haven, Connecticut 06510; 

Adjunct Professor, Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, New York 10029; Deputy Director, 

Clinical Neurosciences Division, Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, Vermont

§

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

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

Avenue NE, 4th Floor, Washington, DC 20002
44

Combat and Operational Behavioral Health

INTRODUCTION

With ongoing military operations in Afghanistan 

and Iraq involving multiple deployments for military 

personnel, there is growing interest in preparatory 

training activities that can increase service members’ 

resilience to the stress of deployment. Service members 

are trained in numerous ways that promote adaptation 

to the stress, strain, and sacrifices of deployments. For 

example, physical fitness training, mission preparation, specialty role training, experiences that promote 

confidence in leaders and trust in peers, and messages 

that emphasize the purpose and function of mission 

goals are necessary ingredients to successful navigation of various deployment demands. It is not known 

whether these standard training activities enhance coping capabilities in the face of severe mission demands 

and traumas. Nor is it known whether existing training regimens effect risk for stress injuries and mental 

health difficulties linked to deployment stress. Finally, 

no systematic research has been conducted to date 

on preparedness interventions specifically designed 

to build psychological resilience and prevent the development of posttraumatic stress disorder (PTSD) in 

military personnel. 

The lack of empirical literature to support unit 

preparedness interventions is compounded by the 

lack of an accepted or unified conceptual framework 

that defines the necessary and sufficient ingredients 

for resilience in the face of trauma. In addition, because most research on combat stress has been crosssectional, little is known about risk, protective, and 

vulnerability factors, and the mechanisms, processes, 

and pathways of influence through which they exert 

their influence on trajectories of adaptation to deployment stress.1

 Unfortunately, the constructs used 

to define resilience are often extrapolated loosely or 

interchangeably. Furthermore, research in resilience, 

hardiness, coping self-efficacy, and biological components of resilience has been conducted within the 

areas of developmental pathology, trauma, and positive psychology, with little cross-referencing among 

these disciplines.2

Because of the high probability of exposure to severe 

stress and the extensive motivation to retain a ready 

and fit fighting force, the military is a natural laboratory to study the effectiveness of resilience-building 

strategies. What few findings do exist from the adult 

literature on resilience often come from studies of 

men in combat. These studies suggest that resilience 

is related to an ability to bond with a group with a 

common mission, a high value placed on altruism, the 

capacity to tolerate high levels of fear and still perform 

effectively, and psychobiological factors related to a 

low tendency to dissociate.3

 This chapter will extrapolate from theoretical models about resilience as well 

as related fields investigating stress, traumatic stress, 

and recovery from trauma. The goal is to generate an 

agenda for resilience training that can be examined in 

future research.

THEORETICAL MODELS OF STRESS, TRAUMA, AND RESILIENCE

It is necessary to first define theoretical models and 

core constructs related to stress, trauma, and resilience, 

as well as the implication of these models for preparation and early intervention. 

Stress

Research on posttrauma mental health belongs to 

the broader field of stress research. Stress theory generally assumes that external demands (the traumatic 

event as primary stressor) evoke responses that draw on 

internal and external resources. Loss of resources, either 

concrete (social, financial) or symbolic (beliefs, expectations) may, as secondary stressors, significantly impact 

the recovery trajectory.4

 Survivors’ own responses 

(anxiety, insomnia, depression) may additionally tax 

overall resources, becoming tertiary stressors.5

 With 

sufficient infusion of resources and the passage of 

time, recovery is the expected outcome of time-limited 

exposure to a stressor (with great variation depending 

on the intensity and duration of the stressor6

). Stress 

management typically involves identifying and ameliorating those factors that interfere with recovery (lack 

of supportive others, ongoing stressors, maladaptive 

beliefs), and providing the resources that help support, 

organize, and make a plan for survivors.7

Trauma 

There is no single cause of maladaptive responses to 

trauma. Traumatic stress theories often draw on psychological and biological research that has identified 

and mapped processes distinctly reactive to traumatic 

stress.8,9 These findings support the proposition that 

when traumatic responses are overwhelming, uncontrollable, and involve extreme physiological arousal, 

they may consolidate the link between fear and traumatic recall, leading to avoidance, repeated recall, and 

ultimately to PTSD. Additional adversity, such as that 

often seen in the aftermath of extended deployments, 
45

Preparation for Deployment: Improving Resilience

can create a chain of mutually reinforcing reactions that 

may be present forever in a person’s memory.

Ehlers and Clark’s10 cognitive model of trauma suggests that preventive interventions focus on reframing 

negative appraisals of posttraumatic reactions, help 

individuals to distinguish between past and present 

threat, and help them process intrusive recollections. 

Specifically, 

	 •	 Individuals are at higher risk for persistent

PTSD when they make excessively negative 

appraisals of the trauma and exhibit disturbed 

memory processes such as poor elaboration 

and contextualization, strong associative 

memory, and strong perceptual priming. 

If individuals appraise their reactions to 

trauma negatively, they are at risk for enduring PTSD.11 Therefore, helping individuals to 

reframe their reactions in a more neutral or 

positive light should reduce the likelihood of 

long-term PTSD.

	 •	 Because a central process in PTSD is an inability to distinguish past trauma associations 

of threat with current conditions, Ehlers and 

Clark advocate interventions that assist with 

contextual discrimination of past and present 

circumstances via cognitive therapy.

Intrusive recollections are natural responses to severe and salient life events. Processing (sharing, articulating in a therapeutic manner) incongruous, intrusive, 

distressful, and unremitting recollections, as well as 

examining and correcting the cognitive and behavioral 

responses to them, are the unique factors that should be 

addressed by trauma interventions above and beyond 

stress and negative affect management.12

Recovery following traumatic stress is promoted by 

individually chosen disclosure and social support; the 

perception that the social milieu accepts one’s reactions 

and welcomes disclosure; seeing oneself as a hero or 

survivor rather than victim; a sense of relationship with 

“God,” a higher power, or some philosophical sense 

of meaning; and trauma-focused treatment that helps 

reframe negative reactions, process intrusive recollections, and assist in distinguishing past from present 

threat.13 Posttrauma social support and relatively fewer 

posttrauma negative events may serve as protective 

factors mediating posttrauma recovery.14,15

Resilience

The American Psychological Association Task Force 

on Promoting Resilience in Response to Terrorism 

defines resilience as “the process of adapting well in 

the face of adversity, trauma, tragedy, threats, or even 

significant sources of stress.”16 It cites many studies 

showing that the primary factors in resilience are (a) 

caring relationships within and outside the family 

that create love and trust, provide role models, and 

encourage and reassure; (b) the capacity to make realistic plans and implement them; (c) self-confidence; (d) 

communication and problem-solving skills; and (e) the 

capacity to manage emotions. It is generally accepted 

that resilience is common and derives from the basic 

human ability to adapt to new situations.17 

Most research on resilience comes from developmental psychopathology, where initially researchers 

tried to identify general characteristics associated 

with resilient recovery from stressors.18 These general 

characteristics included hardiness, efficacy (both self 

and collective), and neurobiological components of 

resilience. 

Hardiness

Research with hardy individuals suggests that 

they have various personal attributes that may foster 

resilience. They report seeking help and building large 

support networks, reframe their experiences more 

positively (difficulties as leading to benefits); believe 

they can change a stressor or recover from its detrimental effects; endorse focusing selectively on the positive 

effects of severe life challenges; view themselves as 

controlling their fate; are committed to meaningful 

goals; view stress as a surmountable challenge; are less 

likely to endorse behavioral disengagement, denial, 

mental disengagement, and use of alcohol to confront 

stress; and are more likely to describe themselves as 

problem solvers.19–21 

Maddi and Kobasa22 studied healthy executives to 

discern the methods they used to increase “mental 

toughness.” They found hardy people were committed to their work (they have a mission they believe 

in), have a sense of control over what happens in their 

life, and zestfully seek and take on challenges, feeling 

they will learn from the experiences. They seldom 

get sick. 

Coping Self-Efficacy

A sense of being able to be effective in the world 

is the foundation of human agency (the power to 

originate actions for a given purpose).23 Unless people 

believe they can produce desired results and forestall 

detrimental ones by their actions, they have little incentive to act or to persevere in the face of difficulties. 

It is partly on the basis of efficacy beliefs that people 

choose what challenges to undertake, how much effort 
46

Combat and Operational Behavioral Health

to expend in the endeavor, how long to persevere in 

the face of obstacles and failures, and whether failures 

are motivating or demoralizing. Benight and Bandura24

recommended that individuals be taught to set achievable goals, which will enable them to have repeated 

success experiences as well as to establish a sense of 

environmental control, thus increasing their resilience. 

Moreover, teaching new problem-solving skills can 

increase an individual’s sense of coping efficacy. A 

strong sense of coping efficacy, in turn, reduces vulnerability to stress and depression in taxing situations 

and strengthens resiliency to adversity.

Collective Efficacy

Social cognitive theory extends the conception of 

individual efficacy to “collective agency,”25 which is 

particularly relevant to the military. People’s shared 

belief in their collective power to produce desired 

results is a key ingredient of collective agency. The findings taken as a whole demonstrate that the stronger 

the perceived collective efficacy, the higher the group’s 

members aspirations and motivational investment in 

their undertakings, the stronger their staying power in 

the face of impediments and setbacks, the higher their 

morale and resilience to stressors, and the greater their 

performance accomplishments. Both at the societal and 

individual level of analysis, a strong perceived efficacy 

fosters high group effort and performance attainments. 

Military leaders’ efforts to shape collective efficacy 

require merging diverse self-interests in support of 

common core values and goals.

Military communities play a proactive role in the 

resilience-building process by planning and constructing environmental conditions to promote preparedness, leadership, and support.23,25 Social resources, such 

as social support, socioeconomic status, and access to 

services, have shown strong effects on mental health 

and played a variety of roles in the stress process.26

Mediational analyses show that social support provides its benefits to the extent that it raises perceived 

self-efficacy to manage environmental demands.27

However, beyond receiving positive social support, 

a number of research studies indicate that it is not positive social support, but negative social support, that 

affects recovery. Dunmore, Clark, and Ehlers28 reported 

that perception of negative social interactions, rather 

than perceived positive support, predicts chronic 

PTSD. It would appear that the military would benefit 

from programs that build and maintain buddy support 

(including conflict resolution), model and reinforce 

social support, and teach strategies for providing support and understanding to those service members, for 

whatever reason, who express dissatisfaction or show 

signs of disengagement and withdrawal. 

Neurobiological Factors

Neurobiological factors play a central role in the 

capacity to tolerate stress and trauma. Twin studies 

have found that overall heritability of PTSD ranges 

from 28% to 33%.29 DNA (deoxyribonucleic acid) 

studies have found that a variety of gene polymorphisms contribute to stress reactivity and possibly the 

development of trauma-associated psychopathology. 

Examples include differences in sympathetic nervous 

system activity (polymorphism of the α-2C-adrenergic 

receptor gene),30 cortisol release in response to psychosocial stress (glucocorticoid receptor gene variant),31

and serotonin metabolism (polymorphism of the 

serotonin transporter gene).32

The role of serotonin metabolism in stress reactivity 

was studied by Caspi,32 who found that a functional 

polymorphism in the promoter region of the serotonin transporter gene moderated the influence of 

stressful life events on the likelihood of developing 

depression. Among individuals who had experienced 

childhood maltreatment, those with two long alleles 

were significantly less likely to develop depression 

than those with two short alleles. Thus two long 

alleles appear to protect against trauma-related psychopathology while two short alleles are associated 

with vulnerability to trauma. Of note, it appears that 

environmental factors can serve a protective role even 

among those with a genetic vulnerability. Kauffman33

recently found that strong social support protected 

against the development of depression in traumatized foster children, even among those with genetic 

vulnerability (ie, two short alleles of the serotonin 

transporter gene). 

A wide variety of hormones, neurotransmitters, 

and neuropeptides that are known to be activated by 

stress and trauma are also thought to be associated 

with resilience. In a comprehensive literature review, 

Charney3

 highlighted eleven neurochemicals that appear to have particular relevance to the neurobiology 

of resilience. The evidence posits that resilient individuals will score in the highest range for measures 

of dehydroepiandrosterone (DHEA), neuropeptide 

Y (NPY), galanin, testosterone, serotonin (5-HT1a), 

and benzodiazepine receptor function. These same 

resilient individuals will score in the lowest range 

for hypothalamic-pituitary-adrenocortical (HPA) 

axis, corticotropin-releasing hormone, and locuscaeruleus-norepinephrine activity. The findings are 

opposite for those individuals vulnerable to stress. For 

example, NPY is an amino acid that helps to maintain 

sympathetic nervous system reactivity within an 
47

Preparation for Deployment: Improving Resilience

optimal range. Under conditions of danger, the sympathetic nervous system (SNS) releases epinephrine 

and norepinephrine (NE) as part of the fight–flight 

response. During these high-stress situations, NPY is 

also released and helps to inhibit continued release of 

NE so that the SNS does not overshoot and possibly 

contribute to anxiety, hypervigilance, and fear. High 

levels of NPY during extreme training stress have been 

associated with adaptive performance in Special Forces 

soldiers. It is likely that robust increases in NE are held 

in check by similarly robust increases in NPY among 

these highly resilient soldiers.3,34,35

Galanin and DHEA are two other neurochemicals 

that may enhance resilience by containing or modulating the stress response.3

 For example, cortisol is released during stressful situations and helps to mobilize 

energy stores and increase arousal, selective attention, 

vigilance, and consolidation of emotional memory, all 

of which tend to be adaptive. However, when cortisol remains chronically high and unchecked, it can 

have toxic effects on the body and brain.36,37 DHEA, 

which is released with cortisol, helps to lower levels 

of cortisol, and thus has protective effects.35 Like NPY, 

high DHEA-to-cortisol ratio has been associated with 

better performance in Special Forces soldiers during 

high-stress training exercises and may play a role in 

modulating psychological, physiological, and behavioral responses to stress. 

It is likely that individual neurobiological factors 

by themselves have relatively limited impact on stress 

resilience. However, in accordance with a model of allostasis,38 the additive effects of multiple neurobiological factors may have a substantial effect on resilience. 

Thus, Charney3 hypothesized that resilient individuals 

might be those with relatively high stress-induced 

NPY, galanin, DHEA, and testosterone, and relatively 

low stress-induced SNS and HPA-axis activation. 

Numerous brain regions and neural pathways involved in the processing and regulation of fear, learning, memory, reward, emotion, motivation, and social 

behavior are also undoubtedly involved in resilience to 

stress. For example, resilience may be associated with 

optimal stimulation or inhibition of prefrontal corticalamygdala circuitry, which would facilitate appropriate 

and adaptive responses to stressors. Similarly, the capacity for mutual cooperation, social bonding, positive 

emotions, and hope in the face of adversity, all of which 

have been associated with resilience, may be dependent on well-functioning reward circuitry involving 

the nucleus accumbens dopamine system.3,34

It is likely that relevant neurotransmitter and hormone systems, as well as neural pathways, can be 

modified by experience. Developmental studies have 

shown that early experiences with stress can have 

long-term effects on behavioral and neurobiological 

responses to future fear and stress.38 Thus, uncontrollable or overwhelming stress during infancy can 

cause exaggerated emotional, SNS, and HPA-axis responsiveness to future stressors even into adulthood. 

Mild-to-moderate stressors that are controllable can 

have a “steeling” or stress inoculating effect, where the 

organism becomes less reactive to future stressors.39

Although attention and arousal are necessary for survival, going outside an optimal range has detrimental 

biological effects. During stress, multiple cortical and 

subcortical brain regions (including sensory, motor, prefrontal and cingulate cortex, hippocampus, 

amygdala, thalamus, striatum, midbrain, and brain 

stem monoaminergic nuclei and hypothalamus) 

become activated. Communication between these regions facilitates evaluation of, psychomotor response 

to, and memory for stress-related events. Although 

arousal may be life saving, it has been hypothesized 

that excessive and sustained arousal following trauma 

may increase the likelihood of developing PTSD.5,40,41

Numerous animal studies have shown that extended 

and excessive states of alarm and arousal may contribute to stress sensitization and long-term potentiation,42

both of which likely contribute to trauma-related 

psychopathology. 

Understanding and working with biological components of resilience is an area with great potential for 

intervention. Based on the neurobiological findings on 

use-dependent neuroplasticity, it is likely that certain 

preparation and training regimes will alter relevant 

neural and neurotransmitter systems that are involved 

in resilience to stress. These include training to regulate 

emotions, face fear, dispute and reappraise negative 

cognitions, find positive meaning in adversity, help 

others in need, and attract social support. 

Defining Resilience 

Resilience is generally considered to be “multidimensional,”18 with different characteristics 

expressed variably across many areas of the individual’s life (eg, occupation and social). These 

“resilient trajectories” may be uneven.18,43 For example, an individual may function adequately in 

work settings following a trauma but suffer from 

interpersonal numbing or withdrawal. Furthermore, 

the expression of resilience is influenced by context: 

the quality of the stressor, the individual’s traits, and 

the surrounding culture.43 Many researchers in this 

area conclude that resilience is not a fixed attribute 

but a type of “functional trajectory” dependent on 

circumstances and individual variations (eg, vulnerability and protective mechanisms) in response to 
48

Combat and Operational Behavioral Health

risk. If circumstances change, resilience trajectories 

can change.18,44

Multidimensional analysis indicates that resilient 

behavior in one domain may extract a price in another; 

for example, competence in work domains may involve emotional detachment from family problems,45,46

and at-risk individuals with exemplary behavior may 

experience internal distress.47,48 Finally, there has been 

some acknowledgment that the factors that bolster 

resilience may not be adaptive in all domains (ie, sociopathy and narcissism13). 

Experts in the field of resilience hold that all plans 

for research and intervention should clearly define 

resilience as a state, not a trait.18 Therefore, they recommend avoiding the term “resiliency,” with its connotation of a trait. Rather, it is recommended to use the 

phrase “resilient trajectory or adaptation,” explaining 

that these trajectories vary across situations and within 

individuals at different times.18

Indeed, resilience is both a process and an outcome. There are resilient outcomes (eg, in the face of 

enormous combat traumas, a service member does 

not develop any mental health problem or significant 

problems functioning) and there are resilient processes 

(mechanisms that create resilient outcomes), which 

change over the life-course, as demands, circumstances, and service members change. The goal of 

resilience training is to promote or augment existing 

personal and social resources and create new resources 

that contribute to adaptation.

EVALUATING RESILIENCE OUTCOMES

Three things are necessary to evaluate resilience as 

an outcome: (1) the nature of the exposure to trauma; 

(2) the prevalence of symptoms and problems, with 

an emphasis on the degree of subjective distress and 

suffering; and (3) functional capacities in diverse areas 

(eg, work, leisure, self-care, relationships). However 

resilience is operationalized, successful adaptation or 

recovery from deployment trauma within and across 

service members is dependent on the nature of the 

trauma and the extent of exposure to war-zone events. 

It is inappropriate to compare resilience across individuals without accounting for variability in exposure 

to trauma. In the case of severe and extensive war-zone 

trauma, resilience should not be narrowly defined as 

the absence of posttraumatic mental health disorders, 

such as PTSD. Service members will report a variety 

of symptoms reflecting the enduring psychological 

impact of their deployment experiences. What should 

define resilience is not the mere absence of symptoms, 

but the degree of subjective distress caused by these 

problems and, more importantly, the extent to which 

their functioning is compromised.49

In terms of studying resilience as a process, measures need to be developed to evaluate individual 

differences in protective factors and processes, so 

that studies can test potential mechanisms mediating 

exposure to trauma and outcome. Other goals would 

be to describe the prevalence of various resilience 

indicators in a given trauma context across time and 

to evaluate the efficacy of interventions designed to 

promote resilience. What mechanisms or processes 

facilitate resilience at a given posttraumatic interval? 

One way to look at resilience is that resources and 

strengths in the individual and in the group’s culture 

(eg, a cohesive and supportive squad in the military) 

outweigh the influence of liabilities and weaknesses. 

In this context, individual and social resources are 

used to: (a) manage posttraumatic demands; (b) find 

meaning, purpose, and hope; (c) reduce or eliminate 

current adversities and stressors; and (d) derive 

positive feelings from various repertoires of activities (eg, work, leisure). In research on resilience, it is 

particularly important to recognize that the process of 

resilience lies in both the individual and in the environment (and the transaction of the two). A thorough 

evaluation of resilience resources should take into account social-demographic factors, current adversities, 

social networks, and intimate relationships. 

MEASUREMENT OF RESILIENCE FACTORS IN THE MILITARY

The Deployment Risk and Resilience Inventory 

(DRRI)50,51 treats resilience as an unfolding process and 

multidimensional construct, with the individual, exposure characteristics, and the social milieu (within the 

military and in the home) seen as equally important. It 

was developed based on literature review, survey and 

focus group input, and confirmatory factor analysis, to 

assess risk and resilience variables that are related to 

health and well-being following military deployments. 

The DRRI assesses risk and resilience in 14 domains, 

divided into prewar factors, war-zone factors, and 

postwar factors.

Prewar Factors:

1. Childhood family environment (cohesion, 

closeness of family)

2. Prior stressors (exposure to highly stressful 
49

Preparation for Deployment: Improving Resilience

or traumatic events)

War-Zone Factors:

3. Preparedness (perceived preparedness, 

including belief in quality and quantity of 

equipment, supplies, and training)

4. Combat (exposure to objective warfare experiences)

5. Aftermath of battle (observing or handling 

remains, dealing with prisoners of war, 

exposure to devastated communities and 

refugees)

6. Perceived threat (subjective fear for one’s 

safety and well-being in war zone)

7. Difficult living and working environment 

(day-to-day pressures, discomfort, deprivation)

8. Concerns about life and family disruptions 

(career-related concerns, family concerns)

9. Sexual harassment (exposure to unwanted 

sexual touching or verbal conduct)

10. General harassment (harassment on basis of 

biological sex or minority status)

11. War-zone social support (assistance and 

encouragement from leaders, other unit 

members)

12. Nuclear, biological, and chemical exposures

Postwar Factors:

13. Postwar social support (emotional sustenance and instrumental assistance from 

family, friends, coworkers and employers, 

community)

14. Postwar stressors (general stressful events 

such as accidents, illness; reintegration issues 

such as job interruption, difficulties reestablishing roles)

Because the DRRI is specifically geared to evaluate 

adaptation to deployment stress and trauma, and is 

psychometrically sound, its broad use is recommended. However, the DRRI does not measure individual 

differences in psychological resilience, which is also 

an important personal resource. Prior to enlistment, 

all service members possess varying degrees of an 

innate and acquired capacity to manage serious life 

challenges and threats effectively (resilience). Unfortunately, there is no “gold standard” method of 

evaluating resilience as a individual characteristic, 

which should not be surprising because there is no 

unified conceptual or definitional framework. One 

measure that has been found to have adequate content 

coverage is the Connor-Davidson Resilience Scale,52

which is a 25-item questionnaire tapping attitudes 

about coping with adversity (eg, “having to cope 

with stress makes me stronger”). Items require respondents to indicate their degree of endorsement on 

a five-point scale ranging from not true at all to true 

nearly all the time. Connor and Davidson reported 

a Cronbach’s alpha of .89 in a validation sample of 

general population subjects, which shows that this 

instrument is highly likely to elicit consistent and 

reliable response even if questions were replaced with 

other similar questions.

The National Center for PTSD is developing a measure called the Response to Stressful Experiences Scale, 

which seeks to measure resilience. The scale has been 

structured to cover the following putative mechanisms 

of resilience:

	 • Behavioral. The actions (active or passive) 

an individual exhibits in response to an intense life stressor that facilitate a return to 

psychological baseline functioning or to psychological growth, including actions aimed at 

marshalling social support. 

	 • Emotional. The degree of effectiveness regarding how to use one’s emotions to achieve 

one’s goals. This is accomplished by managing emotional reactions in a flexible, situationappropriate manner.

	 • Cognitive. Conscious thoughts, perceptions, 

and expectations aimed at adapting to, or 

overcoming, stressful situations by orienting 

one’s beliefs when useful, to include a realistic 

and accepting stance about personal vulnerability, the likelihood of future risks, and the 

ability to achieve personal growth. 

It is hoped that by measuring multiple domains, 

a more useful and accurate level of resilience can be 

obtained.

INTERVENTIONS FOR BUILDING RESILIENCE AND PREPAREDNESS

It could be argued that the military continuously 

fosters resilience in service members from recruitment and basic training to retirement. It is beyond 

the scope of this chapter to catalog and operationally 

define all the resilience-building efforts in the lifespan 

of a service member. Instead, this discussion will focus on efforts that occur or should be considered to 

lessen the mental health impact of various deployment 
50

Combat and Operational Behavioral Health

hardships, adversities, and serious traumas (primary 

prevention). 

It is unclear at present whether preparation is likely 

to inoculate individuals fully against severe trauma. A 

number of strategies extrapolated from different fields 

are described as possible components of preparation 

and prevention. One factor that needs consideration 

is that preparation requires motivation, foresight, and 

time and energy, which may not be realistic and cost 

effective under all circumstances. If preparedness is 

not feasible, research suggests that preventing resource 

loss is more efficient in promoting recovery than attempting to introduce additional resources following a 

traumatic event.6 Other programs designed to prepare 

individuals are discussed next. 

Toughening Responses to Stress

Can individuals become better prepared for deployment and combat? The literature on “toughness” suggests that under certain conditions, repeated episodes 

of challenge or threat followed by recovery periods 

(eg, aerobic exercise and working in cold environments) can “toughen” the neuroendocrine system’s 

response to stress. People who undertook programs of 

aerobic training, for instance, were subsequently more 

energetic and more emotionally stable than they were 

before such an experience.53 Better performance and 

learning in even complex tasks was associated with 

greater adrenergic responsiveness in humans. 

Toughness is less relevant, however, to situations 

experienced as harm or loss, where negative outcomes already have occurred, or where instrumental 

coping is considered useless (eg, one can overwhelm 

organisms with excessively intense, extended, or unexpected training; even a single episode of a traumatic 

stressor can overwhelm). Combining unpredictability 

with great severity may overwhelm the organism’s 

capacity to recover, leading to weakness rather than 

toughness.54

Building Strengths Through Training Programs 

A recent expert panel reached consensus that any 

intervention program designed for situations of ongoing threat should incorporate elements designed to 

foster hope, safety, efficacy, calming, and connectedness.55 Learned optimism and positive psychology 

models56,57 incorporate many of these components to 

build strengths in people at risk. The components they 

apply to strength building and prevention include: 

instilling hope; building buffering strengths (ie, interpersonal skill, optimism, perseverance, capacity 

for pleasure, and purpose); narration, or the telling of 

stories about one’s life to another; and disputing (the 

skill of recognizing one’s own catastrophic and exaggerated thinking and effectively disputing it). 

Seligman has found that such training is selfreinforcing and prevents depression and anxiety in 

children and adults. This training is unique in that 

it focuses on building strength rather than repairing 

damage. Seligman’s intervention programs are called 

“training programs” rather than therapy, and yet they 

have similar beneficial effects as psychotherapy.57–59 

Building Resilience Through Self-Help Programs 

The American Psychological Association has recently placed an online module on building resilience 

on its self-help Web site.16 Leading researchers in the 

field of resilience and posttraumatic growth formed 

the committee that created the module. The Web site 

explicates basic self-help steps for improving resilience, based on empirical and consensus information: 

increasing social support, optimism, realistic appraisal 

and goal setting, emotional and social balance, and a 

mix of both problem-focused and emotion-focused 

coping. Because literature on adult learning suggests 

that self-paced instruction is important to successful 

mastery of material, this dissemination strategy may 

be highly effective in assisting soldiers with their own 

recovery course, particularly those who are worried 

about stigma involved with seeking assistance, and 

whose schedules are busy. 

Teaching Skills Commonly Utilized During Survival Situations 

Another approach to training resilience is to interview those who have survived highly stressful circumstances to gain an understanding of common factors 

that are helpful in survival. For instance, a recent case 

study60 illustrates that the use of problem-solving 

techniques in trauma survivors enabled them to retain 

a sense of efficacy and control during life-threatening 

situations. Examples of strategies employed by survivors include the following: 

	 •	 recalling and practicing skills from previous

education about the situation they were in (ie, 

safety and breathing);

	 •	 having confidence in friends to help;

	 •	 analyzing everything closely, and demanding

results;

	 •	 dismissing thoughts of death as unconstructive; 

	 •	 concentrating on how to pacify the person

making the threat; 

	 •	 feeling a sense of control;

	 •	 remaining calm;
51

Preparation for Deployment: Improving Resilience

	 •	 thinking of loved ones;

	 •	 prayer;

	 •	 concentrating on positive coping actions;

and

	 •	 not letting sounds or sights distract them.

Basic survival skills have been delineated by Gonzales,61 who conducted case studies and interviews with 

hundreds of people who had survived life-threatening 

situations. The following list includes the six factors 

that are commonly observed across those who survived dangerous situations.

1. Knowing as much as you can about the situation ahead of time, keeping in mind that the 

forces may be so large (or fast) that they are 

difficult to imagine.

2. Being adaptive and flexible, based on a true 

reading of the environment, and changing 

behavior accordingly.

3. Quickly organizing, setting up routines, and 

instituting discipline; breaking down very 

large jobs into small, manageable tasks; setting attainable goals and developing shortterm plans to achieve them; and dealing with 

what is within your power from moment to 

moment and leaving the rest behind.

4. Knowing your abilities and not over- or underestimating them.

5. Being able to assess and stop if it is clear 

that the environment does not support going forward, no matter how much you have 

planned; being realistic about goals and timeframe, then being content with just being in 

the process.

6. Cultivating a positive mental attitude by:

	 •	 Realizing that life is not always fair.

	 •	 Having fortitude, patience, courtesy, modesty, decorum, and the will (in the worst of 

situations) to do your best.

	 •	 Celebrating successes, and taking joy in

completing tasks, even small ones.

	 •	 Creating an ongoing feeling of motivation, preventing hopelessness, and giving 

yourself small breaks from the stress of the 

situation.

	 •	 Being determined to be careful and do your

best, and becoming convinced that you will 

succeed.

	 •	 Not becoming discouraged by setbacks; accepting that the environment is constantly 

changing; picking yourself up and starting 

the entire process over again, if necessary, 

in manageable steps; and embracing the 

world in which you find yourself and seeing opportunity in adversity.

Military personnel may be better prepared for 

deployment stresses if they have specific information to help them master life-threatening situations 

and are instructed in how to use this as part of their 

problem-solving strategy. In addition to teaching 

skills for specific situations, it may be important to 

prepare individuals to cope with unexpected situations 

where they may feel confused, bewildered, or helpless. Bell’s62 resilience program seeks to address these 

issues through the use of esoteric training principles, 

including meditation exercises that develop steadiness, 

clarity, pliancy, mindfulness, and emotional endurance. These principles, however, have not been tested 

in situations of traumatic stress.

Reinforcing Skills Through Military Training 

Military training focuses on preparation of personnel for battle or other chaotic and disastrous situations. 

The US military strives to prepare its soldiers for 

potential exposure to combat, operations other than 

war, and the stresses of deployment in many ways. 

In combat units, there are many hours devoted to 

field training exercises (some quite long), to include 

exposure to live fire, with reduced sleep, at a high pace 

of operations. Those trained at the Suvival, Evasion, 

Resistance, and Escape (SERE) schools undergo extremely stressful mock captures and interrogations at 

a simulated prisoner-of-war camp. Training in nuclear, 

biological, and chemical warfare is also standard, 

including maintenance of the gas mask and donning 

the mask within 9 seconds. Especially overseas, there 

are exercises in wearing the chemical protective suit 

for long periods of time while performing one’s job. 

The constant repetition and standardized measures of 

mastery are intended to foster a sense of control for the 

service member, at the same time sending the message 

that “we are prepared for anything that may come our 

way down range.” 

Unit cohesiveness is another critical protective factor in war. Spiegel63 speculated that it was regard for 

comrades, respect for leaders, concern for the reputation of the group, and an urge to ensure the success of 

the unit that kept soldiers fighting in World War II.64

Furthermore, he identified that when individual’s decompensated it was often after a change in the soldier’s 

relation to the group.63 During the Vietnam War, it was 

observed that ultimately this unit cohesiveness does 

not represent an altruism born of interpersonal attraction but rather the realization that a soldier’s survival 

depended upon his ability to make others willing to 

help him in his own time of need.65 This cohesiveness 

can extend throughout an entire organization, with the 
52

Combat and Operational Behavioral Health

unit serving as an extension of individual pride. The 

soldier’s self-esteem becomes linked to the reputation 

of the unit, providing additional motivation. In other 

words, an individual’s identity is not just about self 

but also incorporates a collective identity that, when 

well developed, is a protective factor.

Physical fitness is also an essential component of 

military training. Throughout their career, service 

members must take a physical fitness test twice a year. 

This ensures that service members maintain at least a 

reasonable degree of physical fitness, despite having 

many other taskings. In the elite units, physical training is a high priority. In addition to preparing soldiers 

for the physical exertion necessary in battle, physical 

fitness has also been strongly linked to reductions in 

stress, anxiety, and depression.66

Drills and exercises are another component of 

preparedness and building resilience. In the Navy, 

for example, the drills may be centered on reacting to 

fires, the ship sinking, “man overboard,” and other 

mishaps. These exercises utilize the constructs of stress 

inoculation, which in the civilian world takes the form 

of cognitive-behavioral methods to anticipate and 

diminish responses to anxiety-provoking events, with 

the aim of reducing the response to a perceived threat.67

Beyond enhancing cognitive knowledge, exercises in 

the military encourage bonding and a sense of mastery 

about disaster. Some of the military survivors of the 

September 11, 2001, attack on the Pentagon believed 

that previous drills prepared them for the chaos of the 

exit, while civilian employees complained that they 

were underprepared.68

Despite the potential benefit of stress inoculation 

and drills, recent experience has shown that many 

military members are not prepared for the sights and 

smells of civilian casualties, nor the experience of handling the bodies of their friends or the enemy. For example, after the USS Iowa explosion, when shipmates 

handled the bodies of their friends, several developed 

PTSD symptoms.69 The US Army has developed a 

pamphlet, Just the Facts . . . Dealing With the Stress of 

Recovering Human Dead Bodies, to provide guidance on 

how troops should handle remains in order to reduce 

stress levels.70 What is not currently known, however, is 

the best assortment and intensity of stimuli to prepare 

people, rather than oversensitize them.

In the military, leadership is always emphasized. 

Military leaders are taught to foster hardiness, unit 

cohesion, and morale by “leading by example”; facilitating open communication regarding how missions 

are planned; stating how mistakes or failures are corrected and learned from; seeking out (and creating if 

necessary) meaningful and challenging group tasks; 

remaining aware of the basic needs of the team (to 

include the need for rest); and providing opportunities 

for all individuals to make use of their unique coping 

skills (to include prayer or writing letters home). A 

study conducted with a group of Norwegian navy 

officer cadets demonstrated that units that increased 

significantly in cohesion after a stressful exercise also 

rated their leaders as better skilled and more caring 

and concerned compared to units that did not increase 

in cohesion. Individuals who see their leaders as more 

effective and concerned, even when these leaders 

are under extreme stress, are in turn more likely to 

interpret the experience positively. For group tasks, 

this positive interpretation is reflected in increased 

group cohesion. 

Another component to which the US military pays 

particular attention in preparation for deployment 

is the “state of affairs at home,” because emotional 

support has been shown to affect the impact of deployment.71 Data from the Israeli Defence Forces, 

for example, show that 30% of their casualties in the 

Lebanon War were caused by combat stress reactions. 

The Israeli Defence Forces found that soldiers who 

had experienced certain marital discord or stress in 

personal relationships were at high risk of suffering 

combat stress reactions.72 Recently, the US Army has 

developed a vigorous deployment cycle support 

plan called Battlemind73 to help reintegrate returning soldiers into their families and society, especially 

those who have been wounded. The Navy and Marine 

Corps have developed a multifaceted program centered around acknowledgement that stress reactions, 

injuries, and illness fall on a dimensional combat and 

operational stress continnum, with efforts to intervene 

with both service members and their families early in 

the continuum to reduce long-term problems.74–76

Finally, the military has been increasingly sensitive 

to properly recognizing the deceased. Following the 

attack of the USS Cole the leadership made a concerted 

effort to ensure that the deceased were given a proper 

military burial and that the survivors were allowed to 

pay their respects. By putting the crew to work to ensure 

a proper burial, the leader was giving the crew back a 

sense of control, sending the message to the survivors 

that each life is valuable and will be treated with due 

dignity, especially in death, and beginning the mourning 

process for those more closely linked to those lost.77

SUGGESTIONS FOR FUTURE RESEARCH ON RESILIENCE 

Primary prevention and training prior to stressful 

military situations often involves interventions such 

as teaching problem-solving skills or toughening 

exercises like those in military training. This form of 
53

Preparation for Deployment: Improving Resilience

stress inoculation is designed to foster “resistance.” 

However, by its nature traumatic stress is unpredictable and uncontrollable. Therefore, although stress 

resistance is related to specific or probable stressors, 

traumatic stress preparation should be geared more toward preparing individuals for the unexpected, when 

they may not yet understand what is going on, when 

conditions are new, and when they may feel confused, 

bewildered, or helpless. 

Another strategy seeks to enhance resilience by 

teaching certain factors that have worked for others 

following traumatic or stressful situations, such as 

social support and self-efficacy or positively changing 

beliefs or actions. This approach may involve building 

restorative, replenishing activities into the posttrauma 

schedule, having individuals try to find what might 

restore their inherent capacity to thrive, and raising 

awareness about the cost and benefit of denial at different phases postincident. Programs need to prepare for 

active outreach and assistance for weeks and months 

following deployment. 

It is important to keep in mind that what works for 

individuals in one context may not work for the same 

or other groups in others. A sensible research strategy 

for maximizing resilient trajectories before, during, and 

after deployment would be multidisciplinary, multifaceted, and sensitive to the context of the event, as well 

as to differential exposure and response. There is also 

a strong need to partner clinicians and researchers in 

designing and evaluating programs. 

It is also important to remain cautious in any statement regarding what interventions can accomplish 

toward prevention of long-term functional and symptomatic impact. For example, it is unknown whether 

interventions are associated with significant improvements in functioning. Additionally, care should be 

taken to include the preferences of soldiers when an 

intervention is planned. Research on service utilization indicates that the majority of individuals exposed 

to a traumatic event will not choose to seek mental 

health services, and therefore a careful study of what 

interventions are acceptable and supportive of natural 

recovery trajectories may be called for prior to strong 

recommendations for any mental health intervention. 

A more acceptable intervention than individual crisis 

response might be to provide a “resilience training 

model” that is implemented as part of basic training for 

all military personnel, as well as providing family and 

friends with the tools necessary for helping loved ones 

more effectively process traumatic or enduring stress.

SUMMARY

This chapter has extrapolated from theoretical 

models about resilience, as well as related fields 

investigating stress, traumatic stress, and recovery 

from trauma, to generate an agenda for resilience 

training that can be examined in future research. The 

construct of resilience represents a dynamic process 

involving protective and vulnerability factors in different risk contexts and developmental stages, and 

thus is an area of considerable interest and importance to the military. However, the lack of empirical 

literature to support unit preparedness interventions 

is compounded by the lack of an accepted or unified 

conceptual framework that defines the necessary 

and sufficient ingredients for resilience in the face of 

trauma or resilience-building interventions to prepare 

soldiers for deployment.

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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.
68

Combat and Operational Behavioral Health

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 
69

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 
70

Combat and Operational Behavioral Health

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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Combat and Operational Stress Control

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. 
74

Combat and Operational Behavioral Health

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.
75

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

Chapter 5

WALTER REED ARMY INSTITUTE OF 

RESEARCH CONTRIBUTIONS DURING 

OPERATIONS IRAQI FREEDOM 

AND ENDURING FREEDOM: FROM 

RESEARCH TO PUBLIC HEALTH POLICY

CHARLES W. HOGE, MD*; AMY B. ADLER, PhD†; KATHLEEN M. WRIGHT, PhD‡; PAUL D. BLIESE, PhD§; 

ANTHONY COX, MSW¥; DENNIS McGURK, PhD¶; CHARLES MILLIKEN, MD**; and CARL A. CASTRO, PhD††

INTRODUCTION

WALTER REED ARMY INSTITUTE OF RESEARCH

FROM RESEARCH TO PUBLIC HEALTH POLICY

INITIAL RESEARCH ON THE IMPACT OF MENTAL DISORDERS BEFORE 

SEPTEMBER 11, 2001

MENTAL HEALTH IMPACT OF THE PENTAGON ATTACK

RESEARCH RELATED TO OPERATIONS ENDURING FREEDOM AND IRAQI 

FREEDOM

OTHER WRAIR MENTAL HEALTH RESEARCH INITIATIVES

SUMMARY

*Colonel, US Army (Retired); formerly, Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Robert Grant 

Avenue, Silver Spring, Maryland 20910

†

Research Psychologist, US Army Research Unit—Europe, Walter Reed Army Institute of Research, CMR 442, APO AE 09042-1030

‡

Research Psychologist, US Army Medical Research-Europe, Walter Reed Army Institute of Research, CMR 442, Box 94, APO AE 09042; formerly, 

Deputy Chief, Department of Military Psychiatry, Walter Reed Army Institute of Research, Silver Spring, Maryland

§

Colonel, Medical Service Corps, US Army; Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Grant 

Avenue, Silver Spring, Maryland 20910

¥

Lieutenant Colonel, Medical Service Corps, US Army; Social Work Consultant, Great Plains Regional Medical Command; Chief, Social Work, Brooke 

Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 78234

¶

Major, Medical Service Corps, US Army; Commander, US Army Medical Research Unit—Europe, Walter Reed Army Institute of Research, CMR 442, 

APO AE 09042-1030

**Colonel, Medical Corps, US Army; Program Director, National Capital Consortium Psychosomatic Medicine/Geriatric Psychiatry Fellowship, Walter 

Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307; formerly, Principal Investigator, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, 503 Grant Avenue, Silver Spring, Maryland

††Colonel, Medical Service Corps, US Army; Director, Military Operational Medicine Research Program, US Army Medical Research and Material 

Command, 504 Scott Street, Fort Detrick, Maryland 21702-5012; formerly, Chief, Department of Military Psychiatry and Chief, Soldier and Family 

Readiness, Walter Reed Army Institute of Research, Silver Spring, Maryland
76

Combat and Operational Behavioral Health

INTRODUCTION

Research examining the mental health impact of 

war has typically been conducted years (and often 

decades) after combat.1–3 Before Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF), 

researchers at Walter Reed Army Institute of Research 

(WRAIR) established an international reputation in 

deployment psychology. This experience put WRAIR 

researchers in a position to become leaders in new 

initiatives to understand the psychological impact 

of OIF and OEF. During the 1991 Persian Gulf War 

(Operations Desert Shield and Desert Storm), WRAIR 

research teams surveyed and interviewed US Army 

units in theater and postdeployment to assess the 

psychological impact of deployment to combat.4–12

WRAIR teams also conducted in-theater research with 

units deployed to Operation Just Cause in Panama in 

1989,13 Operation Restore Hope in Somalia in 1993,14

Operation Uphold Democracy in Haiti in 1994,15 and 

throughout the Balkans in the mid-1990s in support 

of Operation Provide Promise in Croatia,16 Operation 

Joint Endeavor in Bosnia,17 and Operation Joint Guardian in Kosovo.18 When troop mobilizations began for 

both OEF and OIF in 2002 and 2003, researchers at 

WRAIR developed and executed a comprehensive 

research plan to examine the psychological health 

of soldiers during combat. This program provided 

real-time data as the war was occurring that led to 

multiple health policy changes to improve the mental 

health and well-being of service members and their 

families. This chapter outlines some of the key mental 

health research initiatives by WRAIR scientists with a 

focus on efforts that directly influenced mental health 

policies, programs, and training for service members 

serving in war. 

WALTER REED ARMY INSTITUTE OF RESEARCH

WRAIR is a premier Department of Defense 

(DoD) biomedical research center that integrates 

basic research and advanced technology to protect 

and sustain military service members. The WRAIR 

mental health research program is located at two 

sites: (1) the Department of Military Psychiatry, Division of Psychiatry and Neuroscience, at the main 

institute in Silver Spring, Maryland, and (2) the US 

Army Research Unit—Europe in Heidelberg, Germany. Approximately 35 employees work at the two 

sites. The program is multidisciplinary, including 

research and clinical psychologists, psychiatrists, 

social workers, and sociologists, as well as expertise 

in clinical evaluation and management, organizational psychology, individual and unit performance, 

leadership, psychiatric epidemiology, and healthcare 

services research. In addition to military psychology 

and psychiatry research, the division includes two 

other world-class research programs, one focused 

on sustaining performance during sleep deprivation 

and the other on reducing the impact of battlefield 

head injuries. 

FROM RESEARCH TO PUBLIC HEALTH POLICY

After the events of September 11, 2001, and the 

onset of the war in Afghanistan, WRAIR researchers 

embarked on a comprehensive research program to 

measure the mental health impact of OEF and OIF 

on military service members. The program, called 

“Interventions to Enhance Warfighter Psychological 

Resilience,” was predicated on the recognition that 

few studies examined combat-related mental health 

problems, posttraumatic stress disorder (PTSD), or 

healthcare utilization proximal to the time of war. Such 

population-based health service utilization research 

had generally been impossible in previous wars, in 

part because of the lack of integrated electronic databases, which became available only after the Persian 

Gulf War.

The research program also recognized the need 

for data to guide public health policies to address 

war-related mental health problems. The research 

agenda established by WRAIR focused on three types 

of products: (1) information products identifying 

factors that predict high rates of mental disorders, 

gaps in service delivery, stigma and barriers to care, 

and the association of mental health with functional 

impairment and readiness; (2) assessment tools that 

provide effective methods of conducting psychological health screening in deployed troops; and 

(3) prevention and early interventions to support 

psychological adjustment to the demands of combat, 

prevent stress-related performance degradation, and 

improve resiliency and health. These tools are the 

cornerstones of prevention and early intervention 

efforts. The remainder of this chapter lists WRAIR’s 

significant efforts and accomplishments from this 

research program.
77

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

INITIAL RESEARCH ON THE IMPACT OF MENTAL DISORDERS BEFORE SEPTEMBER 11, 2001

Using population-based healthcare data systems, 

researchers at WRAIR established baseline prevalence rates of healthcare service use for mental health 

problems before September 11, 2001.19–22 These studies, comparing major International Classification of 

Disease, 9th revision, illness categories, established 

that mental disorders were the most important 

source of occupational and medical morbidity as 

measured by use of medical services and attrition 

from service. The studies demonstrated that 12% 

of service members utilized mental health services 

each year, that mental disorders was the leading 

category of inpatient hospital bed days, and that 

mental disorders was the disease category most 

strongly correlated with attrition from military service and attrition from initial entry training. Such 

results provided a benchmark for understanding 

the importance of supporting the mental health of 

service members during the ensuing wars in Iraq 

and Afghanistan. 

MENTAL HEALTH IMPACT OF THE PENTAGON ATTACK

Immediately after the September 11th attack on 

the Pentagon, the Army Surgeon General’s Office 

established a comprehensive outreach program for 

Pentagon employees named “Operation Solace” and 

tasked the US Army Center for Health Promotion and 

Preventive Medicine to conduct a survey assessing 

the mental health effects on the employees. WRAIR, 

together with colleagues at the Center, Uniformed 

Services University of the Health Sciences, and the Office of The Army Surgeon General, rapidly developed 

and validated a brief survey instrument and provided 

descriptive data on the outreach program.23–25 This 

survey instrument, along with prototype instruments 

fielded during deployments in Bosnia and Kosovo, 

influenced the development of the Post-Deployment 

Health Assessment (PDHA) implemented by the DoD 

in 2003 to assess the population-level impact of deployment to a combat zone. 

RESEARCH RELATED TO OPERATIONS ENDURING FREEDOM AND IRAQI FREEDOM

In October 2001, the United States and coalition 

partners initiated OEF combat operations in Afghanistan, followed by OIF, the largest sustained ground 

operation since the Vietnam War, in Iraq in March 2003. 

The wars in Afghanistan and Iraq offered a unique 

opportunity to examine the mental health impact 

of combat deployment and, in turn, inform military 

health policy as the wars progressed. 

Epidemiological Consultations of Suicide and 

Homicide Clusters 

Just before OIF and OEF, WRAIR investigators 

established procedures to conduct epidemiological 

investigations of clusters of serious behavioral health 

problems, such as suicides or homicides, applying 

methodology developed for infectious disease outbreaks. Although infectious disease epidemiological 

consultations (EPICONs) were common in the military 

and in civilian public health departments, investigations of behavioral health clusters lacked well-established methodology. 

The first military behavioral health EPICON to 

establish the methodology was conducted in 2000. 

Its objective was to identify correlates of an outbreak 

of suicidal behaviors and completed suicides among 

soldiers in basic training at Fort Leonard Wood, Missouri.26 Since then, WRAIR investigators have been 

involved as part of Army Medical Department multidisciplinary teams in conducting EPICONS to address 

clusters of suicides and homicides at other posts. These 

clusters have been linked primarily to the high operational tempo of combat operations in Afghanistan and 

Iraq, as well as marital and family stressors.27–29

An EPICON that received national media attention 

pertained to a cluster of suicides and homicides at Fort 

Bragg, North Carolina, among soldiers involved in 

operations in Afghanistan.27 This investigation resulted 

in recommendations that led to the 2003 establishment 

of the Army Deployment Cycle Support Program,30 a 

comprehensive program designed to support soldiers 

and family members throughout the deployment cycle 

and assure that soldiers who return home from the 

combat environment because of serious family stressors are evaluated upon return to duty. 

Land Combat Study 

One of the most well known epidemiological surveillance studies pertaining to OIF and OEF is the 

large-scale, 5-year Land Combat Study. Initiated in 

2003, the study involves anonymous cross-sectional 
78

Combat and Operational Behavioral Health

and longitudinal surveys that assess the mental health 

and well-being of service members in combat infantry 

brigades serving in Iraq and Afghanistan. The surveys 

use validated measures to assess the mental health and 

well-being of service members at different points during their deployment cycle (before, during, and after 

deployment). Surveys have been collected from over 

50,000 service members, mostly from Army brigade 

combat teams but also from Marine Expeditionary 

Forces and Navy engineers working in ground operational units. Data have also been collected from 

military spouses. 

Data from some of the first units to return from 

OIF and OEF deployments were rapidly analyzed 

and published in the New England Journal of Medicine 

in July 2004.31 This publication provided the first 

systematic look at the mental health of soldiers and 

Marines involved in combat operations in Iraq and 

Afghanistan. The study indicated that 12% to 13% of 

soldiers and marines from combat units surveyed 3 to 

4 months after returning from deployment to Iraq met 

the screening definition of PTSD, compared with 5% 

at predeployment. In addition, 15% to 17% of those 

surveyed at postdeployment met the screening definition of PTSD, major depression, or generalized anxiety 

disorder, compared with 9% at predeployment. 

To maximize specificity for population-level prevalence estimates, investigators used stringent cut-off 

criteria to determine mental disorders in this study. 

Using more sensitive criteria widely validated in clinical care settings, the study indicated that 18% to 20% of 

soldiers returning from combat in Iraq had significant 

symptoms of PTSD, and 28% to 29% had significant 

symptoms of PTSD, depression, or anxiety. The study 

also found deployment to be associated with alcohol 

misuse: 24% to 35% of subjects reported using more 

alcohol than intended, and 20% to 29% reported wanting or needing to drink less. 

Besides establishing the prevalence of mental health 

symptoms among military personnel returning from 

combat, another critical finding identified by this 

study was the problem with stigma and barriers to 

care. The study showed that the majority of service 

members who had significant mental health problems 

did not receive care, and concerns about stigma and 

other barriers to care were pervasive. The study led 

to widespread DoD, public, media, and congressional 

interest, as well as multiple new clinical, research, and 

public health efforts throughout DoD and the Veterans 

Administration to mitigate stigma, remove barriers to 

care, and improve the screening and treatment of PTSD 

after deployment. 

A subsequent publication from the Land Combat 

Study assessed the prevalence of mental health problems 12 months postdeployment. In this sample, 17% 

of service members met the criteria for PTSD, major 

depression, and/or generalized anxiety using the stringent cut-off criteria.32 This finding confirmed that no 

decrease in symptoms occurred during the first year 

postdeployment. This 1-year period was the same 

amount of time many units had before rotating back 

to Iraq or Afghanistan for a subsequent deployment, 

suggesting that the soldiers had not recovered from 

the first deployment when they left for their second 

deployment. 

The study also demonstrated that soldiers with 

PTSD symptoms were much more likely than soldiers 

from the same deployments who did not have PTSD 

symptoms to experience lower ratings of general 

health, more missed work days, higher use of medical 

services, and higher somatic symptom levels. These 

findings were independent of being wounded or injured. The study highlighted the comorbidity of PTSD 

with physical health problems and the need to evaluate 

veterans who present with somatic concerns for PTSD. 

This study was one of several that provided data supporting the implementation of new DoD programs to 

enhance mental health screening and management in 

primary care settings.33

Mental Health Advisory Teams

Another important OIF initiative is the epidemiological assessment of the mental health and well-being 

of troops during deployment. Each year, the Army 

surgeon general deploys a team of mental health 

experts together with researchers from WRAIR to 

conduct anonymous assessments of the mental health 

of troops in Iraq. These teams use similar surveys to 

those administered as part of the WRAIR Land Combat 

Study research protocol, and also assess the adequacy 

and distribution of behavioral health resources in 

theater.34–37

Key findings from the mental health advisory team 

missions included: 

	 •	 Fifteen to twenty percent of combat troops

deployed to Iraq experience significant symptoms of acute stress, PTSD, or depression, and 

twenty percent of married service members 

experience marital concerns.

	 •	 Longer deployments, multiple deployments,

greater time away from the basecamp, and 

combat frequency and intensity all contribute to higher rates of PTSD, depression, and 

marital problems.

	 •	 Combat frequency and mental health problems are associated with ethical mistreatment 
79

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

of noncombatants.

	 •	 Good unit leadership is key to sustaining

mental health and well-being among combat 

troops.34–37

As a result of these findings, the Army revised the 

combat and operational stress control doctrine and 

training,38 mandated stress control training for all 

deployment mental health professionals, and ensured 

that sufficient mental health personnel (credentialed 

providers and mental health technicians) are available 

in theater. The mental health advisory teams identified 

an optimal ratio of at least one mental health professional for every 1,000 troops, supporting the Army’s 

effort to ensure optimal distribution and access to 

services throughout theater. The findings also led to 

the inclusion of new training initiatives for soldiers and 

leaders developed by WRAIR researchers.39

Research on Deployment Mental Health Screening 

Another important WRAIR research initiative has 

focused on psychological screening. DoD-wide psychological screening began in 1996 with the deployment of US forces to Bosnia and continued as a commander’s program with the subsequent deployment 

to Kosovo.40 Psychological screening was designed to 

identify individuals in need of follow-up mental health 

services and provide a proactive way to link individuals with mental health professionals. 

The current DoD screening program was launched 

in April 2003, a month after the ground war began in 

Iraq. At that time, the DoD mandated that all service 

members complete a PDHA immediately upon return 

from any deployment using a brief screening instrument combined with a clinical interview.41 Initiated 

to meet an immediate need, the program generated 

controversy for being started before any evidence 

was available to support the effectiveness of such a 

program.42,43

The goal of WRAIR’s screening research program 

has been to validate and improve the screening for 

mental health problems associated with deployment. 

In keeping with these goals, WRAIR conducted a series of studies to identify the appropriate content for 

predeployment and postdeployment screening,44 the 

best approach to screening,45 the psychometrics of the 

screening instruments,46 and effective implementation 

strategies.47 The results of this research and subsequent 

program evaluation48 have influenced the development of the DoD psychological screening program for 

military personnel returning from Iraq. Three WRAIR 

studies were particularly notable in guiding the DoDwide postdeployment screening program. 

The first study looked at the timing of the screening process. Shortly after the PDHA was initiated, researchers at the WRAIR unit in Europe determined that 

soldiers were two to five times more likely to report 

mental health concerns 4 months after returning from 

deployment than they were immediately upon return 

from deployment.47 The data were communicated to 

DoD Health Affairs in early 2004 and led to an immediate triservice mandate to expand the PDHA program to 

include a second screen, the Post-Deployment Health 

Reassessment (PDHRA), 3 to 6 months after return 

from deployment.49

A second study included a series of analyses that 

validated the mental health questions used on the 

PDHA and PDHRA against a “gold-standard” structured diagnostic interview.46 This study demonstrated 

that the PDHA questions had acceptable sensitivity 

and specificity in identifying individuals who needed 

further evaluation or treatment and contributed to a 

better understanding of how to score the PDHA and 

PDHRA questionnaires. 

The third study, conducted in collaboration with 

the Army Medical Surveillance Activity, evaluated 

the lessons learned from the PDHA program on a 

population-wide level. The study showed that combat duty in Iraq was correlated with high utilization 

of mental health services and attrition from military 

service postdeployment.48 One third of soldiers returning from OIF utilized mental health services in medical 

treatment facilities in the year after returning home (including screening, prevention, and treatment services). 

However, the PDHA was found to have limited utility 

in predicting the level of mental health services that 

were needed postdeployment. These data highlight 

the challenges in ensuring that adequate resources are 

available to meet the mental health needs of returning 

veterans. The data also supported the DoD Health Affairs’ decision to expand the PDHA program to include 

the PDHRA 3 to 6 months postdeployment. 

Wartime Studies of Leadership and Unit Factors in 

Operational Units 

A unique feature of WRAIR research has been studies of the relationship between mental health and unit 

factors such as leadership. Studies have collected data 

from large intact units (eg, brigade combat teams), 

thereby including responses from members of the 

same subordinate units (eg, companies and platoons). 

This sampling strategy provides an opportunity to 

examine shared collective perceptions of unit members about cohesion and leadership and understand 

how these perceptions relate to mental health.50,51 The 

research has shown that variables of this nature have 
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Combat and Operational Behavioral Health

both main-effect and moderating influences.52 In terms 

of main effects, perceptions of leadership, cohesion, 

and other aspects of the social environment have been 

shown to be directly related to mental health outcomes. 

That is, units with positive perceptions of leadership 

and cohesion also tend to report low levels of psychological problems, and this shared unit effect is often 

stronger than the effect analyzed as an individual-level 

relationship.51,53 Leadership and other unit factors have 

also been shown to interact with various stressors such 

that the negative effects of stressors are weakened 

when unit factors are positive. This finding suggests 

that leadership, cohesion, and other forms of social 

climate may serve to protect soldiers from combat 

stressors. In one example, shared perceptions of leadership provided a protective influence for soldiers 

deployed to Haiti.54 As noted, a key finding from the 

fourth mental health advisory team assessment in Iraq 

(2006) was that good unit leadership was associated 

with fewer mental health problems.37 As a result of 

these research findings, WRAIR developed training 

materials to improve leader behaviors and enhance 

the mental health of units. 

Battlemind Training

At the time that the DoD’s Deployment Cycle Support Program was initiated, no standardized combat 

and deployment stress training packages existed to 

prepare soldiers for the stressors of war, or to facilitate 

their transition home, and no integrated mental health 

training occurred across the deployment cycle. Thus, it 

was up to behavioral health professionals at each military post to come up with their own training material 

to meet the requirements of the program. 

To address this need, WRAIR researchers created a 

validated standardized mental health risk communication training program called “Battlemind.” Battlemind 

educates soldiers and leaders about

	 •	 what to expect at each phase of the deployment cycle,

	 •	 how to look out for their own mental health,

	 •	 how to help their fellow unit members, and

	 •	 resources available forthem to get help if they

need it during and after deployment.

The content of Battlemind training, based on results 

and lessons learned from studies of OIF and OEF 

combat soldiers, focuses on the strengths and skills 

that help soldiers survive in combat. 

Following the piloting of the first Battlemind products in 2005 and 2006, several new products have been 

developed and disseminated in collaboration with 

the Army Medical Department (AMEDD) Center and 

School. Several prototype Battlemind training modules 

have been developed and piloted for each phase of the 

deployment cycle. Predeployment training includes a 

module for soldiers and leaders that builds resilience 

by anticipating combat stressors and typical reactions 

while identifying actions that can be taken to meet 

these challenges. Predeployment modules have also 

been developed for behavioral health professionals 

and military spouses. 

During deployments in Iraq, mental health professionals are using two types of Battlemind psychological debriefing techniques developed by WRAIR.55

Event-driven Battlemind psychological debriefing is 

designed for use after a critical event, and time-driven 

Battlemind psychological debriefing is designed for 

use periodically over the course of a 12- or 15-month 

deployment. Both of these techniques actively integrate Battlemind concepts, using structured group 

discussion to review key issues, reinforce positive 

mental health strategies, encourage unit members to 

look out for one another, and keep individuals focused 

on professional and ethical conduct. 

The practice of psychological debriefing is controversial, and controlled research examining the efficacy 

of debriefing with at-risk cohesive occupational groups 

is lacking.56,57 WRAIR demonstrated the efficacy of 

postdeployment Battlemind psychological debriefing 

in a group randomized-control trial in which platoons 

were assigned to different types of postdeployment 

transition training.58 The debriefing techniques used 

in this study were the basis for in-theater debriefing 

models and a postdeployment Battlemind psychological debriefing model now integrated into the Combat 

Operational Stress course taught at the AMEDD Center 

and School. 

In the same study, Battlemind training conducted at 

reintegration and at 3 to 6 months postdeployment was 

also found to effectively reduce mental health symptoms over time.59 These two postdeployment training 

modules highlight combat skills that can be adapted 

to facilitate the transition home. A postdeployment 

Battlemind training module has also been developed 

for spouses. Additional Battlemind training products 

under development include a first aid module for medics, basic Battlemind during initial military training, 

and leadership development courses. Several training 

DVDs have also been developed to supplement the 

Battlemind system. 

Battlemind training is currently integrated into the 

Deployment Cycle Support Program directive and 

is part of the standard training that soldiers receive 

before and after combat deployment.30,39 Battlemind 

training offered for spouses is specifically designed to 
81

Walter Reed Army Institute of Research Contributions During Operations Iraqi Freedom and Enduring Freedom

strengthen their resilience during times of separation 

due to war. As each Battlemind product is fielded, it 

has been made available on its Web site, www.battlemind.org. Other nations including Canada, the United 

Kingdom, and Australia are also adopting Battlemind 

training.

Army Medical Department General Officers Behavioral Health Summit 

In June 2006, WRAIR hosted a general officers summit for the Army surgeon general and the commander 

of the US Army Medical Research and Materiel Command. The 2-day conference, attended by 20 AMEDD 

general officers, was conducted with three primary 

goals: (1) to arrive at a common understanding (or 

“lexicon”) of available data on the mental health 

impact of combat, (2) to evaluate best practices and 

lessons learned so that consistent approaches can be 

established across components and installations, and 

(3) to establish the AMEDD behavioral health strategy. 

The conference achieved its goals and led to the publication of a comprehensive report on Army behavioral 

healthcare strategy.60

OTHER WRAIR MENTAL HEALTH RESEARCH INITIATIVES

WRAIR researchers have been involved in a variety 

of related efforts, including assessing how adverse 

early childhood experiences affect psychological adjustment following combat,61 assessing the appropriateness of PTSD diagnostic criteria applied to combat 

veterans,62 and developing a conceptual model for understanding the stigma of mental health problems.63

The research program has also led to innovations 

in the development of tools to help unit leaders assess 

the behavioral health status of their units. WRAIR 

researchers have used their knowledge of health measures, military norms from the Land Combat Study, 

and feedback from unit commanders to develop a 

unit needs assessment program, designed for behavioral health professionals to provide consultation to 

military units. The program includes tools, scoring 

guidelines, implementation recommendations, and 

a briefing template to facilitate the behavioral health 

assessment of units. 

Given the complexities associated with analyzing large data sets collected from soldiers hierarchically nested within military units (squads, platoons, 

companies, etc), the WRAIR research program has 

also contributed to innovations in statistical software 

and statistical techniques. Many of these innovations 

have been implemented in the open-source statistical 

language R.64 For instance, the “lme4” package in R is 

designed to analyze hierarchical mixed-effects models 

containing dichotomous outcomes (eg, meeting or not 

meeting PTSD thresholds). The algorithms used in 

the lme4 package were developed by the University 

of Wisconsin and the Toyon Research Corporation 

(Goleta, Calif) in a Small Business Technology Transfer 

Program grant managed by WRAIR scientists. 

In another example, WRAIR researchers developed 

and maintain the multilevel package for R, providing 

a number of routines for determining whether group 

members significantly agree about shared concepts 

such as unit leadership or cohesion. Finally, the package “ltm” is designed to perform item response theory 

analyses on specific survey items to aid in creating 

scales with good psychometric properties. WRAIR 

scientists provided funding to expand the ltm package 

to handle multiresponse items (eg, strongly disagree, 

disagree, neither, agree, strongly agree). Each of these 

developments has contributed to the analyses of complex multilevel data sets involving health outcomes.

WRAIR researchers are active in publishing their 

work in peer-reviewed journals and other outlets. 

In 2006 the work of several WRAIR researchers was 

showcased in a four-volume book series, Military 

Life: The Psychology of Serving in Peace and Combat.

65–68

WRAIR research figures prominently throughout this 

comprehensive examination of the psychological issues facing military personnel and their families. The 

series also provides an agenda for military psychology 

research in the coming years. 

Finally, WRAIR research has been widely cited by 

medical policy makers and lawmakers, and has contributed to significant increases in funding for PTSD 

treatment and research within the DoD and Veterans 

Administration. The fiscal year 2007 Congressional 

appropriation, for example, included a total of $450 

million for research and treatment initiatives in the 

area of PTSD, and another $450 million for traumatic 

brain injury. 

SUMMARY

In keeping with its tradition of working directly 

with military units in times of conflict, WRAIR has 

been at the forefront of mental health research since 

the events of September 11, 2001. Researchers have 

conducted comprehensive analyses of the mental 

health impact of OIF/OEF, improved deployment-
82

Combat and Operational Behavioral Health

related screening initiatives, and developed interventions to improve the psychological health of US 

troops. The program has been focused on directly 

supporting operational units, deploying research 

teams into Iraq and Afghanistan, generating timely 

products relevant to current operations, and informing 

healthcare policies on an Army- and DoD-wide level. 

Future directions include the development of advanced training modalities to improve resiliency and 

mitigate the mental health effects of combat, randomized controlled trials to assess early interventions, and 

studies of the relationship between PTSD and combat 

injuries, including traumatic brain injuries. Through 

balancing scientific rigor with the behavioral health 

needs of military personnel, WRAIR researchers will 

remain focused on delivering quality information and 

training products in support of service members and 

their families. 

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63. Greene-Shortridge TM, Britt TW, Castro CA. The stigma of mental health problems in the military. Mil Med. 2007;172:157–

161.

64. The R Foundation for Statistical Computing. The R project for statistical computing. Available at: http://www.Rproject.org. Accessed June 18, 2007.

65. Britt TW, Castro CA, Adler AB, eds. Military Performance. Vol 1. In: Military Life: The Psychology of Serving in Peace and 

Combat. Westport, Conn: Praeger Security International; 2006.

66. Britt TW, Castro CA, Adler AB, eds. Operational Stress. Vol 2. In: Military Life: The Psychology of Serving in Peace and 

Combat. Westport, Conn: Praeger Security International; 2006.

67. Britt TW, Castro CA, Adler AB, eds. Military Family. Vol 3. In: Military Life: The Psychology of Serving in Peace and Combat. 

Westport, Conn: Praeger Security International; 2006.

68. Britt TW, Castro CA, Adler AB, eds. Military Culture. Vol 4. In: Military Life: The Psychology of Serving in Peace and Combat. 

Westport, Conn: Praeger Security International; 2006. 
86

Combat and Operational Behavioral Health
89

The Division Psychiatrist and Brigade Behavioral Health Officers

Chapter 6

THE DIVISION PSYCHIATRIST AND 

BRIGADE BEHAVIORAL HEALTH 

OFFICERS

CHRISTOPHER H. WARNER, MD*; GEORGE N. APPENZELLER, MD†; TODD YOSICK, LISW‡; MATTHEW J. 

BARRY, DO§; ANTHONY J. MORTON, MD¥; JILL E. BREITBACH, PsyD¶; GABRIELLE BRYEN, MSW, LCSW**; 

ANGELA MOBBS, PsyD††; AMANDA ROBBINS, PsyD‡‡; JESSICA PARKER, PsyD§§; and THOMAS GRIEGER, MD¥¥

INTRODUCTION

DOCTRINE

PERSPECTIVES ON THE POSITION

DUTIES AND RESPONSIBILITIES

CHALLENGES OF THE POSITION

FUTURE DIRECTIONS

SUMMARY

*Major, Medical Corps, US Army; Chief, Department of Behavioral Medicine, Winn Army Community Hospital, Building 9242, Room 20, 1083 Worcester 

Drive, Fort Stewart, Georgia 31324; formerly, Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

†

Colonel, Medical Corps, US Army; Commander, US Army Medical Activity, Alaska, 1060 Gaffney Road #7400, Fort Wainwright, Alaska 99703-7400; 

formerly, Deputy Commander for Clinical Services, Command Group, Winn Army Community Hospital, Fort Stewart, Georgia 31314

‡

Major, Medical Service Corps, US Army; Deputy Director, Resilience and Prevention Directorate, Office of the Assistant Secretary of Defense for Health 

Affairs, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, 1335 East-West Highway, Silver Spring, Maryland 20910; 

formerly, Chief, Battlemind Training Office/Chief, Combat and Operational Stress Control, AMEDD Center and School, Fort Sam Houston, Texas

§

Major, Medical Corps, US Army Reserve; Staff Psychiatrist, 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

¥

Major, Medical Corps, US Army; Medical Director, Department of Behavioral Health, Moncrief Army Community Hospital, 4500 Stuart Street, Fort 

Jackson, South Carolina 29207-5720; formerly, Division Psychiatrist, 1st Armored Division, Wiesbaden, Germany

¶

Major, Medical Service Corps, US Army; Neuropsychologist, Department of Psychology, Evans Army Community Hospital, USAMEDDAC, Fort 

Carson, Colorado; formerly, Group Psychologist, 1st Special Warfare Training Group, Fort Bragg, North Carolina

**Major, Medical Service Corps, US Army; Deputy Chief, Department of Social Work, Womack Army Medical Center, Stop A, Fort Bragg, North Carolina 

28310; formerly, Brigade Behavioral Health Officer, 3rd Brigade Combat Team, 4th Infantry Division, Fort Carson, Colorado 80913

††Special Forces Assignment and Selection Psychologist, Special Warfare Center and School, Rowe Training Facility, Building T-5167, 1500 Camp Mackall 

Place, Marston, North Carolina 28363; formerly, Brigade Psychologist, 3rd Brigade Combat Team, 3rd Infantry Division, Fort Benning, Georgia

‡‡Captain, Medical Service Corps, US Army; Brigade Combat Team Behavioral Health Officer, 4th Brigade Combat Team, 10th Mountain Division, Fort 

Polk, Louisiana 71459

§§Captain, Medical Service Corps, US Army; Chief, Warrior Restoration Center, Department of Behavioral Medicine, Winn Army Community Hospital, 

541 East 9th Street, Building 359, Fort Stewart, Georgia 31314-5674; formerly, Psychology Resident, Traumatic Brain Injury, Brooke Army Medical 

Center, San Antonio, Texas

¥¥Captain (Retired), US Navy; Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 Jones Bridge 

Road, Bethesda, Maryland 20814

A portion of this chapter has been published as: Warner CH, Breitbach JE, Appenzeller GN, Barry MJ, Morton A, Grieger T. The evolving 

role of the division psychiatrist. Mil Med. 2007;172:918–924.
90

Combat and Operational Behavioral Health

INTRODUCTION

The psychological effects of warfare have been well 

documented throughout history, with names such as 

nostalgia, soldier’s heart, shell shock, battle fatigue, 

and most recently, combat operational stress. In the late 

19th and early 20th centuries, military leaders began to 

recognize the impact of treating and addressing these 

reactions. This led to an increased presence of mental 

health providers on the battlefield. Since World War 

I, the United States Army has been deploying mental 

health assets to the front line for treatment of combat 

operational stress and to advise unit commanders 

on mental health issues and the effect of war on soldiers.1–3 

The first battlefield psychiatrist for the US Army 

was Dr Thomas Salmon. During World War I, he 

noted the value of maintaining a psychiatrist on the 

division staff who works directly with the surgeon 

to provide consultation, as well as the importance of 

the role as a staff officer for the command.2 Salmon 

created a successful battlefield management system 

incorporating treatment, prevention, and consultation. 

Unfortunately, many of those lessons learned were 

lost or were deemed unnecessary after the end of the 

war. It was not until World War II that General Omar 

Bradley again realized the value of organic mental 

health assets during the North African campaign of 

1943 and reestablished the division psychiatrist position.3

 Since the Korean War, the division psychiatrist 

has led the division mental health activity (DMHA), 

both in garrison and during deployment.1,3 The roles 

and responsibilities for a division psychiatrist and the 

DMHA were first outlined in Army Regulation 40-216, 

Neuropsychiatry and Mental Health, in 1957.4

The division psychiatrist serves as the leader of 

the division mental health team whose mission is to 

assist command in controlling combat operational 

stress through training, consultation, and restoration.5

Until recently, the DMHA consisted of three providers 

(a psychiatrist, a psychologist, and a social worker), 

complimented by six mental health technicians (Figure 

6-1). However, in the midst of the global war on terror, 

the Army began its largest restructuring since World 

War II, changing the emphasis from the division to the 

brigade combat team (BCT).6 This restructuring effort 

was designed to make the Army a more modular force, 

increase efficiency and combat power, and increase the 

number of BCTs within the force.6

In conjunction with the restructuring, there has been 

a reorganization and an increase in the behavioral 

health assets assigned to each division. The new force 

structure eliminated a formal centralized mental health 

section and created a modular DMHA. The new modular DMHA structure, outlined in Figure 6-2, includes 

a division psychiatrist and senior noncommissioned 

officer located with the division surgeon at the division 

headquarters unit, and a brigade behavioral health 

officer (BCT BHO; psychologist or social worker) and 

an enlisted mental health specialist assigned to each 

BCT. Multiple BCTs are under the control of the division, such that five to six mental health providers (psychiatrists, psychologists, and social workers) can be 

assigned to a DMHA. This new, modular design yields 

more providers and allows for projection of resources 

to commanders at lower levels (ie, battalion and company). With this rapid expansion and evolution of the 

DMHA, the role of the military mental health provider 

Mental Health

Specialist 

(91X)

Division

Psychiatrist

Division

Psychologist

Division

Social Worker

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Mental Health

Specialist 

(91X)

Figure 6-1. Prior structure of division mental health activity.
91

The Division Psychiatrist and Brigade Behavioral Health Officers

Aviation Brigade

(No Assests)

Mental Health

Specialist 

(68X10)

Division

Psychiatrist

Mental Health

Specialist 

(68X10)

Mental Health

Specialist 

(68X10)

Mental Health

Specialist 

(68X10)

1st BCT

BHO

3rd BCT

BHO

2nd BCT

BHO

4th BCT

BHO

DMH

NCOIC 

(68X30)

Figure 6-2. Current structure of division mental health activity in the modular Army. 

BCT: brigade combat team

BHO: behavioral health officer (psychologist or social worker)

DMH: division mental health

NCOIC: noncommissioned officer in charge

has become more diverse and multifaceted. 

The complex effects of combat on soldiers in modern 

warfare demonstrate the importance of combat and 

operational stress control during deployment and 

the need to monitor mental health issues following 

deployment.7–11 This has led to recent updates in US 

Army doctrine, though, unfortunately, little guidance 

on the specific roles of division mental health has been 

provided.12 The purpose of this chapter is to outline 

the role and utilization of the division psychiatrist and 

the BCT BHO in both the division and in the DMHA as 

defined by current military doctrine and based on the 

more than 10 combined years of deployment experience of the authors. 

DOCTRINE 

Although much has been published on the psychological consequences of combat and deployment, little 

has been published on the specific roles of the division psychiatrists, DMHA, or BCT BHOs in garrison 

or during deployment.13–20 Army Regulation 40-216, 

Neuropsychiatry and Mental Health, the primary regulation associated with mental healthcare, has not been 

updated since 1984 and cites only that the division 

psychiatrist will lead the DMHA, serve as a consultant 

on neuropsychiatric issues, and in conjunction with the 

DMHA, provide care to soldiers with neuropsychiatric 

conditions.4 Field Manual 8-51, Combat Stress Control 

in a Theater of Operations: Tactics, Techniques, and Procedures, was released in 1994 and updated in 1998.5

 It 

provided an outline of the overall mission and role of 

the DMHA and gave some additional insight into the 

roles and responsibilities of the division psychiatrist 

as a supervisor. This guidance was recently updated to 

outline combat and operational stress control (COSC) 

in Field Manual 4-02.51, Combat and Operational Stress 

Control, but provides little guidance on the operation 

of a DMHA or on the roles and responsibilities of a 

division psychiatrist and the BCT BHO.12 

 Lieutenant Colonel Albert Glass defined in his 

chapter “Lessons Learned” from Neuropsychiatry in 

World War II the need to maintain a strong regiment 

of active duty psychiatrists, both in war and in peacetime, to manage the operational needs of the armed 

services. He argued that civilian psychiatric agencies were unable to meet the ongoing demands and 

maintain the operational preparedness that military 

psychiatry requires. He also reviewed the complexity of psychiatric diagnosis and screening/selection 

in wartime, as it effects conservation of the fighting 

force.1

 In Combat Psychiatry, Lieutenant Colonel Glass 

specifically discussed the role of “Psychiatry at the 

Division Level.” This in-depth review outlined the 

specific principles for the evaluation, treatment, and 
92

Combat and Operational Behavioral Health

disposition of soldiers in a combat environment. Additionally this chapter provided historical data analysis 

from World War II.21

Rock and colleagues discussed the historical development of US Army mental health resources in 

War Psychiatry, in a chapter titled “US Army Combat 

Psychiatry.” This chapter provides insight into changes 

that were made in doctrine and in the development 

of division mental health units from World War I 

through Vietnam. However, as Army mental healthcare evolved into the 1980s, it moved away from 

the roles of the divisional units and focused on the 

development of nonembedded combat stress control 

units.3 Although both chapters are an excellent source 

of information on the historical development of military mental health systems and the treatment role of 

division-level behavioral health officers, they provide 

little guidance on other duties and responsibilities of 

these positions.

In 1993, two relevant articles were published in 

Military Medicine. In the first of these, Engel and Campbell addressed the challenges facing a division mental 

health unit. They discussed the minimal attention focused on their role while not deployed and noted the 

importance of ongoing preventive missions based on 

their lessons learned from deployment to Operation 

Desert Storm.14 In the second of these, Ritchie and 

White outlined the guidelines for becoming a successful division psychiatrist, providing practical guidance 

for preparing psychiatrists who were relatively new 

to the military on effective means of interacting and 

engaging with infantry commanders. Additionally, the 

latter article outlined the various duties and responsibilities of the position including (in their listed order 

of importance): behavioral health provider, supervisor of other behavioral health providers, educator of 

division medical providers, administrative psychiatry, 

consultation to command, planning and oversight of 

the division mental health section, and serving as an 

officer in the division.15 This guidance was recently 

revised by Hill, Lange, and Bacon. Their focus was 

on what psychiatry residents should do to prepare 

for assuming the role.16 Although these two articles 

did not deal with the role of the division psychologist 

or the division social worker, they did outline some 

of the duties and responsibilities expected of a unit 

behavioral health leader. 

During Operation Iraqi Freedom, Warner, Appenzeller, and colleagues published a group of articles in 

Military Medicine on the roles and responsibilities of 

division mental health units in the new brigade combat team structure. These articles provided a roadmap 

of prevention, early identification, and intervention 

methods for other DMHAs. Additionally, the authors 

cited several advantages to the new structure, including the increased ability to provide mental health services closer to the front line and the ability to interact 

and regularly serve as consultants to lower levels of 

command. Additionally, they noted several limitations 

of the new structure, including dispersed command 

and control, increased independence of each provider 

with decreased supervision, and an increased risk for 

provider burnout due to the smaller teams. Although 

there was some discussion about garrison actions required prior to the deployment and the role of the division psychiatrist while in garrison, these articles were 

predominantly focused on the deployed role.20,22,23

Expanding beyond the role of the division psychiatrist to include other mental health providers, 

Military Psychiatry: Preparing for Peace in War addresses 

the evolving interface between the behavioral health 

leader and command. Chapter 9 highlights the heightened value by command of services mental health 

officers offer via command consultation, including 

cross service consultation needs.24 Also discussed, in 

Chapter 10, is the need for mental health providers in 

recognizing the stressors of those in leadership positions and offering support to build resilience of those in 

command.25 Chapters 11 and 12 approach the training 

needs of mental health workers, emphasizing the value 

of field training exercises,26 and proposes a two-part 

training model to assist medical personnel and command in recognizing combat stress concerns and how 

to effectively triage combat stress casualties.27

PERSPECTIVES ON THE POSITION

According to one division commander, the division psychiatrist and the DMHA are responsible for 

“maintaining a ‘finger on the pulse’ of the unit.”28 This 

guidance provides a global commander’s intent to the 

DMHA, but interpretation and execution of that intent 

is subject to individual variability. 

There are multiple perspectives to consider, as illustrated in Figure 6-3. Division psychiatrists rely on their 

own perspectives, but must be cognizant of the requirements and expectations of the division surgeon and 

division commander. Similarly, the BCT BHO must 

consider the expectations of the division psychiatrist, 

brigade surgeon, and brigade commander. Additionally, behavioral health providers’ different training 

backgrounds may influence which areas they are both 

competent and confident to address. For instance, a 

BCT BHO who is a psychologist has different skill capabilities than a social worker. Despite these training 

differences, all providers bring their own experiences 

to the position, which also influences their scope and 
93

The Division Psychiatrist and Brigade Behavioral Health Officers

Division 

Psychiatrist

BCT

Behavioral

Health 

Teams

Division 

Commander

Division 

Surgeon

Soldiers

Special Staff Officer

Consultant

Supervisor/Educator

Clinician

Figure 6-3. Perspectives on the position of the division 

psychiatrist.

BCT: brigade combat team

breadth of practice. 

The division psychiatrist position tends to be assigned to junior officers following completion of their 

psychiatric residency or fellowship. Many enter the 

position as a company-grade officer (captain) and are 

promoted to field grade (major) while in the position. 

For many incoming division psychiatrists, this is their 

first opportunity to practice independently. Furthermore, few of the incoming division psychiatrists are 

familiar with the operation and function of a division 

staff and most have not attended their branch-specific 

career course.

Like the psychiatrist, the BCT BHO position tends 

to be assigned to a junior to mid-level officer. Many 

enter the position as a company-grade officer and some 

will be promoted to field grade while in the position. 

In the past, the psychologists would likely have just 

completed their internship training and have not done 

any other operational tour. However, that has changed 

recently with requirements for licensure for deployability. Currently, most psychologists have completed 

a 1- or 2-year postinternship tour prior to arriving to 

the BCT. For social workers, most have completed 

one tour, generally at a medical center working with a 

senior social work officer, and then are assigned to an 

operational billet. For many incoming BCT BHOs, this 

is their first opportunity to practice without a senior 

supervisor in their discipline. Like psychiatrists, few of 

the incoming BCT BHOs are familiar with the operation and function of a brigade staff, and most have not 

attended their branch-specific career course. 

In keeping with their recent training program experience, both incoming division psychiatrists and BCT 

BHOs tend to focus on their roles as clinicians, and 

quite possibly, as educators for their enlisted mental 

health technicians and BCT primary care physicians. 

They may not rapidly embrace their roles as staff 

officers, advisors, and consultants to the division or 

brigade leadership or comprehend how these roles 

affect care for soldiers. In some instances, division 

psychiatrists have relinquished their leadership and 

administrative responsibilities to a brigade BHO to 

increase time available for their own clinical work. 

Similarly, for many BHOs, this is their first experience integrating with a line combat unit. The BHO 

must quickly adjust to training and operation tempo 

requirements that are expected in these units.

In contrast, division and brigade surgeons expect 

BHOs to act as advisors and consultants. They envision 

the psychiatrist or BCT BHO providing assistance in 

planning for the behavioral health aspects of the entire 

spectrum of operations and coordinating behavioral 

health support resources for garrison and deployed 

activities. They expect their behavioral health consultant to be able to identify the behavioral health 

threats to the units and make recommendations on 

preventive mechanisms for the division or brigade. 

They further expect the BHO to be familiar with the 

Army Medical Department (AMEDD) principles of 

treatment, evacuation, and restoration in theater. This 

includes arranging transportation, coordinating care 

for evacuated soldiers, and patient tracking. 

Additionally, the division psychiatrist expects the 

BCT BHO to serve as both an advisor and a clinician. 

In many cases, BCTs are not collocated with their 

divisions, and division psychiatrists rely on the BCT 

BHOs to advise them on behavioral health issues that 

occur within the brigade. Furthermore, they expect the 

BCT BHO to be the primary provider of behavioral 

healthcare within the units and to be responsible for 

evaluating soldiers’ behavioral health fitness for duty. 

Further requirements include training and developing 

the enlisted mental health technicians and consulting 

with BCT medical and command personnel. 

Both division and brigade commanders expect their 

staff officers to be able to provide expert advice and 

alternative courses of action to enable them to make 

educated decisions in the best interest of the unit. 

Many commanders see BHOs as an important part of 

the division or BCT medical team and expect them to 

be experienced in analyzing behavioral health trends 

and their potential impacts on unit readiness. 

In general, commanders have become very attuned to the behavioral health effects of combat and 
94

Combat and Operational Behavioral Health

deployment on their soldiers and look to the unit 

BHO to provide expert consultation on what they, as 

commanders, can do to mitigate the inherent stress 

of deployment, ensure proper surveillance of mental 

health issues upon redeployment, reduce the stigma 

of seeking care, and help their soldiers. 

Case Study 6-1: During one recent deployment, a division commander told his division psychiatrist that he was 

“concerned about the mental health of my unit and I want my 

commanders to know that we as a unit have the resources, 

ability, and concern to do something to help them.” He frequently had the division psychiatrist travel with him throughout the theater of operations to ensure that the behavioral 

health team was aware of the various conditions soldiers 

were encountering but also for the subordinate commanders 

to see the importance that he placed on soldier behavioral 

health. The division psychiatrist was able to get a “finger on 

the pulse” of the units that they were visiting, identify the 

potential risks for combat and operational stress within the 

unit, and provide the commanders with recommendations 

on how to mitigate those risks. 

These various duties, responsibilities, expectations, 

and external pressures on unit behavioral health 

officers pose a formidable challenge for relatively 

junior officers to properly prioritize their duties. In 

this setting, optimal performance will be achieved 

through proper professional development and updated doctrine.

DUTIES AND RESPONSIBILITIES

There are several areas of responsibility of particular 

importance to these junior officers. These will be discussed in this chapter; a comprehensive listing of the 

multiple duties and responsibilities of the unit BHO 

can be found in Exhibit 6-1.

Planning and Oversight for Behavioral Healthcare

The division psychiatrist or BCT BHO is the unit’s 

subject matter expert on the behavioral health effects 

of combat and other deployments. Therefore, it is 

imperative that the division psychiatrist or BCT BHO 

serve as a staff officer within the division or brigade 

leadership to provide recommendations on the positioning and utilization of behavioral health resources, 

both in garrison and during deployment.

Prior to deployment the division psychiatrist is responsible for developing and implementing training 

programs for primary care providers, nonmedical officers, and noncommissioned officers. Training should 

focus on prevention and management of operational 

stress and other mental health problems that may be 

encountered during deployment. 

During deployment, it is the responsibility of the 

division psychiatrist and the BCT BHO to assess 

the behavioral health threat of the environment and 

work closely with the command surgeon to review 

how behavioral health assets are being deployed and 

utilized within the operational environment. Sources 

of information include historical data from prior conflicts both in the unit and for that area, rates of combat 

stress in other units deployed to the conflict, rates of 

behavioral health issues in the unit in garrison, and 

effects of psychological profiles related to combat 

on the fighting strength. The division psychiatrists 

or BCT BHOs can make recommendations to their 

respective commands on where to position and how 

to implement the behavioral resources within the 

unit. Furthermore, the division psychiatrist should 

develop standard operating procedures for division 

mental healthcare, create traumatic event management 

plans, and provide guidance on the utilization of the 

Unit Behavioral Health Needs Assessment or other 

unit evaluation tools. Additionally, it is imperative to 

coordinate with external assets such as combat stress 

control units when they are positioned within the area 

of operations. 

Key concepts to be considered when planning the 

distribution of resources are safety, security, and a 

close proximity to the units at greatest risk for combat 

operational stress reactions. This not only involves the 

division psychiatrist, but also the BCT BHO who must 

develop plans for allowing outreach from a primary 

clinic location to extend throughout the unit area of 

operations that requires logistical support. 

Also of significance is the monitoring of, and guidance on, the use of psychotropic medications within 

the division and brigade, an area that has come under 

recent public scrutiny. The division psychiatrist needs 

to work with the medical logistic assets to determine 

which medications should be used in the area of operations and should help set guidelines for indications, 

use, and monitoring of psychotropics within the division. In general, use of antidepressants and mild sleep 

aids is common practice. Use of other psychotropics 

such as benzodiazepines, stimulants, and antipsychotics should be considered on a case-by-case basis and 

warrant increased vigilance. This topic is covered in 

great depth in Chapter 10, Psychiatric Medications in 

Military Operations, in this volume.

 Although BCT BHOs are not credentialed to prescribe medication, they need to be aware of the utilization of psychotropics and their effects on the soldiers 

within the unit. The BCT BHO needs to work closely 
95

The Division Psychiatrist and Brigade Behavioral Health Officers

EXHIBIT 6-1 

DUTIES AND RESPONSIBILITIES OF THE UNIT BEHAVIORAL HEALTH OFFICER

Planning/Oversight for Division Mental Healthcare

	 •	 Plans and coordinates pre- and postdeployment mental health screening

	 •	 Provides recommendations on positioning of division mental health assets in garrison and deployment

	 •	 Develops division traumatic event management plan

	 •	 Consults with combat stress detachment (CSC) commander on placement of resources within division area

during deployment

	 •	 Monitors and provides guidance on use of psychotropic medications

 ° Determines which medications medical logistical personnel need to have on hand during deployments

 ° Knows that use of antidepressants and mild sleep aids is common practice; use of other psychotropic 

medications such as benzodiazepines, stimulants, and antipsychotics should be considered on a case-bycase basis and based on current guidance from higher levels

	 •	 Liaisons with other support resources in garrison and during deployment

 ° Consults with garrison medical treatment facility, Army Substance Abuse Program, chaplains, Army 

Community Services, Military OneSource, and local civilian mental health providers and hospitals

 ° Works with deployment chaplains, combat stress detachments, and medical providers

Consultant to Commanders and Division Surgeon on Behavioral Health Trends/Issues

	 •	 Coordinates behavioral health prevention efforts

 ° Provides routine consultative updates on behavioral health threats through monitoring of utilization rates 

of the division mental health clinic, behavioral health hospitalization rates, child/spouse abuse cases, DUI 

reports, positive drug test results, and pre- and postdeployment health assessment results

 ° Oversees standardized Army Battlemind training for development of mental resiliency of soldiers, spouses, 

and their families

	 •	 Prepares for potentially traumatic events

 ° Works with commanders, chaplains, and other medical personnel to develop a unit traumatic event 

management plan for addressing potentially traumatic events

	 •	 Monitors issues of public attention

 ° Educates the commander about current ongoing issues of mental health significance and advises commander about potential mental health impacts of varying policy/strategic changes

 ° Provides commander with information updates and potential questions/answers for media encounters 

about mental health prevention and ongoing issues within the unit

Supervisor of BCT Behavioral Health Officers and Enlisted Mental Health Specialists

	 •	 Serves as the officer in charge of division mental health

	 •	 Establishes the standard of care for practice within the division mental health activity (should be published

in some format and reviewed on a regular basis)

	 •	 Supervises all BCT behavioral health officers

 ° Conducts frequent supervision and chart reviews

 ° Ensures that BCT behavioral health officers are adequately supervising their enlisted mental health technicians

	 •	 Manages continuing education

 ° Develops a continuing education plan for each provider including local training (morning reports, routine 

training) and other opportunities (combat operational stress course, behavioral health short course)

 ° Ensures that all providers are obtaining necessary continuing education requirements and completing 

necessary tasks for licensure, etc

	 •	 Officer and noncommissioned officer development

 ° Ensures that all personnel are working towards advancement and achieving necessary requirement to 

include schooling (captain’s career course, NCO Academy) and civilian schooling

 ° Serves as a rater for all of the behavioral health officers

Educator of Division Medical Providers

	 •	 Ensures that all medical providers are educated about most recent practices in recognition and management of:

 ° Posttraumatic stress disorder

(Exhibit 6-1 continues)
96

Combat and Operational Behavioral Health

 ° Sleep disorders

 ° Depression and anxiety

 ° Psychiatric emergencies

 ° Traumatic event management

 ° Use of psychotropic medications during deployment

Clinician

	 •	 Serves as a direct provider both in garrison and during deployment

	 •	 Understands that care is generally limited to medication management because of limited resources

Administrative Psychiatry

	 •	 Performs command-directed evaluations

 ° Knows that guidance is provided in Department of Defense Directive 6490.1 and Department of Defense 

Instruction 6490.4; (can be ordered by the commander or required by Army regulation)

	 •	 Performs security clearance evaluations

	 •	 Performs forensic exams (sanity boards)

	 •	 Writes medical evaluation boards (MEBs)

	 •	 Writes Army suicide evaluation reports (ASERs)

Officer and Leader in the Division

	 •	 Maintains personal readiness

	 •	 Serves as a leader and example for junior officers and enlisted soldiers

ASER: Army suicide evaluation report

BCT: brigade combat team

DUI: driving under the influence

MEB: medical evaluation board

NCO: noncommissioned officer

Exhibit 6-1 continued

with the division psychiatrist, BCT providers, and the 

medical logistic assets as they determine which medications should be used in the area of operations, and 

know the guidelines for indications, use, and monitoring of psychotropics within the division. 

Additionally, the unit behavioral health officer must 

consider other potential operational activities that 

might require behavioral health participation, such as 

detainee operations and preventive training, as well as 

the soldier resiliency programs. A comprehensive, division level, planning and oversight program, spanning 

the entire deployment lifecycle, will identify unforeseen obstacles while ensuring that access to care is not 

impeded by faulty screening programs, unprepared 

clinical services, or inadequate personnel staffing. At 

the brigade level it is imperative that a comprehensive 

planning and oversight program, including brigade 

behavioral health standard operating procedures 

(SOPs), be developed within the guidelines of the 

divisional mental health SOPs.

Attention has been focused on pre- and postdeployment screening by the media and Government Accountability Office for several reasons. These include 

reports of soldiers being identified during screening 

but not receiving their consultations or treatment, 

as well as multiple studies of returning soldiers indicating that rates of reported deployment-related 

symptoms can increase with time after returning from 

deployment.7,9,10,29,30 The responsibility for overseeing 

an effective screening program (that commanders 

fully endorse) falls to the division psychiatrist and 

the DMHA. These plans must focus on education, 

early identification, and prompt treatment. Additionally, education and coordination must be made with 

commanders to ameliorate the stigma associated with 

behavioral healthcare. 

Lastly, both during deployment and in garrison, the 

division psychiatrist must coordinate between, and 

communicate with, ancillary resources available both 

within the unit, such as the chaplains and medical providers, and external to the unit. These latter resources 

include the department of behavioral medicine at the 

local medical treatment facility and representatives 

from Military OneSource, Army Community Service, 

the Army Substance Abuse Program, social work services, garrison chaplain services, and civilian community agencies. Coordination and discussion with these 

assets arms the psychiatrist with an array of resources 
97

The Division Psychiatrist and Brigade Behavioral Health Officers

available for individual soldiers, families, units, and 

commanders. In general, for BCTs that are collocated 

with their division headquarters, the responsibility of 

coordinating with external resources should fall on 

the division psychiatrist. However, for BCTs that are 

in isolated locations, it is the responsibility of the BCT 

BHO to perform this coordination. 

Provide Consultation to Commanders and Command Surgeons on Behavioral Health Trends and 

Issues

One of the vital roles of unit behavioral health 

officers is the consultation that they provide to commanders and medical staff. There are many areas on 

which the psychiatrist or BCT BHO can provide expert 

advice. Three major areas of concern are prevention, 

responding to critical events, and dealing with current 

public affairs issues. 

Preventive advice involves prioritizing the threats 

that have been identified and making recommendations to the medical staff and command on measures to 

be taken and areas requiring command emphasis. This 

includes monitoring ongoing trends such as utilization 

rates of the DMHA, behavioral health hospitalization 

rates, child and spouse abuse cases, driving under 

the influence reports, positive drug test results, Army 

Substance Abuse Program utilization, and pre- and 

postdeployment health assessment results. Additionally, longitudinal analysis should be made over a 

significant time frame to visualize current trends and 

examine behavioral health indicators from current 

and previous deployments. The outcome of crucial, 

predictive information could help direct placement 

and utilization of the limited resources available. Monitoring of these trends should be a regular action and 

the command should be updated on a monthly basis, 

in consultation with the command surgeon. 

Additionally, a mental health service utilization 

tracking system that includes the unit, diagnosis, and 

primary stressor to identify smaller organizational 

trends, such as at the battalion level, can provide commanders at all levels with valuable information and 

facilitate targeted interventions. 

Case Study 6-2: During a recent deployment, one DMHA 

was monitoring unit behavioral health trends and noted a 

significant spike in combat operational stress in a particular 

battalion. This trend was reported to both the battalion and 

brigade commander shortly after it developed. The commander then was able to relate that information with safety 

officer reports of a recent increase in accidents, coupled with 

a noted decrease in combat effectiveness. This led to the 

commander switching areas of operation to “give the unit a 

break” and resulted in both a rapid improvement in combat 

effectiveness for both units and maintenance of the ongoing 

combat mission.

In addition to prevention, unit behavioral health 

officers can have a significant effect in response to 

potential traumatic events. Working with the unit 

chaplains, medical resources, and commanders, the 

division psychiatrist can advise and determine how 

to respond to deaths, nonbattle injuries, casualties, 

and other significant events within units. The unit 

behavioral health officer should develop a traumatic 

event management plan for advising commanders and 

responding to soldiers’ needs after these occurrences. 

Being successful in this realm involves good communication, a knowledge and understanding of current 

medical literature, and good relationships with unit 

commanders and support resources. 

Case Study 6-3: During a recent deployment, one DMHA 

established a formalized traumatic event management policy. 

This policy provided clear guidance to the unit commanders 

and support personnel on how to respond after a potential 

traumatic event, including contacting the unit mental health 

and ministry teams to conduct a unit assessment and perform a debriefing if necessary. Additionally, if required, the 

debriefing would be a joint venture by the behavioral health 

providers and the chaplains. Whereas during a prior deployment, many of the commanders or chaplains often wanted 

to conduct sessions immediately upon the return of the unit 

or conduct full critical incident stress debriefings (which may 

be harmful), this plan provided clear guidance on how to 

respond to potentially traumatic events and helped to reduce 

confusion within the unit.31 In this case, it was imperative for 

the BHO to educate command on the importance of the timing and the type of debriefings to reduce potential negative 

outcomes for the soldiers. 

Educating and advising commanders on current 

ongoing issues of public attention is of critical importance. For example, recent media reports have been 

critical of the military on such topics as the ability to 

identify and treat posttraumatic stress disorder and the 

use of psychotropic medications in combat settings.30–33

Both the division psychiatrist and BCT BHOs must 

be aware of these ongoing issues through their own 

reading and attention. They should be able to advise 

the commander of any potential questions from media 

encounters. Identification of these potential topics is 

accomplished through various sources of information 

including the unit public affairs officer and review of 

critical incident reports and serious incident reports. 

Information can also be gathered from local and 

national newspaper reports about behavioral health 

issues in the military and via ongoing communication 

with the various behavioral health consultants, fellow 

division psychiatrists, and BCT BHOs about such re-
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Combat and Operational Behavioral Health

quests. Responses to media queries should always be 

coordinated through the unit public affairs officer.

Education of command and support staff can be 

conducted through various methods: e-mail updates, 

power-point educational briefings, or prepared commander talking points. The method is at the discretion 

of the commander and is dependent upon how he 

or she best processes information. A recommended 

method is to prepare written talking points in a question-and-answer type format with bulleted responses. 

It will provide commanders with the information in a 

succinct format while also preparing them for potential 

questions from the media. 

Supervise the Brigade Combat Team Behavioral 

Health Officers and Enlisted Mental Health 

Technicians

The division psychiatrist establishes the standards 

of care and practices for all the behavioral health providers in the division. The BCT BHO further refines 

and applies those procedures to the brigade. This task 

requires the setting of the standards and monitoring 

practices through ongoing supervision and routine 

feedback for all BCT BHOs. This is generally done first 

through a written SOP. Certain taskings or reporting 

requirements might require a fragmentary order. Areas 

that require SOPs include operation of the division 

mental health clinic, record keeping procedures, and 

management of high-risk personnel. Additionally, the 

division psychiatrist should establish a supervision 

policy for chart review and routine feedback, generally 

conducted on a monthly basis, to all brigade behavioral 

health officers. For BCTs that are not collocated with 

the DMHA, it is important for the BCT BHO to obtain 

the division SOPs and augment them to fit the working 

environment of the BCT.

Enlisted mental health technicians require ongoing supervision by a licensed provider. Mental health 

technicians must be supervised at the time of every 

new soldier encounter and as needed during followup evaluations. The supervising provider should 

use the context of the soldier encounter to teach the 

enlisted mental health technician about such topics 

as interviewing techniques, the epidemiology of 

behavioral disorders, and common adverse medication effects. 

Providing this supervision can be challenging 

with some divisions because not all of the personnel 

are located at the same installation. Additionally, it is 

imperative that this feedback and supervision continue throughout deployments, keeping in mind that 

with the new BCT structure it is likely that BCTs and 

behavioral health staff from outside the division will 

be joining the unit during deployment. 

An additional responsibility for division psychiatrists is the provision of accruing continuing education 

for themselves, the BCT BHOs, and the mental health 

technicians. The BCT BHOs share this responsibility 

and should be closely involved in the training and 

education of their assigned technicians. This includes 

ensuring that there are ongoing training opportunities 

for educational advancement and access to teaching on 

the latest information and practices in combat operational stress management. How that is implemented 

is the responsibility of each division psychiatrist, 

but consideration can be given to morning reports, 

monthly training sessions, use of “sergeant’s time” 

training, utilization of local medical treatment facility 

training, or sending personnel to training conferences 

or schools. 

All behavioral health officers should be encouraged 

to attend the annual Army Behavioral Health Short 

Course. This opportunity ensures that behavioral 

health officers earn sufficient continuing education 

credits to maintain licensure and promotes professional development, while providing an opportunity for 

collegiality among officers who are dispersed around 

the globe. Additionally, all soldiers in the DMHA 

should attend the combat operational stress course 

prior to deployment because it provides the most 

current training on theater policies, lessons learned, 

and ongoing practices. It also provides an opportunity 

for teambuilding, predeployment planning, and SOP 

guidance for those deploying units that are not collocated in garrison. 

Lastly, there is the responsibility, as a supervisor, to 

provide opportunities and advice for career development for BHOs and mental health technicians. This includes counseling soldiers on their duty performance 

and affording them opportunities to participate in 

required training, such as the AMEDD career course. 

Additionally, both the division psychiatrist and the 

BCT BHOs need to ensure that they develop the writing skills necessary for contributing to, or initiating, 

developmental counseling forms, officer evaluation 

reports, noncommissioned officer evaluation reports, 

and awards. 

Educate Division Medical Providers

Because there is only one psychiatrist for a unit 

of approximately 20,000 soldiers who are, at times, 

spread over several locations, teaching the unit’s 

primary care providers about key behavioral health 

issues is imperative, as well as a force multiplier. This 

can be done through a variety of teaching modalities; 

creativity is encouraged. Key topics to cover include 
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The Division Psychiatrist and Brigade Behavioral Health Officers

postdeployment stress, psychiatric emergencies, sleep 

management, posttraumatic stress disorder, traumatic 

event management, and depression. This education 

should include information on recognition, diagnostic evaluation, and pharmacologic management. 

Pharmacologically, providers should understand the 

indications for use, common side effects, drug interactions, monitoring requirements, and deployment 

considerations of each somatic intervention.

The BCT BHO should take responsibility for developing and incorporating this curriculum with the BCT 

surgeon for providers within the unit. This becomes 

most important in the deployed environment where the 

division psychiatrist may not be located close to the brigade. It is incumbent on both the division psychiatrist 

and the BCT BHO to plan for the continuing curriculum 

during all portions of the deployment cycle.

Provide Direct Care of Patients

As previously mentioned, the division psychiatrist 

functions as the senior behavioral health provider for 

the entire division. Due to other demands, direct clinical opportunities for the division psychiatrist will be 

limited, and will most often involve brief interventions 

and medication management. However, to retain skills 

and credibility, it is important that the psychiatrist 

continue to maintain practice both during deployment 

and in garrison. 

In garrison the division psychiatrist will be a 

provider at the consolidated division mental health 

clinic. Where the division psychiatrist should be located during deployment has been an area of ongoing 

debate since World War I.3

 With enhanced battlefield 

communication capabilities offering accessibility to 

other widely dispersed mental health providers, placing division psychiatrists within the division surgeon 

section allows them to perform as staff officers and 

consultants to the command while also providing 

consultative advice on care, medication management, and other guidance throughout the division via 

telephonic, e-mail, and, when required, face-to-face 

evaluations. However, the division psychiatrist should 

frequently travel to remote sites to provide on-site 

care, supervision, consultation, guidance, and teaching. This practice not only ensures that the division 

psychiatrist has a clear understanding of conditions 

and potential problems throughout the division, but 

it also enhances visibility from all elements of the 

forward line units.

The BCT BHO functions as the primary behavioral 

health provider for the entire BCT. In garrison, BHOs 

should work in a combined DMHA clinic when possible to help share the workload. When not possible, 

they are encouraged to collocate with their BCT troop 

medical clinic because it allows them to maintain close 

contact with the commanders, medical providers, and 

soldiers in their units. During deployment, BCT BHOs 

will routinely locate with their brigade troop medical 

clinic, but are encouraged to develop close relationships with the combat stress control units supporting 

their units, which may include collocating clinics. 

In both settings, BCT BHOs will be challenged to 

adapt their schedules and modalities of care, based on 

the demands of the unit. In general, opportunities for 

long-term therapy will be very rare. Most interventions 

will utilize psychoeducation and brief supportive, 

cognitive, or group therapy modalities.

Fulfill Administrative Psychiatry Requirements

Both the division psychiatrist and the BCT BHO 

have a large number of administrative responsibilities. Command-directed mental health evaluations 

are defined in Department of Defense Instructions 

6490.434 and Directive 6490.1,35 which outline rules 

for both command-directed discretionary and nondiscretionary referrals. Nondiscretionary evaluations are 

those required by regulation, including drill sergeant, 

recruiter, and sniper evaluations. Additionally, all 

soldiers undergoing certain administrative (“chapter”) separations require mental status evaluations. 

However, when commanders request evaluations for 

soldiers who do not require assessment by regulation, they use their discretionary authority to request 

assessment and feedback. In turn, the qualified unit 

behavioral health officer provides commanders with 

feedback and recommendations about their soldiers. 

When performing a command-directed evaluation, the evaluator should provide the commander 

with a formal report of mental status (Department 

of the Army Form 3822-R, Medical Command Form 

699-R) outlining feedback and recommendations. At 

a minimum, the report should address whether or 

not a diagnosis exists, a prognosis for the soldier’s 

condition, any duty limitations, review of soldier 

safety and any safety interventions required, and the 

soldier’s fitness for duty. Regulations require that the 

commander receive that report no later than 24 hours 

after completion of the evaluation. 

Additionally, BCT BHOs must be familiar with 

the restrictions that their level of professional degree 

places on their ability to perform and sign commanddirected evaluations. In general, non-PhD social 

workers are able to perform and sign nondiscretionary evaluations. Discretionary evaluations and those 

recommending a Chapter 5-13 (personality disorder) 

or a Chapter 5-17 (failure to adapt) discharge require 
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Combat and Operational Behavioral Health

a PhD-level social worker, or a psychologist, or a psychiatrist. Psychologists who are BCT BHOs are able 

to perform and sign all forms required for commanddirected evaluations. 

BCT BHOs who are non-PhD–level social workers should develop contingency plans with their 

colleagues for performing discretionary commanddirected evaluations either in garrison or during 

deployment. During deployment, this may require 

coordination with combat stress detachment assets in 

the area of operations. Additionally, if no psychologists or psychiatrists are available, then a physician 

(preferably the brigade surgeon) may serve as the 

signing authority. 

At times, military mental health providers may 

perceive pressure to recommend use of these chapter 

separations as opposed to a fitness for duty and disability evaluation. This pressure often comes from 

the patient, the unit, or both who are primarily trying 

to expedite a rapid exit from the military for varying 

reasons. These chapter separations are often more expedient, requiring less paperwork and fewer levels of 

review. However, soldiers who are chapter separated 

are not afforded medical disability benefits and may 

reenter military service as early as 6 months after discharge. It is imperative that the military mental health 

provider conduct a thorough evaluation and ensure 

appropriate disposition as defined by the current 

military regulations. It is also important for the service 

member to understand the meaning and consequences 

of the evaluation and rationale for separation. This will 

ensure the best care for the patient, the military, and 

the society that the soldier may be returning to upon 

discharge from the military.

In addition, there are a number of other administrative requirements. These include security evaluations 

for unit soldiers applying for clearance, sanity boards 

and other forensic psychiatry evaluations when ordered by the courts, and medical evaluation boards 

when indicated for disposition through medical channels. These assessments all require that the evaluator 

be either a psychiatrist or psychologist. Lastly, unit 

behavioral health officers may be asked to perform 

line-of-duty investigations for those involved in events 

with unfortunate outcomes, and the Department of 

Defense suicide event reports when soldiers either 

make a suicidal gesture or attempt, or complete a 

suicide. These evaluations can be time consuming, 

but must be performed expeditiously because they 

provide commanders and the Army with important 

information.

Be an Officer and Leader in the Division

Lastly, all BHOs must remember that they are officers in the unit. The Army combat uniform does not 

display branch insignia; hence, it is imperative that as 

officers, the division psychiatrists or the BCT BHOs 

set the standard. They must ensure that they maintain personal readiness and weapons qualification, 

actively participate in physical training, and attend 

all functions. It can also be expected that they assume 

additional taskings; it is their responsibility to perform 

those duties to the utmost of their ability. 

CHALLENGES OF THE POSITION

Balancing the duties and responsibilities of being 

a division psychiatrist or BCT BHO can be very challenging. There are several other factors that confront 

those in this position. First, division psychiatrists tend 

to be junior in rank to other division staff officers. 

With the recent Modified Table of Organization and 

Equipment (MTOE) adjustments, the division psychiatrist serves on the staff of the division surgeon (a 

lieutenant colonel) and works directly with several of 

the division surgeon’s deputies (majors). Additionally, 

the majority of the officers who directly advise the 

commanding general are at field-grade level, while 

the division psychiatrist position has traditionally 

been filled by individuals shortly after residency who 

are still at the company-grade (captain) level. This 

makes it difficult for the individual to gain the trust 

of the key leaders and advisors. Furthermore, recent 

changes in assignments have introduced BHOs working for the BCTs who are senior in rank to the division 

psychiatrist, thus potentially placing psychiatrists in 

the position of supervising those who are senior to 

themselves.

The BCT BHO, in turn, serves as a direct advisor 

to the BCT commander and the BCT surgeon, but is 

not located within the same unit allocation as those 

individuals. With the recent MTOE adjustments, the 

BCT BHO is assigned to the medical company in the 

brigade support battalion, while the BCT surgeon is 

assigned to the BCT headquarters unit. This can be 

very difficult because company and battalion commanders may feel that the BCT BHO “works for them.” 

They may attempt to restrict BHO and enlisted mental 

health technicians’ access to the DMHA and the BCT 

commander without clearing information through 

them first. It is the responsibility of the BCT BHOs 

to work out agreements with their company and battalion commanders about places of duty, interaction 

with command staff, and required unit activities. BCT 
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The Division Psychiatrist and Brigade Behavioral Health Officers

BHOs are reminded to maintain appropriate bearing 

throughout these interactions and seek the assistance 

of their division psychiatrists and their BCT surgeons 

if they are having difficulty. 

Access to the enlisted mental health technicians, 

both in a deployed and garrison environment, can be 

problematic. This may need to be addressed by the 

brigade surgeon, the support planning officer, or the 

division psychiatrist if the BCT BHO is having trouble 

gaining full use of the mental health technician.

Another challenge is that the BCT BHO works with 

the BCT surgeon to directly advise the BCT commander about behavioral health issues, but tends to be more 

junior than other BCT staff officers. In general, both 

the BCT surgeon and the BCT BHO are junior to midlevel captains or junior majors, while most of the BCT 

commander’s deputies are mid-level to senior majors 

or other field-grade officers. Being more junior in experience, especially in the operational arena, makes it 

difficult for the individual to gain the trust of the key 

leaders and advisors. This requires the BCT BHOs 

to demonstrate respect, learn about the mission, and 

develop an understanding of unit capabilities. They 

must also rapidly adapt to the needs and demands of 

the BCT commander’s staff for updates and information dispersal. 

Additionally, both the division psychiatrist and the 

BCT BHO have to coordinate with other behavioral 

health resources within the area. While in garrison, the 

division psychiatrist needs to coordinate resources and 

the flow of information with the Medical Department 

activity, medical center, or the local civilian hospitals. 

This can be difficult at times because many in the 

hospital positions will not understand the full scope 

of the division-level BHO’s duties and responsibilities. 

It is possible that they might request that a division 

psychiatrist, BCT BHO, or enlisted mental health 

technician work at the local facility and share duty 

responsibilities. There are no guidelines or specifics on 

this. Therefore, all such requests should be coordinated 

locally with the supervising command surgeon.

During deployment, similar coordination will be 

required. There is potential that a BCT can be spread 

over a large area through many small forward operating bases, making it difficult for the BCTs limited assets 

to respond to all of the behavioral health needs. It may 

be difficult to coordinate with corps-level behavioral 

health assets for coverage, which will depend on their 

commanders’ opinions on the optimal emplacement 

of behavioral health resources. In these situations it 

is vital to have a theater behavioral health consultant 

who can address these issues. 

Another consideration is that, currently, several of 

the divisions are spread over multiple sites while in 

garrison. In such situations, it is difficult to both gauge 

the climate and establish a channel of communication 

between the BCT BHO and the division psychiatrist. 

This can create a gap in information flow within the 

DMHA and can leave a BCT BHO feeling unsupported 

by the rest of the DMHA. Such a deficiency can persist, 

and even flourish, during deployment because communications can be unreliable in theater and BCTs 

may deploy under a different division command than 

they are assigned to in garrison. It is vital for both the 

division psychiatrist and the BCT BHO to maintain 

open communication lines for continued visibility 

and comprehension of the trends and activities in the 

units. This provides for continuity of ongoing unit 

initiatives.

In the theater of operations, assuming unanticipated 

roles, such as mental health consultant for detainee operations, may present another challenge. In most cases, 

detainee operations have designated mental health 

attachments; however, should this service require support of the division psychiatrist, review of local policy, 

current Army regulations, and Department of Defense 

guidelines is critical. Comprehensive reference documents would include Army Regulation 190-8, Enemy 

Prisoners of War, Retained Personnel, Civilian Internees, 

and Other Detainees, and Annex F of the Mental Health 

Advisory Team (MHAT) II Report.

36,37 These, along with 

current guidance from the US Army surgeon general, 

can assist the division psychiatrist in ensuring ethical 

mental healthcare of detainees.

Other stressors in the garrison environment are 

finances and personnel. The DMHA clinic may be 

“owned” by the division, where there is little emphasis 

on workload capture or compensation. Or, as is the 

case at Fort Drum, New York, DMHA may fold into a 

larger behavioral health department. Regardless of the 

specific arrangement, clear boundaries and working 

agreements must be established between the various 

organizations to address budgetary, logistical, maintenance, operational, and personnel issues. 

There are several possible personnel issues that 

should be considered. First, in garrison the division 

resources are limited, as only the maneuver brigades 

are equipped with BHOs. Units such as the sustainment brigade and combat aviation brigade require 

support from both division and nondivision resources. 

Furthermore, it has not been uncommon for BCTs to be 

missing their full complement of personnel in garrison. 

This may result in BCT BHOs providing care coverage 

for soldiers from other brigades at the DMHA clinic 

or a BCT BHO arriving to the unit shortly before a 

deployment. During deployment, the division is likely 

to add BCTs, bringing additional providers who have 

been working under a different DMHA. It falls upon 
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Combat and Operational Behavioral Health

the division psychiatrist to ensure that all behavioral 

health providers within the division are properly supervised and educated, and function under the same 

policies and standards of care.

Lastly, all BCT BHOs should expect to receive supervision, feedback, and information from their division 

psychiatrist, including those who are not collocated 

with their divisions. However, under certain circumstances, the BCT BHOs might need to seek supervision 

from their local Medical Department activity, such as 

when the division headquarters is deployed while the 

brigade remains in garrison. 

FUTURE DIRECTIONS

With increased public awareness of the behavioral 

health effects of deployment and the shifting of the 

Army to a more modular force, the DMHA has many 

challenging roles. These roles involve a variety of 

duties and responsibilities that demand a clinically 

competent provider fluent in the art of multitasking and executive decision making. With the recent 

Army changes and the increase in size of the division 

mental health activity, it is imperative that capable, 

well-prepared psychiatrists, psychologists, and social 

workers are placed in these positions. With that in 

mind, several areas of discussion are provided for 

future consideration. 

In the last two decades the US Army has shifted 

focus away from assets internal to the combat units 

toward placing emphasis on area support resources 

(combat support hospitals and combat operational 

stress control units), which provide coverage based on 

region rather than units.3

 Furthermore, the combat operational stress control units have larger, more diverse 

teams normally containing several psychiatrists, psychologists, social workers, and mental health specialists as well as occupational therapists and psychiatric 

nurses.11 These units are then spread over a large area 

providing both preventive and restorative care, often 

with a centralized restoration center that can provide 

up to 2 weeks of care.11

Many of these units are called to active duty from 

the Army Reserve or from other branches of service. 

Few, if any, of these units have had any contact with 

the units in garrison and thus have not established 

consultative relationships with the commanders prior 

to the deployment. Therefore, they do not have the 

preestablished credibility necessary to provide effective education and consultation to commanders. The 

essence of this credibility is established in prior demonstration, to command, of the consultant’s availability, 

utility of clinical skills and services, and perception 

that the consultant is not “investigating or blaming 

the unit for its problems.”34

In addition, Department of Defense Directive 6490.5 

states that each unit should have training, curricula, 

and guidance on combat operational stress control 

with a focus on primary, secondary, and tertiary 

prevention in garrison.38 Combat operational stress 

control units are generally not available in garrison for 

teaching. Likewise, many medical treatment facilities 

are not currently capable of providing the primary and 

secondary prevention and training because of ongoing 

demands for treatment of soldiers and their family 

members. This role is, therefore, ideal for the division 

mental health team and allows for development of 

strong bonds with units and a sense of ownership 

among the behavioral teams in their units. 

SUMMARY

Now, more than ever, the DMHA is critical. The 

new modular BCT structure projects mental health 

resources to lower levels and further toward the front 

lines. It also allows for development of long-term consultative and treatment relationships at the battalion 

and company level. This structure can also help to 

strengthen and emphasize pre- and postdeployment 

mental resiliency and medical provider training. 

Maintaining both division and combat stress control 

mental health resources in a collaborative working 

environment—where patient-specific issues and policy 

decisions are jointly determined—allows for continuity of training, education, consultation, and treatment 

during nondeployed times, with additional mental 

health resources available during a deployment. Similar lessons are being seen within the US Marine Corps 

and have led to the development of their Operational 

Stress Control and Readiness (OSCAR) program. Their 

program, like that of the US Army, increases the behavioral health resources within the units. That system is 

placing two psychiatrists within divisions, with one 

focusing toward the consultative and administrative 

aspects while the other is leading a multidisciplinary 

treatment team. 

The position of division psychiatrist and BCT BHO 

presents many challenges, especially in the aspect of 

balancing responsibilities. The US Marine Corps is 

the only other US military service that embeds mental 

health assets with their soldiers and has recognized 

these same challenges. Because of the complexities 
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The Division Psychiatrist and Brigade Behavioral Health Officers

of staff, consultant, leadership, teaching, and clinical 

roles, future assignments to these positions should be 

based on knowledge, skills, and experience. Preferably, 

such individuals should be field-grade officers who 

have served at least one utilization tour after residency 

to gain experience as a practicing psychiatrist, and are 

graduates of the AMEDD career course. Additionally, as noted in the 5th iteration of the Mental Health 

Assessment Team’s report, consideration should be 

given to expanding mental health resources within 

the divisions, including the addition of an enlisted 

mental health technician in each battalion and an 

aeromedically trained psychologist in each combat 

aviation brigade.

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22. Warner CH, Breitbach JB, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental health in the new brigade 

combat team structure. Part I. Predeployment and deployment. Mil Med. 2007;172:907–911.

23. Warner CH, Breitbach JB, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental health in the new brigade 

combat team structure. Part II. Redeployment and postdeployment. Mil Med. 2007;172:912–917.

24. McCarroll JE, Jaccard JJ, Radke AQ. Psychiatric consultation to command. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 151–170.

25. Kirkland FR, Jackson MA. Psychiatric support for commanders. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg 

JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 171–192.

26. Koshes RJ, Plewes JM, McCaughey BG, Stokes J. Educating mental health workers. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of 

Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 

193–213.

27. Lande RG. A model combat psychiatry training program for division personnel. In: Jones FD, Sparacino LR, Wilcox VL, 

Rothberg JM, eds. Military Psychiatry: Preparing for Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military 

Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 215–226.

28. Major General WG Webster. Commander, Task Force Baghdad. Personal communication, September 17, 2005.

29. Government Accountability Office. Post Traumatic Stress Disorder: DoD Needs to Identify the Factors Its Providers Use to 

Make Mental Health Evaluation Referrals for Servicemembers. Washington, DC: GAO; May 2006: 1–34. Report No. GAO06-397.

30. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve 

component soldiers returning from the Iraq War. JAMA. 2007;298:2141–2148.

31. Jacobs J, Horne-Moyer HL, Jones R. The effectiveness of critical incident stress debriefing with primary and secondary 

trauma victims. Int J Emerg Ment Health. 2004;6:5–14.

32. Chedekel L, Kauffman M. Mentally Unfit, Forced to Fight. Hartford Courant. 2006, May 14, 2006. Available at: www.

courant.com/news/nationworld/hc-unfit0515.artmay14,0,7374793.story. Accessed April 24, 2009.

33. Thompson M. America’s medicated army. Time. June 5, 2008. Available at: www.time.com/time/nation/article/0,8599,1811858,00.html. Accessed April 24, 2009.

34. Department of Defense. Requirements for Mental Health Evaluations of Members of the Armed Forces. Washington, DC: 

DoD; August 28, 1998. DoD Instruction 6490.4.

35. Department of Defense. Mental Health Evaluations of Members of the Armed Forces. Washington, DC: DoD; October 1, 

1997. DoD Directive 6490.1.
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36. US Department of the Army. Enemy Prisoners of War, Retained Personnel, Civilian Internees, and Other Detainees. Washington, DC: DA; October 1, 1997. Army Regulation 190-8.

37. Mental Health Advisory Team (MHAT-II). Operation Iraqi Freedom (OIF-II). Annex F: Internment Detainee Facility Assessment of Mental Health Advisory Team (MHAT) II. Report. The US Army Surgeon General. January 30, 2005. Available 

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

38. Department of Defense. Combat Stress Control (CSC) Programs. Washington, DC: Department of Defense; February 

23,1999. DoD Directive 6490.5.
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Chapter 7

US Marine coRps and Navy 

combat and operational stress

continuum model: a tool for 

leaders

WILLIAM P. NASH, MD*

INTRODUCTION

COMBAT AND OPERATIONAL STRESS CONTINUUM

Background and Development

Ready: The Green Zone

Reacting: The Yellow Zone

Injured: The Orange Zone

Ill: The Red Zone

FIVE CORE LEADER FUNCTIONS FOR PSYCHOLOGICAL HEALTH

Strengthen Service Members

Mitigate Stressors

Identify Stress Reactions, Injuries, and Illnesses

Treat Stress Injuries and Illnesses

Reintegrate Stress Casualties

SUMMARY

*Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego; formerly, Senior Consultant, 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Rosslyn, Virginia
108

Combat and Operational Behavioral Health

INTRODUCTION

In the US military, the overall responsibility for preserving the health of operationally deployed service 

members is assigned to commanders of combatant 

commands.1

 Only operational commanders are in a 

position to balance the evolving tactical requirements 

that inevitably place service members in harm’s way 

against the enduring strategic imperative to preserve 

the health of the force. Only line commanders can 

lead the full spectrum of force health protection 

activities necessary to “promote, protect, improve, 

conserve, and restore the mental and physical well 

being of Service members across the range of military 

activities and operations.”1(p10) And only trusted 

leaders and mentors can reduce the stigma associated 

with acknowledging mental health problems, and 

make it acceptable for service members to receive help 

for them. Even in garrison, line commanders cannot 

delegate their force health protection responsibilities 

to medical or religious ministry support personnel, 

although such support is crucial to accomplishing 

the health protection mission. The dual goals of force 

health protection are force conservation and long-term 

physical and psychological health and well-being for 

service members and their families.

Military commanders and their health and religious 

ministry advisors have historically approached 

psychological health (PH) protection, including 

combat and operational stress control (COSC), 

somewhat differently from physical health protection 

because of the “demedicalized” model of combat stress 

reactions that has persisted since World War I.2–4 In 

this model, combat and operational stress reactions 

have been viewed not as injuries or illnesses but as 

temporary and reversible responses to stress over 

which the individual is believed to retain a significant 

degree of control. Principles of forward management 

of stress reactions based on this model, summarized in 

the acronyms PIES (proximity, immediacy, expectancy, 

simplicity) and BICEPS (which adds brevity and contact 

or centrality), recommend that service members 

suffering from combat and operational stress reactions 

not be permitted to perceive themselves as sick, ill, or 

injured (see also Chapter 4, Combat and Operational 

Stress Control).5 Early screening and treatment for 

significant symptoms of mental illness is eschewed 

in favor of “normalizing” stress reactions and using 

the power of suggestion (“expectancy”) to encourage 

return to previous occupational functioning. The 

approach to be taken to service members suffering 

from combat stress in a war zone, according to this 

demedicalized model, is summarized in the words of 

Colonel (Retired) Franklin D Jones, former psychiatry 

and neurology consultant to the US Army surgeon 

general, writing in War Psychiatry in 1995: “You are 

neither sick nor a coward. You are just tired and will 

recover when rested.”5(p9)

However, evolving scientific thought provides a 

strong argument, in this author’s opinion, for developing a model that bases PH protection and COSC 

on the same preventive medicine principles that 

underlie physical health protection. Posttraumatic 

stress disorder (PTSD), for example, is now known 

to be a relatively common, potentially disabling, and 

possibly preventable illness with significant biological, psychological, and social-spiritual components.6

The risk for PTSD rises in direct proportion to the 

level of exposure to combat,7 and the symptoms of 

PTSD and other stress-related mental disorders are 

clearly present in personnel in deployed operational 

settings.8 Also, the overlap between PTSD and mild 

traumatic brain injury, both in symptoms and underlying brain pathology, argues for adopting similar 

approaches to recognizing and managing these two 

separate but related health problems.9 Furthermore, 

PH protection efforts based on previous, demedicalized models have failed to prevent significant 

postdeployment PTSD in veterans of the wars in 

Vietnam10–14 and Iraq.7,15,16

In recent years, operational commanders in the 

US Marine Corps and Navy have collaborated with 

mental health and religious ministry professionals to 

develop new PH protection tools for the operating 

forces. Based on the science of preventive medicine and 

the art of leadership, these tools have been crafted to 

fit the needs of commanders and subordinate leaders 

at all levels. The most basic of these tools is the combat 

and operational stress continuum doctrinal model 

(also known as the stress injury continuum model, 

as described in Chapter 8, Expeditionary Operational 

Stress Control in the US Navy).

COMBAT AND OPERATIONAL STRESS CONTINUUM

Background and Development

The February 1996 Department of Defense (DoD) 

inspector general report on combat stress control in the 

military defined comprehensive COSC as consisting of 

three key activities—(1) prevention, (2) identification, 

and (3) treatment—to be applied before, during, and 

after deployment.17 Three years later, DoD directed all 

services to implement COSC programs that included 

these key activities.18 However, the imperative to 
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

implement PH prevention, identification, and treatment based on the normalizing, demedicalized model 

has posed two challenges:

1. If all reactions to stress in operational environments are truly “normal,” then what is there 

to prevent and treat? After all, normality is 

neither prevented nor treated. 

2. If all reactions to stress are normal, whereas 

PTSD and other stress-induced mental disorders are clearly not normal, where is the 

line to be drawn between them? Where does 

normality end and pathology begin?

To meet these challenges, the bridging concept of 

“stress injuries” was developed in the Marine Corps in 

2004.19 Independently, and for similar reasons, the term 

“operational stress injury” had been established in 

the Canadian Forces by Lieutenant Colonel Stephane 

Grenier, a veteran of the 1994 United Nations mission 

to Rwanda.20 The validity of the idea that overwhelming or persistent stress can inflict literal injuries to the 

brain, mind, and spirit is supported by two lines of 

reasoning. First is the argument that the only alternative to acknowledging that humans can be literally 

injured by stress is to posit that human brains, minds, 

and spirits are invincible and unbreakable regardless 

of the forces acting on them, which cannot be true because the mind and brain are material living systems 

that are susceptible to damage, senescence, and death.

The second argument is based on the assertion that 

some (though not all) stress responses or outcomes in 

operational environments fully meet the definitions 

of the terms “injury” or “wound” as commonly used 

in medical and nonmedical discourse.21 In common 

usage, an injury can be defined as something that

	 •	 happens to a person rather than being chosen,

	 •	 involves a loss of normal integrity,

	 •	 causes at least a temporary loss of function,

	 •	 provokes predictable self-protective and healing responses, and

	 •	 cannot be undone, although it usually heals

over time.

The element of volition in this definition, when 

applied to stress outcomes, is hard to prove; there is a 

long tradition of viewing all stress “responses” as chosen by the individual on at least an unconscious level. 

However, the universal experience of individuals who 

experience traumatic stress involving terror, horror, 

or helplessness is one of being acted upon rather than 

acting. In fact, it may be that the loss of volition during 

a traumatic event partly defines it as traumatic. Furthermore, the most disabling symptoms of unhealed 

traumatic stress, such as panic attacks, flashbacks, and 

rage outbursts, are disabling to the extent they cannot 

be predicted or prevented by conscious choice. 

The second element in the list, loss of integrity, is 

certainly not externally evident in the same way that 

loss of the integrity of skin or bone is obvious in the 

case of physical injury. However, the preponderance 

of evidence from preclinical studies suggests that 

acute or chronic stress can cause a loss of the normal 

integrity of the neurobiological systems necessary 

for effectively coping with stress, particularly those 

responsible for regulating arousal and emotional 

intensity.6

 And the integrity of necessary and deeply 

held beliefs and attachments are clearly compromised 

by trauma or loss.6

The loss of function caused by a stress injury, 

the third listed item, is likely the most evident and 

observable feature, although sometimes only to stressinjured individuals themselves, or those closest to 

them. Little is known about normal self-protective 

and healing responses to stress injuries (the fourth 

item listed), but included in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic 

criteria for PTSD and acute stress disorder are the 

characteristic avoidance of reminders of traumas 

and efforts to reduce excessive arousal through 

isolation.22

Finally, the assertion that stress injuries cannot be 

undone, although also not yet convincingly shown 

empirically, is strongly supported by the characteristic 

and lasting vulnerabilities (or increased growth, in 

many cases) demonstrated by individuals following 

acute traumatic stress or stress-induced depressive or 

anxiety disorders.19 Certainly, traumatic memories and 

losses of close comrades cannot be undone.

The concept of stress injuries, as a bridging construct between reversible stress reactions at one end 

of the stress response spectrum and stress illnesses at 

the other, has gained partial acceptance in the US sea 

services. Analogous to physical injuries, stress injuries 

may be seen as less the fault of the individual than how 

they are considered in the demedicalized model, which 

implied that disabling and persistent stress reactions 

were due to preexisting weakness.3

 However, in 2007, 

the commanding generals of the three Marine Expeditionary Forces expressed concern that a doctrine based 

on the stress injury conception could be problematic 

if it did not give sufficient attention to promoting and 

restoring resiliency before stress reactions progressed 

to become injuries, or injuries became illnesses. Therefore, in September 2007, the three forces convened a 

working group including line commanders, senior 

enlisted leaders, chaplains, medical and mental health 

professionals, and Marine Corps Headquarters policy 
110

Combat and Operational Behavioral Health

makers. The resulting discussion yielded the combat 

operational stress continuum model, Figure 7-1, which 

has since become the foundation for all PH and COSC 

doctrine, training, and early interventions in both the 

Marine Corps and Navy.23

The continuum model is a paradigm that recognizes 

the entire spectrum of stress responses and outcomes, 

from adaptive coping and full readiness (color-coded 

green as the “ready” zone), to mild and reversible distress or loss of function (the yellow “reacting” zone), to 

more severe and persistent distress or loss of function 

(the orange “injured” zone), to clinical mental disorders arising from stress and unhealed stress injuries 

(the red “ill” zone). 

Ready: The Green Zone

The green “ready” zone can be defined as encompassing adaptive coping, effective functioning in all 

spheres, and personal well-being. The green zone is 

not conceived to represent the absence of stress, but 

rather its effective mastery without significant distress 

or impairment. One important goal of all selection, 

training, and leadership in the military is to promote 

green zone readiness, or to restore individuals and 

units to the green zone once they have experienced 

distress or loss of function because of stress. The ability 

to remain in the green zone under stress, and to return 

quickly to it once impaired or injured by stress, are two 

crucial aspects of resiliency. Both individual service or 

family members and entire military or family units can 

be said to operate in the green zone.

The following are some of the attributes and behaviors characteristic of the green “ready” zone:

	 •	 remaining calm and steady;

	 •	 being confident in self and others;

	 •	 getting the job done;

	 •	 remaining in control physically, mentally, and

emotionally;

	 •	 behaving ethically and morally;

	 •	 retaining a sense of humor;

	 •	 sleeping enough;

	 •	 eating the right amount;

	 •	 working out and staying fit;

	 •	 playing well and often; and

	 •	 remaining active socially and spiritually.

Reacting: The Yellow Zone

The yellow “reacting” zone can be defined as 

encompassing mild and temporary distress or loss 

of function due to stress. By definition, yellow zone 

reacting is always temporary and reversible, although 

while stress reactions are occurring it is hard to know 

whether they will be temporary and leave no lasting scars. Yellow zone reactions can be inferred by 

their time course, relative mildness, and commonness. Although no research has yet been done on the 

prevalence of subclinical distress or loss of function 

in operational settings, it is likely that such yellow 

zone stress reactions may be extremely common, if not 

READY

DEFINITION

• Adaptive coping

• Effective functioning

• Well-being

FEATURES

• In control

• Calm and steady

• Getting the job done

• Playing

• Sense of humor

• Sleeping enough

• Ethical and moral behavior

REACTING

DEFINITION

• Mild and transient distress or 

 loss of function

FEATURES

• Anxious

• Irritable, angry

• Worrying

• Cutting corners

• Poor sleep

• Poor mental focus

• Social isolation

• Too loud and hyperactive

INJURED ILL

DEFINITION

• More severe and persistent 

 distress or loss of function

TYPES

• Trauma

• Fatigue

• Grief

• Moral injury

FEATURES

• Loss of control

• Can’t sleep

• Panic or rage

• Apathy

• Shame or guilt

DEFINITION

• Clinical mental disorders

• Unhealed stress injuries

TYPES

• PTSD

• Depression

• Anxiety

• Substance abuse

FEATURES

• Symptoms persist > 60 days 

 after return from deployment

Figure 7-1. The combat and operational stress continuum model with its four color-coded stress zones.

PTSD: posttraumatic stress disorder
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

universal. Figure 7-2 depicts the time course of green 

zone adaptation and yellow zone reactions in the face 

of a new challenge such as an operational deployment 

or combat mission.19 As depicted in this diagram, the 

times of greatest risk for yellow zone stress reactions 

are just before or at the onset of a new challenge, and 

at the very end or immediately following that challenge.

The following experiences, behaviors, and symptoms may be characteristic of the yellow “reacting” 

zone:

	 •	 feeling anxious,

	 •	 worrying,

	 •	 cutting corners on the job,

	 •	 being short-tempered or mean,

	 •	 being irritable or grouchy,

	 •	 having trouble falling asleep,

	 •	 eating too much or too little,

	 •	 feeling apathetic or losing energy or enthusiasm,

	 •	 not enjoying usual activities,

	 •	 keeping to oneself,

	 •	 being overly loud or hyperactive,

	 •	 being negative or pessimistic, and

	 •	 having diminished capacity for mental focus.

Injured: The Orange Zone

The orange “injured” zone can be defined as encompassing more severe and persistent forms of distress or 

loss of function that may not completely reverse over 

time. Whereas yellow zone reactions, by definition, 

are like a tree branch bending with the wind—always 

capable of springing back into place once the wind 

calms—orange zone injuries, by definition, are like a 

branch breaking, to some extent, because it was bent 

beyond its limits. Although stress injuries cannot be 

undone, like physical injuries, their usual course is to 

heal over time. But as with physical injuries, healed 

stress injuries may leave behind a “scar”—a mental or 

physical remnant, vulnerability, or weakness that will 

likely fade but may never disappear. As with yellow 

zone stress reactions, the more lasting nature of stress 

injuries in the orange zone cannot be easily discerned 

in their early stages. However, stress injuries may be 

identified in their early stages both by the severity 

and persistence of the symptoms they provoke and 

the intensity of the stressors that cause them. Because 

stress injuries are not clinical mental disorders, they 

do not require clinical mental health expertise to recognize them, although operational commanders and 

small unit leaders rely heavily on their chaplains and 

organic medical personnel to identify and help take 

care of orange zone stress injuries.

Combat and operational stress injuries have four 

different possible mechanisms or causes19:

1. Life threat: exposure to life-threatening situations provoking terror, horror, or helplessness.

2. Wear and tear: the accumulation of stress 

from all causes, including from nonoperational sources, without sufficient sleep, rest, 

and restoration.

3. Loss: separation from cherished people, objects, or portions of oneself.

4. Inner conflict: carrying out or bearing witness to acts of omission or commission that 

violate or disrupt deeply held moral values 

and beliefs.

Although stress injuries may be caused by one or 

more of these four different mechanisms, the experiences, behaviors, and symptoms that characterize them 

are similar regardless of mechanism. They include

	 •	 losing control of one’s body, emotions, or

thinking;

	 •	 being frequently unable to fall or stay

asleep;

	 •	 waking up from recurrent, vivid nightmares;

	 •	 feeling persistent, intense guilt or shame;

	 •	 feeling unusually remorseless;

	 •	 experiencing attacks of panic or blind rage;

	 •	 losing memory orthe ability to think rationally;

Anticipation or

Alarm at Onset

of Challenge

HIGH

LOW

Rebound After

Challenge Ends

“In the Groove”

Time

Ready

End ofChallenge

Beginningof Challenge

Level of Distress

Reacting

Reacting

Figure 7-2. Time course of coping and adaptation to a new 

challenge.
112

Combat and Operational Behavioral Health

	 •	 being unable to enjoy usually pleasurable

activities;

	 •	 losing grounding in previously held moral

values;

	 •	 displaying a significant and persistent change

in behavior or appearance; and

	 •	 harboring serious suicidal or homicidal

thoughts.

Ill: The Red Zone

The red “ill” zone can be defined as including all 

mental disorders arising in individuals exposed to 

combat or other operational stressors. Because red zone 

illnesses are clinical mental disorders, they can only 

be diagnosed by health professionals. However, commanders, other leaders, peers, and family members can 

and should be aware of the characteristic symptoms 

of stress illnesses. The most widely recognized stress 

illness is PTSD. However, stress illnesses may take 

many different forms, often co-occurring in the same 

individual at the same time or at different times. Common red zone illnesses include

	 •	 PTSD;

	 •	 depressive disorders, especially major depression;

	 •	 anxiety disorders, including generalized anxiety and panic disorder; and

	 •	 substance abuse or dependence.

Although the relationship between orange zone 

stress injuries and red zone stress illness has not yet 

been well studied, the presence of a stress illness 

should be strongly suspected whenever symptoms of 

a stress injury either do not improve or worsen even 

after removal of the sources of stress. Specific indicators for possible stress illnesses—and the need for 

mental health evaluation—include 

	 •	 stress injury symptoms or behaviors that do

not significantly improve within 60 days of 

returning from operational deployment;

	 •	 stress injury symptoms that worsen overtime

rather than improving;

	 •	 stress injury symptoms that return after improving or resolving; and

	 •	 significant and persistent distress or loss of

function that arises after removal from the 

sources of stress.

The 60-day duration threshold suggested above 

for diagnosing stress illnesses is somewhat arbitrary. 

However, it is believed to represent the best compromise between the competing priorities of quickly 

identifying problems that may not get better without 

clinical help, and hesitating to clinically label stress 

problems that may yet resolve on their own. Again, 

military leaders need not be concerned about whether 

particular service members do or do not suffer from 

diagnosable mental disorders, as much as whether the 

individuals warrant immediate referral to a mental 

health professional for evaluation of fitness for duty 

or treatment requirements.

FIVE CORE LEADER FUNCTIONS FOR PSYCHOLOGICAL HEALTH

The combat and operational stress continuum 

model is broad in its scope, encompassing all conceivable responses and outcomes to stress, both for service 

members and their families. Clearly, no one group of 

individuals can manage the entire stress continuum 

as defined. At the far left of the continuum—the green 

and yellow zones—the activities of line leadership 

predominate to promote resiliency. Here, prevention 

is paramount. At the far right of the continuum—the 

orange and red zones—medical and mental health 

professionals are most critical to providing necessary 

treatment. Chaplains act in operational units both to 

promote green zone resiliency and to recognize and 

respond to yellow, orange, and red zone reactions, 

injuries, and illnesses, including making appropriate 

referral decisions, although they usually cannot provide definitive treatment for stress injuries or illnesses. 

Individual service members and family members bear 

responsibility for maintaining their own psychological 

health across the stress continuum, including building their own resiliency, managing their own stress 

reactions, and recognizing and getting help for stress 

injuries and illnesses when needed. Even though managing the stress continuum requires the involvement 

and expertise of several groups of stakeholders, the 

overall PH promotion effort remains the primary responsibility of operational commanders, as previously 

stated. Line commanders and their subordinate small 

unit leaders are responsible for coordinating PH and 

COSC efforts across the stress continuum to preserve 

both fighting strength and the long-term health and 

well-being of service members and families.

The Marine Corps and Navy have identified five 

core leader functions for the promotion of PH across 

the stress continuum: (1) strengthen, (2) mitigate, (3) 

identify, (4) treat, and (5) reintegrate. These five core 

leader functions are defined below as the context 

within which the stress continuum model is utilized.
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US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Strengthen Service Members

Building resiliency in individuals, units, and families is the first core PH function of military leaders. 

Individuals enter military service with a set of preexisting strengths and vulnerabilities based on genetic 

makeup, prior life experiences, personality style, family supports, and a host of other factors that may be 

largely immutable. However, centuries of experience 

in military organizations, as well as a number of research studies, have demonstrated that commanders 

of military units can do much to enhance the resilience 

of unit members and their families. Activities available 

to commanders to strengthen their troops fall into 

three main categories: (1) training, (2) unit cohesion, 

and (3) leadership.

Training

Tough, realistic training develops physical and 

mental strength and endurance, enhances service 

members’ confidence in their ability as individuals 

and as members of units to cope with the challenges 

they will face, and inoculates them to future stressors. 

Exactly how preexposure to stress enhances hardiness 

is not well understood, but emerging evidence suggests that resilience secondary to stress inoculation 

has both psychological and biological components. 

Hardy service members have lower heart rates and 

higher levels of peptides in the brain that are essential 

for staying calm in the face of severe stress.24 They also 

face familiar challenges with greater confidence and 

less anxiety-induced loss of mental focus or dissociation.25 One particular challenge for unit leaders is to 

deliver training that is tough and realistic enough to 

build resilience, without making it so tough that it 

inflicts orange zone injuries on the training field.

Unit Cohesion

Unit cohesion, defined broadly as mutual trust 

and support in a social group, is developed through 

sharing adversity over time in a group with a stable 

membership. Two-way communication, both horizontally among peers and vertically between leaders and subordinates, is essential to unit cohesion. 

Seamless teamwork is a well-known outcome of 

unit cohesion. Less well known is how membership 

in a cohesive unit strengthens unit members against 

the damaging effects of stress, but it is likely that 

unit cohesion has both biological and psychological 

impacts. As psychiatrist and author Jonathan Shay 

has repeatedly pointed out, “the human brain codes 

social recognition, support, and attachment as physical safety.”26(p210) Most leaders know how to build 

cohesive units given enough time and unit stability, but an all too common challenge is to maintain 

unit cohesion in the face of rotations into and out of 

the unit, including casualties and combat replacements. Certainly, the unit rotation policies currently 

practiced in the US military are more conducive to 

unit cohesion than the individual rotations common 

during the Vietnam era, but individual augmentees 

and members of reserve or National Guard units may 

still be disadvantaged in this important component of 

resilience. Another challenge for unit leaders is how to 

forge mutual trust and peer support among families 

left behind; they are no less part of the unit than the 

active duty service members who deploy in cohesive 

units, but they often have much less opportunity to 

develop social cohesion with other families.

Leadership

Although complex and multifaceted, leadership 

is an essential factor for the strengthening of unit 

members and families. Unit members are strengthened by leaders who teach and inspire them, keep 

them focused on mission essentials, instill confidence, 

and provide a model of ethical and moral behavior.27

Another crucial way in which leaders enhance the 

resilience of their unit members is by providing a 

resource of courage and fortitude on which unit 

members can draw during times of challenge.28,29 The 

influence leaders have over their subordinates is a 

sword that can cut both ways—leaders who are in the 

yellow, orange, or red zones themselves may become 

detriments to their units unless their own stress is 

effectively managed.

Mitigate Stressors

Because no service member, however strong and 

well prepared, is immune to stress, the prevention of 

stress injuries and illnesses requires continuous mitigation of the stressors to which individuals and units 

are exposed. Optimal mitigation of stress requires 

balancing competing priorities. On one side is the 

intentional subjection of service members to stress in 

order to train and toughen them, and to accomplish 

assigned missions while deployed. On the other side 

are the imperatives to reduce or eliminate stressors 

that are not essential to training or mission accomplishment, and to restore the biological, psychological, social, and spiritual resources for resilience that 

are depleted under stress. As depicted in Figure 7-3, 

each individual’s stores of resources for resilience can 

be likened to a leaky bucket constantly being drained 
114

Combat and Operational Behavioral Health

Physical 

resources

Mental

resources

Social

resources

Spiritual

resources

Unit and

 family members

 as containers

 of resources

 

Resources continually drained away by stress

Figure 7-3. “Leaky bucket” metaphor for stress. Each individual’s stores of resources for resilience are continually 

depleted by stress, as if contained in a leaky bucket.

by stress. To keep it from running dry, it must be constantly refilled through sleep, rest, and other forms of 

replenishment. 

Mitigation is a prevention activity, aimed at keeping 

unit members in the green “ready” zone in the face of 

operational challenges, and to return them to the green 

zone after yellow zone reactions. A few of the tactics 

that can be used by unit leaders to mitigate stress are 

the following:

	 •	 ensure and enforce adequate sleep—7 hours

per day for most people;

	 •	 ensure physical fitness and recreation;

	 •	 encourage spiritual fitness and religious participation;

	 •	 enforce ethical standards and the “rules of

war”;

	 •	 rotate units to the rear periodically forrest and

replenishment, if possible;

	 •	 rotate individual assignments to reduce boredom and complacency;

	 •	 protect unit members from scenes of gore

whenever possible;

	 •	 anticipate and discourage excessive self-blame

(guilt or shame); and

	 •	 use after-action reviews to give meaning to

sacrifices and losses.

Identify Stress Reactions, Injuries, and Illnesses

Even the best PH prevention efforts cannot eliminate all stress problems that might have an effect on 

occupational functioning or health. Therefore, effective 

PH protection requires continuous monitoring of stressors and stress outcomes. Operational leaders must 

know the individuals in their units, including their 

specific strengths and weaknesses, and the nature of 

the challenges they face both in the unit and in their 

home lives. Leaders must recognize when individuals’ 

confidence in themselves, their peers, or their leaders 

is shaken, or when units have lost cohesion because 

of casualties, changes in leadership, or challenges to 

the unit. Most importantly, every unit leader must 

know which stress zone each unit member is in at 

every moment, every day. Service members cannot be 

depended upon to recognize their own stress reactions, 

injuries, and illnesses, particularly while deployed to 

operational settings. The external focus of attention 

and denial of discomfort necessary to thrive in an arduous environment also make it harder to recognize 

a stress problem in oneself. And stigma can be an 

insurmountable barrier to admitting stress problems 

to someone else. Therefore, the best and most reliable 

method of ensuring that everyone who needs help 

gets it is for small unit leaders to continually watch 

out for their subordinates, and for peers to watch out 

for each other.

To help with this crucial stress zone assessment 

function, the Marine Corps and Navy have developed 

the combat and operational stress decision flowchart, 

Figure 7-4. The flowchart is made up of just four questions. The first is whether there are signs of distress 

or loss of function, both of which are briefly defined 

with examples. In the continuum model and decision 

flowchart, the threshold for recognizing yellow zone 

reactions is set intentionally low. In other words, to 

qualify as “distress” or “loss of function,” subjective 

feelings of uneasiness or observable behaviors that 

interfere with optimal function need not be profound, 

but merely noticeable. The point is to recognize yellow zone stress reactions early and consistently so 

they can be monitored and mitigated by leaders, 

chaplains, and medical support personnel before they 

progress to orange zone injuries. This is not to say that 

service members in the yellow zone cannot be pushed 

harder—just that they may require reassessment 

and at least stress mitigation as soon as operational 

requirements permit.

If neither distress nor loss of function is present, 

then the individual is judged to be in the green zone, 

and no further action is required other than continuing to monitor for stress. If either distress or loss of 
115

US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

Green Zone (Ready):

• Continue to monitor for signs of 

 distress or loss of function in 

 the future

Service Member Under Stress

Distress or Loss of Function:

•Difficulty relaxing and sleeping

•Loss of interest in usual activities

•Unusual and excessive fear, worry, or anger

•Recurrent nightmares or troubling memories

•Hyperactive startle responses to noises

•Difficulty performing normal duties

•Any change from normal personality Yellow Zone (Reacting):

•Ensure adequate sleep and rest

•Manage home-front stressors

•Discussions in small units

•Refer to chaplain or medical if 

 problems worsen

Is the distress 

or loss of function

SEVERE?

Orange Zone (Injured):

•Keep safe and calm

•Rest and recuperation 24–72 h

•Refer to medical or chaplain

•Mentor back to full duty and 

 function

Has the distress

or loss of function

PERSISTED?

Red Zone (Ill):

•Refer to medical

•Ensure treatment compliance

•Mentor back to duty if possible

•Transition to VA if necessary

SEVERE Distress or Loss of Function:

•Inability to fall asleep or stay asleep

•Withdrawal from social activities

•Uncharacteristic outbursts of rage or panic

•Nightmares or memories that increase heart rate

•Inability to control emotions

•Serious suicidal or homicidal thoughts

•Loss of usual concern for moral values

PERSISTENT Distress or Loss of Function:

•Stress problems that last for more than 60 days

 postdeployment

•Stress problems that don’t get better over time

•Stress problems that get worse over time

Are there signs

of DISTRESS or

LOSS OF

FUNCTION?

{

{

{

NO

NO

NO

YES

YES

YES

Figure 7-4. The combat and operational stress decision matrix flowchart.

VA: Department of Veterans Affairs

function is present, the individual is at least in the 

yellow “reacting” zone, and the next question to be 

answered is whether distress or loss of function is 

severe. The decision about whether distress or loss of 

function is severe is admittedly one of the most challenging judgments to be made in the decision matrix, 

but it is also one of the most important. By definition, 

stress responses that involve severe distress or loss of 

function are at least in the orange zone—at least stress 

injuries, if not diagnosable stress illnesses. These are 

stress outcomes that may significantly interfere with 

effective occupational functioning, may persist or 

leave a mental or emotional “scar,” and may confer 

increased risk for long-term mental health problems. 

Because of these risks associated with orange and red 

zone stress, it is imperative that unit leaders quickly 

and consistently identify service members with severe distress or loss of function that places them in 

these two zones. Orange and red zone stress injuries 

and illnesses all potentially benefit from care and 

treatment, and all deserve to be closely monitored to 

ensure recovery. 

If severe distress or loss of function is present, the 

next question—whether these severe stress symptoms have persisted long enough to meet criteria for 

diagnosis of a clinical mental disorder—is not as crucial for operational commanders to answer. Clinical 

medical and mental health professionals are normally 
116

Combat and Operational Behavioral Health

consulted to help form that judgment. However, the 

importance to commanders of having a service member in the red zone is significant because a number of 

important leader decisions follow, including whether 

the red zone service member is fit to deploy or remain 

deployed, and whether and how soon the individual 

can be mentored back to full duty after receiving 

treatment.

Treat Stress Injuries and Illnesses

As in the case of physical injuries and illnesses, 

available tools for the treatment of stress injuries and 

illnesses exist along a broad spectrum, including: 

(a) self- or buddy-applied aid; (b) supportive care 

and advanced aid from a buddy, leader, chaplain, or 

family member; and (c) definitive psychological or 

medical treatment. Although some of these forms of 

treatment can clearly be delivered only by a trained 

medical or mental health provider, others require 

little special training and can be provided by a small 

unit leader, peer, or spouse. However, as with the rest 

of the core functions required to manage the combat 

and operational stress continuum, the primary responsibility for ensuring that every service member 

receives the appropriate level of care for orange zone 

injuries or red zone illnesses rests with operational 

commanders.

Combat and Operational Stress First Aid

The core principles for immediate, preclinical care 

of stress injuries, like those for first aid of physical 

injuries, are built on a simple hierarchy of three priorities: (1) sustain life, (2) minimize further damage, and 

(3) decide whether further care is needed. For physical first aid, life is sustained through the “ABCs” of 

basic life support or cardiopulmonary resuscitation—

airway, breathing, and circulation—and further damage is minimized through the cleaning and covering 

of wounds, rest, immobilization, and other basic 

protective actions. To provide military personnel and 

their families a set of procedures for the care of stress 

wounds analogous to those of physical first aid, the 

Navy, Marine Corps, Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury, 

and the Veterans Affairs (VA) National Center for 

PTSD collaborated to develop combat and operational 

stress first aid (COSFA),30 based on the evidence-based 

principles and procedures of psychological first aid 

previously created by the National Child Traumatic 

Stress Network and the National Center for PTSD.31

The seven core components (the “seven Cs”) of COSFA 

are as follows: 

1. Check: assess continuously for distress or 

changes in functioning suggestive of a possible stress injury and need for further intervention; reassess after every intervention; 

continue to assess for delayed or persistent 

problems.

2. Coordinate: continuously inform those who 

need to know, such as leaders or family 

members, about identified stress problems; 

enlist further help from others, as indicated; 

and ensure that help is obtained.

3. Cover: ensure the safety (get to cover) of those 

experiencing acute distress or alterations in 

functioning, and ensure the safety of others 

until normal functioning returns.

4. Calm: reduce the intensity of physiological 

arousal (heart rate and blood pressure) and 

potentially destructive emotions such as 

fear or anger; practice deep, diaphragmatic 

breathing, mental grounding, and other relaxation techniques.

5. Connect: ensure peer support in the aftermath of a stress reaction, injury, or illness; 

restore normal unit or family cohesion as a 

protective and healing factor; listen empathically and reassure.

6. Competence: restore capabilities and effectiveness in all areas of function, including 

occupational, family, and other social function; mentor back to full duty, if possible.

7. Confidence: restore self-esteem and the trust 

of others in the unit and family in the aftermath of a stress reaction, injury, or illness; 

restore hope. 

Definitive Psychological or Medical Treatment 

Definitive clinical care can be delivered in forward 

operational settings by mental health professionals, 

such as those attached to Marine Corps Operational 

Stress Control and Readiness (OSCAR) teams,32 or it 

can be delivered in higher echelon treatment facilities 

in theater or in garrison. The principles of evidencebased care for traumatic stress injuries and illnesses, 

including PTSD, are contained in the current VA/DoD 

clinical practice guideline for the treatment of posttraumatic stress.33 Some of these treatment principles 

can be applied only by a mental health specialist, 

but others can be delivered by primary care providers organic to, or in support of, operational units. 

Regardless of who delivers definitive clinical care, 

the crucial role of operational commanders and their 

subordinate small unit leaders in this segment of the 

treatment continuum is to ensure that treatment is 
117

US Marine Corps and Navy Combat and Operational Stress Continuum Model: A Tool for Leaders

afforded to all service members who need it, and that 

barriers to care such as stigma and ongoing training 

or operational time commitments do not preclude 

care. The earlier stress-injured or ill service members 

receive definitive clinical care, the more likely they are 

to recover quickly and fully. Operational commanders bear great responsibility for reducing the stigma 

associated with receiving mental healthcare because 

of their influence on the attitudes and behaviors that 

underlie stigma.

Reintegrate Stress Casualties

As stated above, the normal course for a stress 

injury, as for a physical injury, is to heal over time. 

The vast majority of these injuries do heal, with or 

without treatment. Similarly, the normal course for a 

stress illness, especially if properly treated, is to improve significantly over time, perhaps even to remit. 

For example, of all active duty marines diagnosed 

and treated for PTSD between the start of the war in 

southwest Asia in 2003 and the end of 2006, fewer 

than 10% received a medical disability discharge for 

PTSD.34 Therefore, operational commanders face one 

final challenge in their management of service members treated for stress injuries or illnesses—that of 

continually monitoring their fitness for duty, including 

worldwide deployment, and mentoring them back 

to full duty as they recover. This is the challenge of 

reintegration. For stress casualties to be effectively 

reintegrated in their units, stigma must be continually addressed. Confidence in stress casualties, both 

in themselves and their peers and small unit leaders, 

must be restored. This process may take months to 

bring to successful conclusion, for recovery from a 

stress injury or illness can take several months. In 

cases in which substantial recovery and return to full 

duty is not anticipated, the challenge for operational 

commanders is to assist service members as they 

transition to civilian life and VA care.

SUMMARY

The US Marine Corps and the US Navy, in collaboration with the Defense Centers of Excellence 

for Psychological Health and Traumatic Brain Injury, 

have developed and adopted a new model for the 

promotion of psychological health in service members 

and operational units based on the health sciences 

and leadership arts. The core of this new paradigm—

the combat and operational stress continuum—

recognizes that stress responses and outcomes occur 

across a broad spectrum, whose zones can be color 

coded green (for “ready,” adaptive coping); yellow 

(for “reacting,” mild and reversible distress or loss 

of function); orange (for “injured,” more severe and 

persistent distress or loss of function); and red (for 

“ill,” a diagnosable mental disorder). Although chaplains and medical and mental health professionals 

are important for the management of yellow, orange, 

and red zone stress, operational commanders and 

small unit leaders bear primary responsibility for the 

effective management of the entire stress spectrum. 

The five core psychological health leader functions 

developed by the Marine Corps and Navy are: (1) 

strengthen, (2) mitigate, (3) identify, (4) treat, and (5) 

reintegrate.

The new PH and COSC model described in this 

chapter has gained traction in the Marine Corps and 

Navy partly because it reduces stigma and demystifies 

aspects of PH promotion. It has also gained acceptance because it forms an effective bridge between the 

worlds of the troops, the chaplain, the family member, 

and the medical or mental health professional. Only 

through a shared language and set of tools can all these 

stakeholders combine forces to address the challenges 

posed by warfare to the psychological health of service 

members and their families.

The stress continuum model and associated core 

leader functions described in this chapter have not 

yet been empirically tested, although they are solidly 

informed by scientific evidence. It is anticipated that 

empirical evaluation will validate some aspects of 

the model while suggesting improvements to other 

aspects. Regardless of these outcomes, the approach 

to combat and operational stress described here lends 

itself more fully to empirical assessment than previous models based on a less medical view of adverse 

stress outcomes.

Acknowledgment

The author wishes to thank Brett Litz, Patricia Watson, Mark Smith, Jeffrey Rhodes, and Eduardo Leardo 

for helpful comments on the manuscript.
118

Combat and Operational Behavioral Health

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Stress. 2007;20(4):467–479.

13. McNally RJ. Revisiting Dohrenwend et al’s revisit of the National Vietnam Veterans Readjustment Study. J Trauma 

Stress. 2007;20(4):481–486.

14. Kilpatrick DG. Confounding the critics: the Dohrenwend and colleagues reexamination of the National Vietnam 

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15. 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;295:1023–1032.

16. Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D. New onset and persistent symptoms of 

post-traumatic stress disorder self-reported after deployment and combat exposures: prospective population based 

US military cohort study. BMJ. 2008; 336:366–371.

17. US Department of Defense Inspector General. Evaluation Report on the Management of Combat Stress Control in the Department of Defense. Arlington, Va: DoD IG; 1996. Report No. 96-079.

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6490.5.

19. Nash WP. Combat/operational stress adaptations and injuries. In: Figley CR, Nash WP, eds. Combat Stress Injury: 

Theory, Research, and Management. New York, NY: Routledge; 2007.
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20. Grenier S, Darte K, Heber A, Richardson D. The operational stress injury social support program: a peer support program in collaboration between Canadian Forces and Veterans Affairs Canada. In: Figley CR, Nash WP, eds. Combat 

Stress Injury: Theory, Research, and Management. New York, NY: Routledge; 2007.

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Psychiatry. 2000;47:891–901.

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32. Nash WP. Operational Stress Control and Readiness (OSCAR): The United States Marine Corps (USMC) Initiative to Deliver 

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33. Department of Veterans Affairs, Department of Defense. DoD/VA clinical practice guideline for the treatment of posttraumatic stress. 2004. Available at: http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm. Accessed March 12, 

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34. Gaskin TA. US Marine Corps combat/operational stress control program update. Paper presented at: Marine Corps 

Combat and Operational Stress Control Conference; June 18, 2007; Arlington, Va.
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121

Expeditionary Operational Stress Control in the US Navy

Chapter 8

expeditionary operational 

stress control in the us navy

ROBERT L. KOFFMAN, MD, MPH*; RICHARD D. BERGTHOLD, PsyD†; JUSTIN S. CAMPBELL, PhD‡; 

RICHARD J. WESTPHAL, PhD, RN§; PAUL HAMMER, MD¥; THOMAS A. GASKIN, PhD¶; JOHN RALPH, 

PhD**; EDWARD SIMMER, MD, MPH††; and WILLIAM P. NASH, MD‡‡

INTRODUCTION

STRESS INJURY CONTINUUM MODEL

EXPEDITIONARY MEDICAL PLATFORMS

Hospital Ships

Expeditionary Medical Facilities

COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS

Special Psychiatric Rapid Interventions Teams 

Carrier Psychology Program

Operational Stress Control and Readiness (OSCAR) 

EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE

Individual Augmentation

Care for the Caregiver

SUMMARY

*Captain, Medical Corps, US Navy; Director of Deployment Health, Department of the Navy, Bureau of Medicine and Surgery, Deployment Health, 

2300 E Street NW, Washington, DC 20372

†

Commander, Medical Service Corps, US Navy; Chief of Staff, Wounded, Ill and Injured, Bureau of Medicine and Surgery, 2300 E Street NW, Washington, DC 20372

‡

Lieutenant, Medical Service Corps, US Navy; Deployment Health Senior Analyst, Department of the Navy, Bureau of Medicine and Surgery, Deployment Health (M3C3), 2300 E Street NW, Washington, DC 20372

§

Captain, Nurse Corps, US Navy; Psychological Health Promotion Programs, Department of the Navy, Bureau of Medicine and Surgery, Deployment 

Health, 2300 E Street NW, Washington, DC 20372

¥

Captain, Medical Corps, US Navy; Director, Naval Center for Combat and Operational Stress Control, 34960 Bob Wilson Drive, Suite 400, San Diego, 

California 92134-6400 

¶

Director of Combat Operational Stress Control, US Marine Corps, Manpower and Reserve Affairs, Personal and Family Readiness Division, 3280 

Russell Road, Quantico, Virginia 22134 

**Commander, Medical Service Corps, US Navy; Director for Mental Health, National Naval Medical Center Bethesda, 8901 Wisconsin Avenue, Bethesda, 

Maryland 20889; formerly, Officer-in-Command, Presidential Support Program, Marine Barracks, Washington, DC

††Captain, Medical Corps, US Navy; Executive Officer, Naval Hospital, 1 Pinckney, Beaufort, South Carolina 29902; formerly, Senior Executive Director 

for Psychological Health, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, Maryland

‡‡Captain, US Navy (Retired); Assistant Clinical Professor, Department of Psychiatry, University of California at San Diego; formerly, Senior Consultant, 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Rosslyn, Virginia 22209
122

Combat and Operational Behavioral Health

INTRODUCTION

The diversity of US Naval operations, which span 

air, land, and sea/subsea dimensions, places extraordinary demands on sailors and their families. Although 

the US Navy has traditionally been a deployed force, 

the global war on terror (GWOT) has added to the 

Navy’s list of deployment-related stressors. Stress, as 

it is referred to in this chapter, is considered as a transactional model1,2 described as a general strain imposed 

by the operational milieu that disrupts the physical 

and psychological equilibrium of sailors, the outcome 

of which is mediated by a complex interplay between 

variables specific to the individual, the situation, and 

the dynamic interaction between the two. 

The impact of operational stress upon sailors 

is manifested in the prevalence of mental health 

problems among sailors who routinely deploy upon 

operational platforms. For instance, a study of 782 

active duty sailors and marines found the 1-year 

prevalence of any psychiatric illness to be 21% and 

the lifetime prevalence to be 40%, based on structured computerized telephone interviews designed 

to make DSM-III-R (Diagnostic and Statistical Manual 

of Mental Disorders, 3rd edition, revised) psychiatric 

diagnoses.3

 For those deploying to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/

OIF), the risk for having symptoms of either of two 

illnesses, posttraumatic stress disorder (PTSD) or 

major depressive disorder, is nearly the same: 20% 

of these service members reported symptoms of at 

least one of the two disorders, according to a report 

from the RAND Corporation’s Center for Military 

Health Policy Research.4 The dual imperatives of mission effectiveness and moral responsibility for sailor 

health provide the impetus for the Navy Medicine 

Support Command to develop and implement programs based on a comprehensive operational stress 

control doctrine.5

 Discussion of these efforts is the 

focus of this chapter.

Stress Injury Continuum Model

Because stress injuries occur across a continuum 

of severity and settings, Navy stress control doctrine 

must encompass all sailors regardless of their duty, 

platform, or assignment (afloat and ashore), not just 

sailors in specific combat environs. Consequently, 

Navy leadership (in collaboration with the US Marine 

Corps) has developed an overarching operational 

stress control program applicable to the full panoply 

of Navy missions (see also Chapter 7, US Marine Corps

and Navy Combat and Operational Stress Continuum 

Model: a Tool for Leaders). However, much of the 

seminal theory and applications for stress control in the 

military are, as one would expect, derived from stress 

control practices in the combat environment. In that 

vein, the doctrine being developed to forge broader 

Navy stress control initiatives into a more theoretically consistent and unified whole is adapted from 

the combat stress injury model explicated by Figley 

and Nash.1

 The starting point for this new paradigm 

in Navy stress control is the stress injury continuum 

(SIC) model (see Chapter 7, Figure 7-1 for a description 

of the model). This chapter will apply the SIC model 

as the rubric for interpreting extant and future Navy 

stress control programs. 

Adopted because of its ability to educate, acculturate, and engage all sailors in stress control, the SIC 

paradigm highlights how the onus for stress control 

is shared among line-duty leadership (eg, squadron 

commanders, division officers, department heads), 

the individual sailor, and caregivers (eg, Navy Medicine personnel, the Chaplain Corps). The SIC model 

charges unit leadership with ensuring that sailors are 

ready for deployment by fostering an atmosphere 

within commands that promotes mental health and 

resilience through realistic training, unit cohesion, 

and mission focus. Sailors who deploy should be 

competent, socially supported, and mentally prepared 

to encounter and adaptively cope with operational 

stressors.6

 The SIC model contains five functions 

for leaders that encourage them to (1) strengthen 

the mental resiliency of sailors through realistic and 

purposeful training; (2) mitigate physiological stressors by maximizing sailors’ access to proper sleep, 

exercise, and nutrition; (3) develop processes for the 

early identification of stress reactions and injuries; 

(4) encourage sailors to care for one another (eg, with 

“battle buddies”); and (5) remove barriers to care by 

supporting the transition of stress-injured sailors to 

higher levels of care and fostering stigma-free reintegration of stress-wounded sailors. 

At the first stage of the SIC, sailors are prepared 

to confront stress. At the second stage, sailors are 

reacting to the unique operational stressors that challenge their physical and psychological equilibrium. 

The outcome of this reaction becomes a function of 

person, situation, and person–situation interactions 

that influence whether the reaction is mild, transient 

distress or impairment with associated anxiety, irritability, and unwanted behavioral change. However, 

each operational milieu has some degree of stress reaction that is normative, which makes distinguishing 

between normative and abnormal stress reactions a 
123

Expeditionary Operational Stress Control in the US Navy

critical consideration for leadership, caregivers, and 

individual sailors alike. Yet, at the reacting point in the 

continuum, individual sailors must assume primary 

responsibility for identifying whether they and their 

fellow shipmates are effectively coping with the strain 

of their deployment. Although stress reactions are 

considered normal reactions to high-stress environments, the severity, persistence, and impairment experienced by some sailors may transcend the reactions 

experienced by the majority of sailors when perceived 

through the eyes of leaders, shipmates, caregivers, or 

reacting sailors themselves. 

Rather than establishing clear dividing points, the 

conceptualization of stress injury as a continuum acknowledges the complex interplay between sailors and 

situations that must be considered when attempting to 

ascertain whether an individual’s stress reaction has 

surpassed the normative response and moved from 

stress reaction to the third stage in the SIC—stress injury. Use of the term “injury” here is important because 

it conveys to leaders the presence of a more serious 

threat to both the sailors’ individual well-being and 

operational effectiveness. Sources of stress injury can 

include trauma from experiencing horror, terror, and 

helplessness during deployment; fatigue derived from 

accumulated deployment stressors; grief associated 

with the loss of a valued person or thing; and moral 

conflict in belief and value systems.1

Although stress-injured sailors are still expected to 

identify these injuries in themselves and others, Navy 

Medicine and caregivers begin to play a more prominent role in the stress injury phase of the continuum. 

At this phase, sailors are not expected to cope with 

their injury alone, but are empowered to seek help 

from caregivers, who are the primary support for 

prevention of permanent, debilitating stress injuries. 

Once a stress illness (behaviors that fall primarily 

within diagnostic categories such as PTSD, depression, anxiety, and addiction) is identified in a sailor, 

treatment becomes the primary responsibility of Navy 

Medicine. Implementation of the SIC model includes 

the expectation that all leaders, sailors, and caregivers 

will be able recognize and respond appropriately to 

sailors in distress. 

The stress injury decision matrix (see Chapter 

10, Figure 10-3) is an example of an SIC-based tool 

designed to help leaders, sailors, and caregivers 

determine if a sailor is ready, reacting, injured, or 

ill because of an operational or life stressor. The nascent state of SIC makes it difficult to ascertain the 

outcomes of the model as a doctrine for combat stress 

control. However, the model’s multidisciplinary 

and theoretical nature, as well as the incorporation 

of multiple stakeholders, is a promising feature for 

establishing doctrine. The multifaceted nature of the 

SIC model also makes it an ideal context for integrating the various operational stress control programs 

currently in place. 

EXPEDITIONARY MEDICAL PLATFORMS

As alluded to in the SIC model, the Navy as an 

organization assumes two primary roles in combating stress: (1) preventive consultation and (2) care 

provision. To keep sailors ready, preventive consultation with line leadership supports development of 

command policies and procedures that both prepare 

sailors to face the mental rigors of deployment, and 

identify, help, and reintegrate sailors who have experienced stress injuries and illness. The more traditional 

role involves direct healthcare service provision to 

those with stress injuries and the treatment of those diagnosed with stress illness. Because of the quantity of 

medical personnel, expeditionary medical platforms 

offer perhaps the widest range of Navy preventive 

and direct care services in deployed environments. 

Expeditionary platforms in the Navy consist of fleet 

hospital ships and expeditionary medical facilities 

(EMFs). These platforms are a mixture of specific 

capabilities that ensure mission flexibility within the 

logistical constraints of the deployed environment. 

Expeditionary combat and operational stress control 

platforms must be capable of performing missions 

that range from combat service support in GWOT 

to humanitarian assistance and disaster response. 

Serving as major instruments of diplomacy, these 

expeditionary platforms have taken Navy Medicine 

into Afghanistan, Iraq, and Kuwait while simultaneously providing preventive medicine, combat medical 

support, health maintenance, medical intelligence, 

operational planning, and mental health services to 

military personnel. 

Hospital Ships

The fleet of hospital ships consists of the USNS 

Mercy and USNS Comfort, which are home ported on 

the west and east coast of the United States, respectively. The hospital ships have inpatient capabilities 

comparable to major medical facilities ashore. They 

each have 12 fully equipped operating rooms, a 1,000-

bed hospital facility, radiological services, a medical 

laboratory, a pharmacy, an optometry laboratory, a 

computed tomography scanner, and two oxygenproducing plants. Both have a flight deck capable of 

landing large military helicopters, as well as side ports 

to take on patients at sea.
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Expeditionary Medical Facilities 

EMF facilities are designed to approximate the 

same capabilities as fleet hospital ships, yet maintain a 

smaller logistic footprint with high mobility. EMFs are 

fully modular, task-organized structures that can be set 

up in as little as 48 hours. As EMFs continue to evolve, 

they will provide more robust medical care for major 

conflicts, low-intensity combat, operations other than 

war, and disaster/humanitarian relief operations. As 

modular expeditionary units, EMFs may be employed 

independently or in combination with the theater’s 

joint health system for evacuation, medical logistics, 

medical reporting, and other functions.

Taken together, hospital ships and EMFs are unique 

among forward-deployed operational stress control platforms with respect to the medical nature of 

their mission. Perhaps the greatest strength of these 

platforms is that they include high concentrations of 

caregivers, providing a versatile mixture of expertise 

and resources that can anchor both ends of the SIC 

model. 

COMBAT AND OPERATIONAL STRESS CONTROL ELEMENTS

The three combat and operational stress control 

elements discussed in this section—(1) the Special 

Psychiatric Rapid Intervention Teams (SPRINT), 

(2) the carrier psychology program, and (3) the 

Operational Stress Control and Readiness (OSCAR) 

program—have arisen within the last 30 years as 

outgrowths of a larger trend within the US armed 

services to institutionalize the integration of medical 

health expertise within operational units. In relation 

to the SIC model, all three programs are oriented to 

intervene between the stress injury and illness phases 

of the continuum. However, the carrier psychology 

program, and the OSCAR program in particular, also 

play roles at the readiness end of the stress reaction 

continuum, through the use of operationally embedded caregivers to provide training and preventive 

consultation to leaders in supporting individual 

sailor readiness. 

Special Psychiatric Rapid Intervention Teams

History

In 1975 a collision occurred between the USS Belknap

and the USS John F Kennedy, resulting in a significant 

loss of life and extensive damage to both ships. Subsequently, in 1977, a Navy liberty launch collided with 

another ship in the Barcelona harbor. In both incidents, 

the vessels involved were home ported on the east 

coast, and the psychiatry department at Portsmouth 

Naval Hospital (now Naval Medical Center, Portsmouth) in Virginia received a significant number of 

patients presenting with stress symptoms related to 

the incidents. It became apparent to Navy Medicine 

that a plan for early intervention to avoid stress illness was needed. The same concepts developed to 

treat stress in combat were modified for use in early 

intervention with disasters at sea; the result was the 

birth of the Special Psychiatric Rapid Intervention 

Teams—“SPRINT.” 

Composition and Mission

In 1983 SPRINT teams were formally chartered 

as one of the Navy’s Mobile Medical Augmentation 

Readiness teams. Navy SPRINT teams are formally organized at Bethesda, Maryland; Portsmouth, Virginia; 

and San Diego, California. Some informal teams are 

located at various overseas locations. Since their inception, SPRINT teams have not only provided intervention in maritime mishaps, but also supported military 

operations other than war, military contingency operations, terrorist attacks, and natural disasters. Each team 

consist of two psychiatrists, two clinical psychologists, 

one or two chaplains, two or more psychiatric nurses, 

one or two clinical social workers, and four or more 

hospital corpsmen psychiatric technicians. An officer 

is designated as the team leader, and a senior psychiatric technician serves as the leading petty officer. The 

SPRINT team’s mission is to be trained and immediately available in the event of a contingency to (a) assess 

the psychological effects of traumatic stress, (b) offer 

direct support to individuals and units affected by the 

event, (c) identify and refer those needing psychiatric 

treatment, and (d) consult with commanders and leaders to mitigate the negative impact of the event. From 

the SIC perspective, SPRINT teams become involved 

at the reacting stage, the goal being to prevent sailors 

from moving further along toward the injured and ill 

end of the spectrum. Teams also provide support to 

families of active duty members. 

Unit leaders are responsible for bringing SPRINT 

teams into the picture. The teams have limited equipment consistent with their goal of being a rapidreaction force. Rapid fielding requires that the requesting command or agency provide logistical support 

(berthing, messing, communications, transportation, 

etc) to the team. Thus, SPRINT teams are deployable 

worldwide within 24 hours’ notice. Examples of prior 

SPRINT deployments include Hurricanes Andrew, 

Ivan, and Katrina; the terrorist attack on the USS Cole; 
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the TWA [formerly Trans World Airlines] Flight 800 

disaster; a civilian airline crash in Guam; and severe 

flooding and landslides in Central America. SPRINT 

teams also supported the guard force in the early days 

of the detainee mission at Guantanamo Bay, Cuba. In 

addition to high-profile events, SPRINT teams also 

regularly respond to smaller-scale events such as 

work-related accidents that result in the death of a 

crewmember, suicides, and aircraft mishaps. 

Intervention Strategies

SPRINT does not adhere to any specific professional 

doctrine on intervention methodology. However, team 

members are expected to be competent in their respective disciplines and well versed on the latest information in crisis intervention techniques and treatment 

strategies for acute stress and PTSD. This allows the 

teams the flexibility to adapt their responses to the 

demands of a particular situation while ensuring that 

their methodology is based on best practices and, when 

possible, evidence-based science. During the 1980s and 

1990s, the critical incident stress management (CISM) 

technique was developed to help emergency service 

workers, such as firefighters, paramedics, and police 

officers, address particularly stressful events. Attempts 

were made to adopt CISM for use in military interventions, but its use has since been officially discouraged 

because it has not been proven effective in controlled 

trials, and some evidence shows that it could potentially be harmful.7–9

Instead, the current focus is on providing command 

consultation, psychoeducational intervention, and 

psychological first aid. The team assists the command 

in developing a strategy to mitigate the impact of the 

event on the entire organization; provides timely, targeted, and useful information for command members; 

briefly contacts as many potentially affected individuals as possible; and supports individuals in acute distress. Every attempt is made to avoid early labeling 

or diagnoses, even for individuals demonstrating 

significant stress reactions. Rather, affected individuals 

are encouraged to mobilize their own and community 

resources to enhance recovery and restore functioning. 

SPRINT teams generally provide support rather than 

treatment. A benefit to adopting the support role is that 

the teams generally do not contribute documentation 

to medical records, thereby offering a higher level of 

confidentiality. It is thought that such confidentiality 

can reduce the potential stigma associated with seeking mental healthcare. 

In addition to maintaining expertise in intervention 

theory and techniques, SPRINT team members must 

be proficient serving in diverse operational settings, 

including surface ships, submarines, and aviation 

platforms; ground-centric Seabee and marine operating areas; and joint service operations. Team members 

must also be knowledgeable and comfortable in dealing with various Navy systems, organizations, and 

structural issues that affect how well a command 

withstands the impact of a stressful event. Most 

SPRINT responses are short-term (often only 1 day), 

but have lasted up to 6 months. In virtually all cases, 

SPRINT teams work closely with local resources, and 

turn over functions to the local resources as the situation permits. 

Training for SPRINT teams involves a variety of 

approaches. New members always participate in 

SPRINT missions under instruction before leading 

missions. Psychiatric residents and psychology interns 

are encouraged to participate, under supervision of 

experienced team members. Psychiatric technician 

students also receive training in disaster and trauma 

response. Teams conduct regular refresher training in 

combat and operational stress first aid (COSFA),10 and 

many team members also receive familiarity training in 

CISM (although CISM’s use is discouraged, commanders and others often ask about it, and knowledge of the 

technique can help to educate them). SPRINT teams 

remain active during wartime, because natural disasters, maritime accidents, and other noncombat stressful 

events continue during war, although staffing can be a 

challenge. The concepts, skills, and techniques developed through the Navy SPRINT teams’ experiences in 

peacetime are invaluable for informing and educating 

the wider Navy mental health community as a whole 

and contributing to the overall improvement of stress 

intervention and treatment of the operating forces. 

Carrier Psychology Program

History

Since the mid-1990s, psychologists and psychiatric 

technicians have served as permanent members of 

ship’s company on all US Navy aircraft carriers. Before the initiation of the carrier psychology program, 

25 to 30 sailors were medically evacuated (medevaced) from a carrier for mental health reasons during 

a 6-month deployment.11 Since the inception of the 

program, the number of medevacs has averaged fewer 

than five per deployment. In 2001 the average fuel/

transportation cost of a medevac from a deployed 

carrier was estimated to be $4,400, suggesting that 

a typical deployed psychologist saves the Navy at 

least $110,000 per deployment in prevented medevacs 

alone.11 “Prevented medevacs” are defined as situations in which sailors are retained onboard, but due 
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to serious psychological difficulties, would likely not 

have been retained in the absence of a psychologist. 

Moreover, this figure ignores the immeasurable costs 

of losing personnel with valuable experience, and 

the lowered morale among remaining crew members 

who are forced to perform extra work to make up for 

unexpected personnel shortages. Nor does the figure 

include the cost of providing escorts for medevaced 

personnel. Additionally, nondeployed carriers report 

an average of 2.8 prevented medical evacuations per 

month, thus this cost savings extends throughout the 

carrier training cycle.

There are numerous examples of this cost savings. 

Aboard the USS John F Kennedy in 1999, 28 sailors 

were medevaced for psychological problems during 

a 6-month Mediterranean deployment. In 2001, on 

the ship’s first deployment with a psychologist, there 

were no psychological medevacs.12 Similar results were 

seen aboard the USS Carl Vinson in 199911 and the USS 

Enterprise in 2001.13 More recent data continue to support this trend. Through 2006 and 2007, the estimated 

number of prevented medevacs from deployed carriers averaged slightly more than four per month. (All 

statistics are derived from monthly reports made by 

each carrier psychologist; the data are maintained by 

the Navy clinical psychology community.) 

Prevention of Chronic Psychological Problems

Embedded mental health providers are in the 

unique position of being able to identify problems at 

early stages in the SIC. By staying abreast of morale 

and remaining vigilant about the level of stress among 

unit personnel, carrier psychologists can intervene 

before problems become severe, either by reaching out 

to individuals or groups at particularly high risk for 

mental health problems, or by advising the command 

on policies to enhance a unit’s overall psychological 

readiness. For many psychological disorders, most 

notably PTSD, early identification and treatment is 

essential to avoiding long-term difficulties. 

One of the best ways to prevent pathology before it 

occurs is through education. In this role, carrier psychologists also buttress the work of unit leaders, who 

ultimately bear the responsibility of readiness within 

the SIC model. Carrier psychologists and shipboard 

psychiatric technicians conduct an average of 4.5 

prevention-oriented classes per month. Such classes 

are designed to help service members identify growing 

psychological problems at an early stage (yellow and 

orange zone) before they become debilitating. Embedded psychologists can also prevent serious problems 

from developing through frequent interaction with 

unit leadership. Carrier psychologists conduct over 40 

consultations per month with representatives of their 

patients’ chains of command. These consultations are 

intended to educate the command, but also to discuss 

strategies for preventing a worsening of symptoms. 

Sailors who are reacting, injured, or ill constitute a 

considerable responsibility for carrier psychologists 

and their staff. Carrier psychologists report an average of 105 patient contacts per month, so they are well 

utilized in the caregiving role. No doubt contributing 

to the high utilization of carrier psychologist is the 

fact that they live and work among their patients, frequently encountering them throughout the workday, 

observing them performing their jobs and interacting 

with peers. As shipmates, they are able to obtain an 

in-depth understanding of their patients’ daily lives. 

Given this regular presence, unit members are more 

likely to utilize mental health services than they would 

if obtaining such care required a trip to a mental health 

clinic at a medical facility.

Stigma Reduction

Of all factors obstructing the provision of effective 

mental healthcare to military personnel, the most 

powerful may be the lingering perception within many 

military units that seeking psychological treatment 

is a sign of personal weakness, or that such care will 

harm one’s military career. One of the major findings 

of the 2007 Department of Defense (DoD) task force 

on mental health14 was that significant stigma remains 

associated with seeking mental healthcare in the military. A key recommendation, deemed “crucial to the 

psychological health of service members,” was that 

“the military services should embed mental health 

professionals as organic assets in line units.”15(p4)

Three obvious benefits of the SIC model in the 

carrier psychology program are apparent. First, the 

familiarity between sailors and the ship’s psychologist reduces the stigma associated with seeking help, 

making it more likely for a sailor to ask for help before a stress injury becomes a stress illness. Second, 

the proximity of mental health services reduces the 

temporal distance between recognition of stress injury 

symptoms and access to care, lessening the need for 

medical evacuations of sailors who have developed 

debilitating stress illnesses. Third, psychologists detailed to a carrier are able to support the line leadership 

in developing a mentally ready force. 

Operational Stress Control and Readiness (OSCAR)

History

OSCAR teams and carrier psychologists share 

many of the same preventive medicine and direct 

caregiving roles in addressing mental health issues 
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Expeditionary Operational Stress Control in the US Navy

across the spectrum of the SIC. The OSCAR concept 

was begun in 1999 and piloted as the 2nd Marine 

Division’s operational stress control and restoration 

program in 2000. Early OSCAR teams included mental 

health professionals, corpsmen, chaplains, and Marine Corps staff noncommissioned officers in a fully 

integrated multidisciplinary team. In 2004 the Marine 

Corps collaborated with the Navy Bureau of Medicine 

to authorize a 2-year pilot of OSCAR across all three 

active Marine divisions. Staffing of the OSCAR teams 

was tenuous due to competing wartime demands 

for scarce mental health resources, but the pilot team 

performed well, proving to be a valuable asset to Marine Corps leadership. In 2006 the Center for Naval 

Analyses16 evaluated the efficacy of the OSCAR pilot 

and summarized the model as follows:

Applying a community mental health model to the 

expeditionary and forward placed nature of Marine 

life, and taking account of Marine culture, OSCAR is 

an organic program embedded in the units it serves, 

expeditionary (accompanying the unit throughout the 

deployment cycle), multidisciplinary (incorporating a 

team approach), preventative (stressing the full range 

of primary, secondary, and tertiary prevention measures), and therapeutic (providing appropriate mental 

health services).16(p1)

The center deemed the OSCAR pilot and model 

successful in reaching target audiences and capable 

of producing expected outputs. OSCAR was recommended for continuation and expansion beyond the 

active Marine divisions to the air wings, logistics 

groups, and possibly the drilling reserves. 

In 2006 and 2007, the Marine Corps sponsored 

several working groups to further develop OSCAR 

capabilities and requirements, with representation 

from stakeholders including Marine Corps health 

services, religious programs, training and education, 

and the operating forces. Optimal OSCAR capabilities were developed. In acknowledgment of the core 

Marine Corps concept that combat and operational 

stress control is primarily a leadership responsibility, and should be focused on force preservation and 

readiness through prevention and early identification 

more than treatment, the OSCAR program was moved 

from health services to the Combat Operational Stress 

Control Program under the deputy commandant for 

manpower and reserve affairs. 

Despite the 2007 DoD report15 recommending that 

operational psychological health professionals be embedded in line units, staffing of OSCAR teams by the 

Navy remained on an ad-hoc basis because of other 

pressing needs for mental health resources across the 

system. Sustaining OSCAR became increasingly difficult without a formal requirement from the Marine 

Corps. In response, the commanding generals of the 

three Marine expeditionary forces (MEFs) wrote to the 

commandant of the Marine Corps, stating, “We need . 

. . OSCAR teams across the three MEFs. We must fully 

staff, fund, and equip the OSCAR program as soon 

as possible to support current combat operations.”17

A formal request for OSCAR staffing was sent by the 

Marine Corps to the Navy in early 2008. Within a few 

months, the Navy approved funding to permanently 

staff OSCAR in the Marine divisions and regiments, 

both active and reserve, starting in 2010.

Capabilities

OSCAR teams provide the following capabilities 

for operational commanders: 

	 •	 psychological health surveillance of unit

members and units as a whole; 

	 •	 preventive psychological health training and

education when and where needed; 

	 •	 early interventions to promote recovery in

individuals and units from traumatic stressors 

or losses; 

	 •	 clinical mental healthcare services in forward

operational environments where such services 

would otherwise be unavailable; 

	 •	 professional coordination of comprehensive

mental healthcare services in garrison before 

and after deployments to ensure readiness; 

	 •	 support of spiritual fitness of operational forces throughout the deployment cycle through 

partnerships between religious ministry and 

mental health personnel; and 

	 •	 psychological health support for unit medical

and religious ministry personnel who are at 

high risk for stress-related problems. 

OSCAR capabilities are critically dependent on 

teams being organic, that is, embedded within operational units, much like the traditional model of Navy 

hospital corpsmen. By placing OSCAR teams within 

units, team members can fully learn and appreciate the 

specific missions and cultures of the units they support 

throughout the deployment cycle: before, during, and 

after deployment. 

The ultimate objectives of OSCAR capabilities in operational units are (a) enhanced readiness, (b) reduced 

stress-related decrements to mission effectiveness, 

and (c) enhanced long-term health and well-being 

of marines, sailors, and their families. OSCAR teams 

provide psychological health training to marines and 

Marine leaders, and reduce the stigma associated with 

receiving mental healthcare. They can assist leaders 

and marines with informal “hallway consultations” 
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on symptoms and complaints to encourage early mitigation of stress and to promote the earliest interventions when necessary. Team members also serve unit 

leaders as advisors on how to prevent stress, monitor 

the psychological health of their units, and take necessary actions to promote healing. Compared to mental 

health services provided at medical treatment facilities, OSCAR is much more focused on prevention and 

population-based mental health than on individual 

clinical care, relying on familiarity between marines 

and mental health professionals established prior to 

deployment and maintained through and after deployment. The goal is to increase psychological health 

awareness and break down barriers to seeking mental 

healthcare.

Team Design

Marine Corps OSCAR teams provide two licensed 

mental health professionals and two psychiatric technicians per regiment, or approximately one licensed 

professional and one psychiatric technician per 2,500 

marines. According to the 2007 DoD task force on 

mental health report to Congress:

Determining the proper ratio of embedded providers 

to service members would require additional research; 

however, evidence from site visits suggested that the 

Army’s ratio of one psychologist or social worker and 

one psychiatric technician per 5,000 service members 

is probably not sufficient.14(p17)

A team is also attached to each division to provide 

services to independent battalions and oversight to 

the regimental OSCAR teams. OSCAR teams are part 

of each commander’s special staff, reporting to the 

command surgeon. Several different clinical specialties are utilized on OSCAR teams, with a typical team 

configuration as follows: 

	 • one prescribing, licensed, independent mental 

health practitioner (psychiatrist, prescribing 

psychologist, or psychiatric nurse practitioner);

	 • one nonprescribing, licensed, independent 

mental health practitioner (psychologist or 

licensed clinical social worker); and 

	 • two psychiatric corpsmen.

Although still not an ideal ratio of providers to 

marines to meet the intent of close proximity, familiarity, and trust, this configuration affords OSCAR team 

members a much larger presence than previously possible. The use of other unit medical professionals, such 

as physicians and more numerically abundant corpsmen, as OSCAR extenders through training and consultation with team members may be another avenue 

to improve OSCAR efficacy. The goal is to eventually 

place teams in all operating units, not only infantry 

regiments but also air wings and logistics groups.

Although OSCAR may be the newest combat and 

operational stress control program, it has clearly established itself as an integral component in the Navy’s 

mental health support to the Marine Corps. The SIC 

model itself is an outgrowth of experiences derived 

from OSCAR operations. The conceptual link between 

OSCAR and the SIC model is clear: a shared responsibility between unit leadership and medical/chaplain’s 

corps. This interaction fosters hardiness and resilience 

within the individual marine, who ultimately must 

bear the burden of combat and operational stress exposure. Consistent with the core values of the Marine 

Corps, personal responsibility is a critical component 

for maintaining mental health readiness, whereas 

leadership assumes responsibility for cultivating 

mental health resilience, and medical personnel and 

chaplains help restore mental health if stress injury or 

illness overcomes the individual. 

EMERGING CHALLENGES FOR OPERATIONAL NAVY MEDICINE

The US military forces have been strained by the 

GWOT.4

 Despite being a service dedicated to control of the 

seas, the Navy has stepped forward to share the burden of 

this prolonged conflict and continues to play a substantial 

role in ground operations for OIF and OEF. However, the 

allocation of Navy personnel to ground combat operations 

remains a nontraditional deployment, resulting in special 

challenges to combat and operational stress control programs based on the SIC model. Two of the more vexing 

challenges are detailed below. The first challenge is to 

provide care for Navy personnel individually assigned to 

augment positions within combat-deployed Army units, 

a duty referred to as “individual augmentation” (IA). The 

second deals with the development of a program to care 

for a force of medical professionals who, as the OSCAR 

section explicates, are in high demand, and as a result have 

sustained a high operational tempo and been exposed to 

elevated levels of combat. 

Individual Augmentation 

Although the percentage of sailors assigned to 

IA duty constitutes approximately 3% of active and 

reserve duty assignments in the US Navy, the cumulative effect of these deployments has created over 

46,000 combat veteran sailors through 2006, with over 

7,000 sailors being added to this total annually.18 The 

relative obscurity of this duty warrants a description 
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Expeditionary Operational Stress Control in the US Navy

of the IA deployment cycle and the Navy combat and 

operational stress control programs currently in place 

to address the unique and diverse mental health needs 

of “sandbox sailors.” 

Training and Deployment Cycle

As implied by their name, IA sailors prepare, deploy, 

and redeploy alone, and for the most part, outside 

Navy chains of command. Thus, standard Navy medical programs designed to monitor and treat mental 

health problems are not routinely accessible to IAs 

during many of the most critical points in their deployments. Before IAs deploy, Navy Medicine personnel 

conduct a mandatory predeployment health assessment (PDHA). The form used to conduct the PDHA 

is DD2795. The mental health aspect of the screening consists of the question, “During the past year, 

have you sought counseling or care for your mental 

health?” If this question is answered in the affirmative, 

the physician or healthcare specialist conducting the 

PDHA may refer the sailor to a mental health provider. 

Depending on the outcome of the mental health referral, the individual conducting the PDHA can classify 

the member as either deployable or nondeployable. 

Once deemed deployable, the IA detaches (either in 

a temporary duty status or as a permanent change of 

station, depending on the specific assignment) from the 

parent command and travels alone to a Navy mobilization processing site for final health, administrative, 

and legal processing. After spending a week at the 

processing site, sailors essentially leave Navy culture 

as they travel to their next destination, which for most 

is Navy IA combat skills training.

There, a cadre of Army drill instructors teach IAs 

elementary combat skills such as basic marksmanship, 

field medical procedures, rules of engagement, convoy 

operations, and codes of conduct to prepare the IA for 

integration into an Army-centric combat environment. 

In addition, most combat gear is provided at this training. Most Navy IAs receive the same training regardless of the duties they will perform when attached to 

their respective Army unit in theater. Although this 

broad-based training is beneficial because of the possibility of being remissioned (sometimes more than 

once) during an IA assignment, some of the missions 

now taken on by the Navy require competencies that 

can only be achieved by years of experience. 

One such example is detainee operations; although 

sailors with specific master-of-arms (equivalent to the 

Army’s military police) training are prepared for this 

duty, the majority of sailors conducting these missions 

are trained for unrelated positions, such as culinary 

specialists, machine mates, or yeomen. Within the 

typical 60-day IA training period, instruction relevant 

to guard force operations takes 17 days (with a capability for 4 additional days). A lack of confidence 

in performing a job can increase overall anxiety, and 

experience and training improve the ability to modulate combat stress (hence the dictum, “fight like you 

train, train like you fight”). An Army study19 found 

that at the start of OIF, 70% of soldiers deploying to 

Iraq were not psychologically prepared to experience 

combat trauma. 

To address this shortcoming, Navy Medicine has 

introduced a combat stress component to IA training, the goal of which is to cultivate cognitive coping 

strategies consistent with Kobasa’s stress hardiness 

cognitive style,20 characterized by (a) recasting challenges as opportunities for growth, (b) a commitment 

to self-improvement, and (c) the development of internal locus of control (ie, the ability to control events 

that affect one’s life). Evaluating the influence of this 

component is essential to refining and maintaining IA 

combat stress coping training, especially because the 

empirical data evaluating the efficacy of predeployment stress control programs are inconclusive.21

The IA deployment phase starts with transportation 

to the theater of operations for additional field-based 

combat skills training for 3 to 4 days. Then the IA 

platoon is disbanded and individuals are transferred 

to their ultimate combat duty stations, where, except 

for rest and recreational leave (up to 14 days), the IAs 

remain for the duration of their 6-, 9-, or 12-month 

obligation. At their combat duty station, IAs are under 

the authority of the requesting service (primarily the 

Army, although the Marine Corps also utilizes IAs). If 

necessary, the IA seeks healthcare services, including 

mental health, from the parent command. However, 

Navy combat and operational stress control programs 

reenter the picture as soon as the IA returns to the 

continental United States. As the IAs transit from their 

OEF/OIF deployment, they pass through the Navy’s 

Warrior Transition Program (WTP). 

The WTP addresses the “four Rs” of operational 

stress control: (1) reassurance that the IAs’ response 

to their deployment is nonpathological; (2) rest to 

compensate for the high operational tempo associated with 14-hour (or more) days, 6 to 7 days a week; 

(3) replenishment in terms of time to leisurely eat and 

shower; and (4) restoration of confidence.6

 Relieving 

the sailors of their bulky combat gear and completing 

customs inspections in advance also contribute to rest 

and replenishment, while reassurance and restoration are initiated with combat stress briefs delivered 

by mental health and faith-based caregivers. More 

than a prudent use of logistics, the act of gear turn-in 

(off-loading of “battle rattle”) and the surrendering 

of issued weapons (after one last ritualistic cleaning) 

are as symbolic as they are practical. The sudden 
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Combat and Operational Behavioral Health

absence of weapons may produce anxiety, which can 

be addressed by caregivers as part of the preparatory 

framework for returning home. 

The impetus for this program can be found in the 

postdeployment experiences of combat veterans like 

those described in Jonathan Shay’s seminal volume, 

Achilles in Vietnam.

22 In his book, Shay explored the 

need for leadership to provide a sanctioned time for 

“mutual support and communal reworking of combat 

trauma,”22(p61) which was part of “the long trip home” 

in World War II but tragically absent in Vietnam. Rather 

than screen for, or immediately address, combat stress 

reactions (eg, PTSD), a goal of WTP is to give IA sailors 

“permission” to grieve and acknowledge the toll of 

their deployment, while also celebrating successes and 

gains made during the deployment. These efforts are 

to help IAs begin integrating potentially fragmented 

and disassociated deployment experiences into a 

more coherent and integrated self-script or schema. By 

institutionalizing time for the IA to acknowledge the 

psychological effect (positive and negative) of deployment, it is hoped that WTP will reduce the perception 

of organizational stigma that service members consistently cite as a barrier to accessing mental healthcare.23

Mental health services are readily accessible during 

the WTP process. 

Analogous to the “third location decompression” 

process practiced by North Atlantic Treaty Organization countries, WTP takes place at temporal and 

geographical distance from the deployment site (the 

potential source of trauma), making it much different 

from critical incident stress debriefing approaches, 

which have been found to be ineffective or even detrimental to mental health.7–9 WTP is more consistent 

with end-of-tour unit debriefings shown to improve 

perceptions of organizational support.24 Nevertheless, 

because IAs do not participate in WTP with their 

combat comrades-in-arms, but with other IAs from 

different deployment locations and experiences, it 

remains to be seen whether group debriefing works 

for the IA population. Following WTP, which lasts 3 

days, IAs are flown directly home. Upon arrival at 

their destination airport, parent commands of some 

IAs may provide formal homecoming ceremonies 

that help foster reintegration. However, for many 

IAs, their mission often ends how it started—in 

isolation. 

Isolation Issues

In Vietnam, soldiers trained with one group of 

people, deployed alone to serve a 1-year combat tour 

in units of ever-changing composition, and returned 

home alone to either finish their service commitment 

or integrate into a new unit.22 By the 1980s a renewed 

appreciation for the protective nature of unit cohesion 

had arisen: 

One of the most significant contributions of World

War II and modern warfare was the recognition of the 

sustaining influence of the small combat unit on the

individual member. . . . Interpersonal relationships 

develop among soldiers and between them and their 

leaders. . . . It is these relationships which, during 

times of stress, provide a spirit or force which sustains the members as individuals and the individuals 

as a working, effective unit.19(pI-1)

Recent data indicate that unit cohesion can help 

reduce factors that place service members at risk for 

combat-stress–induced mental disorders such as PTSD. 

Brailey et al25 evaluated the contribution of unit cohesion to the prediction of PTSD symptoms in a sample 

of 1,579 nondeployed US Army soldiers. Next to 

predeployment life trauma, the degree of unit cohesion was the best predictor of predeployment PTSD 

symptoms.25 A diagnosis of PTSD or other psychological illness prior to deployment has been shown to put 

service members at increased risk for future development of PTSD.26 In another study,27 a comprehensive 

metaanalysis of 39 military samples prior to OEF/OIF 

indicated that unit cohesion was a significant predictor 

of well-being among a host of other outcomes such 

as individual performance, job/military satisfaction, 

retention, and readiness. 

Despite the general consensus that mental health in 

combat-deployed units is bolstered by the social support structures that emerge within cohesive units that 

train, deploy, and return together, the IA deployment 

has exposed a new generation of service members to 

the isolation of Vietnam-style individual deployments. 

Adding to this problem is the IA’s loss of service and 

professional identity. Data clearly support a link between job satisfaction and work-related stress.28 A common frustration voiced by IAs is dissatisfaction with 

the substance of their mission—work that may not utilize their hard-earned Navy designation or operational 

specialty. Also sometimes lost when sailors go on IA 

duty is respect for their rank. Each service emphasizes 

ranks differently. For instance, once enlisted sailors pin 

on the coveted anchors of a chief petty officer at E7, 

they become “khaki” (the same uniform officers wear) 

and are afforded great respect and autonomy within 

the Navy. However, many IAs indicate that the social 

status given to E7s in the Navy is equivalent only to 

that given to an E9 sergeant major in the Army. Data 

indicate that loss of social rank status is detrimental to 

mental health and a source of both psychological and 

physiological stress.29

Unfortunately, due to the nascent nature of IA 

deployment, little or no data are publicly available 
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Expeditionary Operational Stress Control in the US Navy

to evaluate the relative contributions of absent unit 

cohesion, low job satisfaction, and loss of social rank 

status in the prediction of combat-related stress reactions. One of the few studies to compare the mental 

health status of Navy IAs to nondeploying sailors18

found that in both the enlisted and officer ranks, 

sailors deployed to an IA billet exhibited significantly more mental health problems, but only if that 

deployment was to a hostile combat zone. This finding suggests that deployments to the Army have the 

greatest impact within the combat zone, highlighting 

the interaction between combat exposure and type of 

deployment. 

Administrative issues can also cause stress for Navy 

IAs. The handoff from Army to Navy at the end of a deployment is not always well coordinated, and because 

many Army units are unfamiliar with writing evaluations, fitness reports, or awards for Navy personnel, 

recognition for IA duty can be lacking (if evaluations 

and fitness reports are not in a Navy format, they are 

not accepted by the Navy Bureau of Personnel for inclusion in the service record). The Navy also reviews 

awards given by the Army, and has occasionally refused to accept or downgraded these awards, with a 

significant impact on the IA’s morale.

 An additional issue is family support. Although 

deployed Army units have robust family support 

programs, these programs are generally not designed 

to cross service lines and include the families of assigned Navy personnel. For IAs who are transient 

between permanent commands, the family may be left 

with little support. Thus, an area for further attention 

is ensuring that the families of deployed IAs receive 

appropriate support and information from the Army 

unit’s family support system. 

Adding to problems caused by the unique risks of 

combat and operational stressors for IA soldiers is the 

logistical distance between these sailors and the traditional Navy medical infrastructure. Navy Medicine 

personnel have limited opportunities to share the SIC 

model with the IA’s Army leadership, and thus the 

model’s emphasis on the interaction between unit 

leadership and caregivers to develop mental health 

resiliency is difficult to carry out. New initiatives based 

on IA duty continue to emerge, such as GWOT Support Assignment orders, wherein GWOT requirements 

are folded into normal permanent change-of-station 

orders. In response, Navy Medicine has initiated the 

development of combat and operational stress control 

programs tailored to meet the evolving needs of the 

IA mission, with programs at both the predeployment 

and postdeployment phases that introduce sailors to 

resilience-inducing cognitive coping skills and provide 

institutionally sanctioned time to grieve and begin the 

healing process. However, access to IAs in the combat 

zone remains a challenge to Navy Medicine and its 

health surveillance programs. 

Care for the Caregiver

Mission and Personnel

Navy caregivers include a broad range of professional and paraprofessional personnel charged with 

providing care and support to wounded, ill, and injured sailors and marines. Navy caregivers assume a 

number of roles, both traditional and nontraditional, 

including corpsmen, chaplains, substance abuse counselors, recovery coordinators, case managers, nurses, 

clinical support staff, and physicians. Some are civilians and some are contractors. 

Operational and occupational stress faced by caregivers is cumulative and extends across the deployment cycle. The acute injuries and chronic illnesses 

of war are treated across a continuum of care, from 

the front to hospitals and outpatient centers in the 

United States. For instance, a corpsman who tended 

to wounds in Iraq in July may be dressing wounds in 

San Diego, California in January. Dwell time (ie, the 

amount of time between deployments) does not necessarily include a respite from exposure to the wounds 

of war for caregivers. As a result, caregivers have an 

especially abbreviated opportunity for rest, replenishment, and restoration. The consequences of untreated 

cumulative stress can result in medical errors; somatic 

complaints such as changes in eating habits, gastrointestinal distress, headache, fatigue, and sleep disorders; 

change in work habits such as tardiness and absenteeism; mental and emotional difficulties such as memory 

disturbances, anger, self-doubt, isolation, and impaired 

judgment; and accidents.30–32

Navy Medicine caregivers are usually deployed 

as IAs to the combat zone, the exceptions being caregivers who are assigned to embedded duty within 

operational units (eg, hospital ships, EMFs, SPRINT 

teams, OSCAR teams). Uniformed caregivers selected 

for IA duty typically possess specific skill sets that 

are synergized to form an operational field medical 

asset. Personnel with combat-essential skills (Fleet 

Marine Force corpsmen, surgery, anesthesia, critical 

care, mental health) are particularly likely to deploy, 

often making multiple deployments within a given 

tour of duty. IA medical personnel are selected from 

hospitals and clinics around the world, given “just in 

time” training, and then configured with other caregivers to form a functional unit. At the end of their 

deployment, caregivers return as individuals to their 

hospitals and clinics. The protective connectedness 

of unit cohesion is lost when they leave their parent 

command and again when they leave their operational 
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Combat and Operational Behavioral Health

unit. Even more stress may be encountered by those 

who joined preexisting deployed units, a situation that 

makes “fitting in” even more difficult.

Trauma Exposure and Intervention Strategies

Providing care in a combat zone increases the likelihood of experiencing direct and secondary exposure 

to traumatic injuries. Direct exposure constitutes the 

threat to physical safety from direct and indirect fire, 

as well as the plethora of fatigue-inducing operational 

stressors. Secondary trauma can be encountered by 

working in close contact for extended periods of time 

with wounded, ill, and injured sailors, the result to 

caregivers being a phenomenon known as occupational or compassion fatigue. In relation to the SIC 

model, direct and secondary trauma can, individually 

or in tandem, contribute to full-blown stress illnesses 

for Navy caregivers. Stress injury and illnesses can affect mission effectiveness in the form of medical errors, 

job dissatisfaction, and poor retention.33

Part of the responsibility for enhancing the resilience of Navy caregivers rests with the leadership of 

Navy Medicine itself. Actions are underway within 

Navy Medicine to implement training based on the 

SIC model to run through all phases of training for 

Navy medical personnel. The core leader functions 

have been applied to day-to-day clinical leadership 

activities as well as facilitating the transition of Navy 

Medicine personnel in and out of different operational 

settings. One key point the SIC model should impart 

to the leaders of caregivers is that their roles and work 

environments are inherently stressful, and that stress 

reactions are common. Many leaders recognize that 

initial stress reactions increase caregivers’ energy and 

focus their attention on critical changes in a patient’s 

condition, while sustained stress causes a degradation of performance. Leaders should be aware that in 

caregivers’ work environments, occupational stress 

is endemic and may go unrecognized because such 

reactions become normalized. A difficult challenge to 

the leaders of caregivers is reintegrating individually 

deployed staff into a cohesive unit that did not deploy; the IA caregiver faces the dual task of reintegration while simultaneously letting go of relationships 

formed during deployment. 

The traditional work-stress–response paradigm in 

both civilian and Navy literature has several common 

elements: know the sources of job stress, know the 

signs and symptoms of stress, take care of oneself, and 

seek help when there is the beginning of impairment 

in daily life.5

 There are several significant barriers to 

self-help for caregivers. First, endemic job stress produces some level of stress symptoms in all workers, so 

that moderate and high stress appear normal. Second, 

early stress symptoms such as fatigue, impaired sleep, 

and confusion decrease the self-awareness necessary to 

initiate self-care. Third, caregivers are “other focused” 

and may consider self-care unnecessary or antithetical 

to their goals. 

When intervention is necessary, the “five Cs” of 

COSFA1—cover, calming, connectedness, capacity, and 

confidence—can prove especially helpful. Using the 

COSFA model, caregivers are encouraged to focus on 

other caregivers and their shipmates: facilitating connectedness and accessing the healing capability of unit 

cohesion requires breaking the “code of silence” by 

asking coworkers questions about their stress coping. 

Most caregivers do not feel comfortable approaching 

their peers with questions and concerns about the 

peer’s behaviors. The typical, “How are you doing?” 

is usually met with a response of, “Fine.” 

A strategy for facilitating connectedness is based on 

role expectations of shipmates and uses an “OSCAR” 

acronym (Exhibit 8-1). The OSCAR communication 

strategy encourages shipmates to address coworker 

behavior in five steps. First, observe the behavior, 

particularly signs of possible impairment, such as 

poor concentration, looking tired, falling asleep during change of shift, or irritability. Second, state the 

observation. The observation must be overtly stated 

because decreased self-awareness is one of the early 

casualties of a stress reaction. Third, clarify one’s role. 

The roles of shipmate, subordinate, supervisor, friend, 

and spouse help show why the behavior is being addressed, and help determine which options should 

EXHIBIT 8-1

OPERATIONAL STRESS CONTROL

ASSESSMENT AND RESPONSE

COMMUNICATION

Observation: actively observe behaviors; look for 

patterns.

State observations: focus all attention on the 

behaviors; just the facts without interpretations or 

judgments.

Clarify role: state why you are concerned about the 

behavior, which validates why you are addressing 

the issue.

Ask why: seek clarification; try to understand the 

other person’s perception of the behaviors.

Respond: clarify concern if indicated; discuss desired behaviors; state options in behavioral terms.
133

Expeditionary Operational Stress Control in the US Navy

be used for the shipmate. Fourth, ask the shipmate 

for personal perception of what the behaviors are. 

Often, the act of talking about the behavior will allow 

the individual to clarify how a problem is affecting 

work behavior. Fifth, respond with guided options 

that are intended to facilitate change or offer to help 

the shipmate connect with other resources, such as a 

leader, chaplain, financial counselor, the Navy-Marine 

Corps Relief Society, or mental healthcare. 

Despite the increased risks of sustaining stress injuries when deployed or in the course of day-to-day 

work, Navy caregiver duty can be extremely rewarding and satisfying. The Navy “care for the caregiver” 

concept, based on the SIC model, encourages caregivers to use the same skills they developed to help their 

patients for helping each other. 

SUMMARY

The SIC model represents an ambitious attempt 

to assimilate the disparate conceptual frameworks of 

various stress control programs within the Navy, each 

of which has its own unique history, into a single yet 

comprehensive operational stress control paradigm. 

Within this model, three major stakeholders are responsible for supporting sailors and marines faced 

with the inevitable challenge of sustained operations: (1) leadership, (2) the service member, and (3) 

the caregiver. Leadership establishes the foundation 

for effective combat stress control by cultivating a 

command climate that recognizes the importance 

of mental health, institutionalizes stress resilience 

training, and removes barriers to care for those who 

experience stress reactions and develop illness or 

injury. Individual service members trained in stress 

resilience should be capable of developing their own 

individual stress coping strategies, identifying when 

their stress reactions are beyond their coping capacity, 

and knowledgeable and comfortable enough with the 

care options available to easily seek help when needed. 

Caregivers must actively pursue a consultative role, 

working to support the leadership in stress control 

efforts, yet remaining vigilant to identify sailors who 

react adversely to stress, and providing quality care 

to those whose stress reactions lead to illness and 

injury.

Expeditionary medical platforms, such as hospital 

ships and EMFs, provide a large, forward-deployed 

medical capacity for applying the SIC model. However, combat stress control program elements such 

as SPRINT, carrier psychologists, and OSCAR teams 

are the best embodiment of the SIC model. In fact, 

the SIC model itself is an outgrowth of OSCAR philosophy. Unfortunately, both the forward-deployed 

medical platforms and combat stress control elements 

are straining to adapt to the burgeoning demands of 

GWOT that have focused pressure on caregivers themselves, and taken sailors outside of the Navy sphere of 

influence during the course of IA duty assignments. 

Building upon the successes of the combat stress 

control program elements described in this chapter, 

which arose to meet specific operational demands, 

Navy medicine can again rise to meet the challenge 

of caring for combat deployed sailors.

A consistent theme in this chapter has been the utility of mobile and expeditionary Navy Medicine assets. 

Despite the necessity and quality of the centralized 

Navy medical capacity, it has been recognized that 

delivering care within deployed units has reduced the 

stigma associated with seeking help for stress-related 

illness. Moreover, the benefit is reciprocal: proponents 

seem to agree that caregivers themselves benefit from 

the social cohesion of serving within a unit, a situation that appears to improve caregivers’ credibility 

as well as their overall ability to intervene and treat 

stress-related injuries. 

Each section of this chapter represents cumulative knowledge gleaned from professional training, 

reviews of the literature, and most importantly, firsthand experiences with Navy combat and operational 

stress control programs. This chapter should also 

alert readers to areas where data are needed to evaluate whether the programs discussed are effective in 

managing combat and operational stress. Despite 

the myriad models and approaches described, Navy 

combat and operational stress control programs in 

their present state are a mission-centered collection 

of efforts that reflect the multifaceted and dynamic 

issues associated with stress control in combat and 

operational environments. The SIC model is a bold, 

yet necessary, attempt to weave these programs’ elements into an overarching Navy combat stress control 

philosophy. 

REFERENCES

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2. Stokes AF, Kite K. On grasping a nettle and becoming emotional. In: Hancock PA, Desmond PA, eds. Stress, Workload, 

and Fatigue. Mahwah, NJ: Lawrence Erlbaum Publishers; 2001: 107–132.
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3. Gunderson E, Hourani LL. The epidemiology of mental disorders in the US Navy: the neuroses. Mil Med. 2001;

166:612–620.

4. Tanielian T, Jaycox L. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to 

Assist Recovery. Santa Monica, Calif: RAND Corporation; 2008.

5. Cooper CL, Cartwright S. A strategic approach to organizational stress management. In: Hancock PA, Desmond PA, 

eds. Stress, Workload, and Fatigue. Mahwah, NJ: Lawrence Erlbaum Publishers; 2001: 235–248.

6. Lewis SJ. Combat stress control: putting principle into practice. In: Britt TW, Castro CA, Adler AB, eds. Military Life: 

The Psychology of Serving in Peace and Combat. Westport, Conn: Praeger Security International; 2006: 121–140.

7. McNally RJ. Psychological debriefing does not prevent posttraumatic stress disorder. Psychiatric Times. 2004;21(4).

8. McNally RJ, Bryant RA, Ehlers A. Does early psychological intervention promote recovery from posttraumatic stress? 

Psychol Sci Pub Int. 2003:42:45–79.

9. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD).

Cochrane Database of Systematic Review. 2001;4. Art No. CD000560.

10. Nash B, Watson P, Litz B. USN-USMC combat and operational stress first aid (COSFA). Paper presented at: US Marine 

Corps Combat Operational Stress Control Conference; August 12–14, 2008; San Diego, Calif.

11. Wood DP, Koffman RL, Arita AA. Psychiatric medevacs during a 6-month aircraft carrier battle group deployment to 

the Persian Gulf: a Navy Force Health Protection preliminary report. Mil Med. 2003;168:43–47.

12. Smith D. Taking it to the fleet. Monitor Psychol. 2002;33:52–53.

13. Jones DE, Lee JJ. Take the tough cases to sea. Proceedings. 2002;128:61–64.

14. US Department of Defense. An Achievable Vision: Report of the Department of Defense Task Force on Mental Health. Falls 

Church, Va: Defense Health Board; 2007.

15. US Department of Defense. Plan to Achieve the Vision of the DoD Task Force on Mental Health: Report to Congress September 

2007. Washington, DC: DoD; 2007.

16. Harris DM, Edwards JD. A Preliminary Evaluation of the OSCAR Pilot Program. Alexandria, Va: Center for Naval Analyses; 2006. Report CRM D0013962.A2/Final.

17. US Marine Corps. Tri-MEF Combat Operational Stress Conference. Camp Pendleton, Calif: I, II, and III Marine Expeditionary Forces. Letter to the Commandant, 12 September 2007. Available at: http://www.mca-marines.org/Gazette/

PDF/USMCLetterPP.pdf. Accessed March 30, 2009.

18. Andres JM. Effects of Navy Individual Augmentee Deployments on Mental Health Outcomes [master’s thesis]. Monterey, 

Calif: Naval Postgraduate School; 2008.

19. US Army Office of the Surgeon General. Operation Iraqi Freedom Mental Health Advisory Team Report, 16 December 2003. 

Washington, DC: OTSG; 2003.

20. Kobasa SC. Stressful life events, personality, and health: an inquiry into hardiness. J Pers Soc Psychol. 1979;37:1–11.

21. Sharpley JG, Fear NT, Greenberg N, Jones M, Wessely S. Pre-deployment stress briefing: does it have an effect? Occup 

Med (Lond). 2008;58:30–34.

22. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York, NY: Atheneum; 1994.

23. 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;351:13–22.
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24. Adler A, Suvak M, Litz B, et al. A controlled trial of group debriefing in the military: preliminary findings. Poster session presented at: 38th Annual Meeting of the Association for Advancement of Behavior Therapy; August 2004; New 

Orleans, La.

25. Brailey K, Vasterling JJ, Proctor SP, Constans JI, Friedman MJ. PTSD symptoms, life events and unit cohesion in US 

soldiers: baseline findings from the neurocognition deployment health study. J Trauma Stress. 2007;20:495–503.

26. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a metaanalysis. Psychol Bull. 2003;129:52–73.

27. Oliver L, Harman J, Hoover E, Hayes S, Pandhi N. A quantitative integration of the military cohesion literature. Mil

Psychol. 1999;11:57–83.

28. Ostroff C. The relationship between satisfaction, attitudes, and performance: an organizational level analysis. J Appl 

Psychol. 1992;77:963–974.

29. DeVries AC, Glasper ER, Detillion CE. Social modulation of stress responses. Physiol Behav. 2003;79:399–407.

30. Jacobson BH, Aldana SG, Goetzel RZ, Vardell KD, Adams TB, Pietras RJ. The relationship between perceived stress 

and self-reported illness-related absenteeism. Am J Health Promot. 1996;11:54–61.

31. Barger L, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl

J Med. 2005;352:125–134.

32. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249–

1255.

33. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United 

States and Canada. Jt Comm J Qual Patient Saf . 2007;33(8):467–476.
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137

Provision of Mental Health Services in Operation Iraqi Freedom 05-07

Chapter 9

PROVISION OF MENTAL HEALTH 

SERVICES IN OPERATION IRAQI 

FREEDOM 05-07

MARC A. COOPER, MD*; SHARON M. NEWTON, MHS†; and JEFFREY S. YARVIS, MSW, PhD‡

INTRODUCTION

CHANGING DYNAMICS OF THE CONFLICT

A More Sophisticated Enemy

More Developed Forward Operating Bases, More Developed Mental Health 

Services

Increased Multiple Deployers 

New Department of Defense Policies

Improvements in Command and Control of Echelon-Above-Division Stress 

Control Personnel

Standardization of Practices 

Quality Assurance

ROLE OF THE MEDIA 

Reporting Increase in Suicide Rates

Airing the Baghdad ER Special

Media Coverage of Civilian Deaths in Haditha 

SUMMARY

*Chief, Community Mental Health Service, Moncrief Army Community Hospital, 4500 Stuart Street, Fort Jackson, South Carolina 29207; formerly, 

Major, Medical Corps, US Army; OIF 05-07 Theater Mental Health Consultant, Task Force 30th Medical Brigade, Baghdad, Iraq

†

Lieutenant Colonel, Medical Specialist Corps , US Army; Command Inspector General, 30th Medical Command, CMR 442, APO AE 09042; formerly, 

Theater Consultant for Combat and Operational Stress Control, Iraq 

‡

Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland
138

Combat and Operational Behavioral Health

INTRODUCTION

During Operation Iraqi Freedom (OIF) 05-07, the 

third anniversary of combat operations in Iraq was 

observed. The battlefield had changed dramatically 

since US forces first invaded Iraq in March 2003. Open 

fighting along the routes into major cities had been 

replaced with door-to-door city fighting. The enemy 

had changed from a visible fighting force into a largely 

unseen guerilla force. As the battlefield transformed, 

so did the provision of mental health services. Mental health providers still supported soldiers, but this 

task evolved, resulting in the improvement of earlier 

operations, the incorporation of new missions, and an 

increased emphasis on data collection. Being in country for 3 years and utilizing the widespread availability 

of computerized technology, military mental health 

provision developed to a level of sophistication never 

before seen in a theater of operations.

This chapter will explore how duration of the conflict affected the provision of mental health services 

during OIF 05-07. It will look at factors that influenced 

the entire military that had consequences for mental 

health providers, such as facing a more sophisticated 

enemy, living on more developed bases, and implementing new Department of Defense policies. It will 

also look at ways in which mental health services 

expanded based on lessons learned from OIF-I and 

OIF-II. Finally, the length of the conflict and the increasing number of casualties amplified media interest in 

the conflict and in mental health services available to 

soldiers in combat. This chapter will discuss the influence of the media on the provision of mental health 

services during OIF 05-07.

CHANGING DYNAMICS OF THE CONFLICT

A More Sophisticated Enemy

In March 2003, the enemy was clear—the Iraqi Army 

commanded by Saddam Hussein. After Hussein’s 

troops surrendered in April 2003, defining the “enemy” 

became more complicated. Pockets of insurgent groups 

coupled with sectarian violence began producing coalition casualties through various guerilla warfare tactics. 

During the ensuing years, these tactics became more 

sophisticated, using the skills of sharpshooters and 

explosives experts. These deadly encounters with insurgents resulted in the decision by the US military that 

there had to be increased preparedness for all deployed 

soldiers. Consequently, one of the improvements 

made during OIF 05-07 was that all soldiers already 

deployed, as well as those soon to deploy, were given 

protective equipment that was normally provided only 

to combat units. In addition to the Army combat uniform and improved Kevlar helmets, all soldiers were 

also issued “hemcon” (hemorrhage control) bandages, 

which were a vast improvement over the previous field 

bandage. Soldiers received deltoid and axillary protector plates, and enhanced small arms protective insert 

plates, aimed at providing better protection. However, 

these protective measures also significantly increased 

the weight each soldier had to carry. This extra weight, 

especially in the hot summer months, was an added 

stressor for all soldiers, including the combat operational stress control providers during travel outside 

the forward operating base (FOB). 

Travel between FOBs was improved during OIF 

05-07. During the first half of OIF-I, travel was in softsided vehicles for the simple reason that there were 

no up-armored vehicles. The dangers of ground travel 

(ie, improvised explosive devices, rocket-propelled 

grenades, suicide bombers) became more common and 

deadlier, necessitating the requirement that all vehicles 

traveling outside the FOB be up-armored. In general, 

although more travel now occurs via aircraft than 

during OIF-I (where nearly all travel was by ground 

convoy), most combat stress control teams continue 

to travel by convoy. 

Another area in which there was improvement 

as the conflict continued was the standardization of 

convoy procedures. During OIF-I, depending on the 

location of the team and its higher headquarters, there 

was a wide variation in procedures. Some teams traveled by nontactical vehicle, while other teams were 

required to be in a convoy of at least three vehicles, 

with a specified number of crew-served weapons. 

Although the standardization of convoy procedures 

was developed to enhance safety, this more-involved 

process has created frustrations for the combat stress 

control teams who regularly need to leave a FOB to 

provide services to a supported unit. 

More Developed Forward Operating Bases, More 

Developed Mental Health Services

The living and working conditions improved 

considerably by OIF 05-07. During OIF-I, soldiers 

(including mental health personnel) lived and worked 

out of tents for the most part, using burnout latrines, 

field-expedient showers, and meals, ready-to-eat. 

Conditions began to improve even before the end of 

the OIF-I rotation, and the improvements continued 

through each rotation. During OIF 05-07, the majority 

of personnel lived and worked in trailers or buildings 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

that were climate controlled and had electricity, including hygiene facilities with running water. Even the 

presence of beds instead of an Army cot contributed 

to the overall improvement in the standard of living. 

Obviously, these improvements affected the level of 

stress perceived by the supported soldiers as well as 

the mental health personnel providing the support. 

One observation of the 30th Medical Brigade (TF30 

Med) mental health personnel is that subordinate units 

seemed to be reporting more psychiatric patients than 

expected by combat operational stress control (COSC) 

doctrine. A rough comparison was made of the average monthly number of new psychiatric contacts to 

the average monthly number of new combat stress 

contacts from the Combat Operational Stress Control 

Workload Activity Reporting System (COSC-WARS) 

reports from OIF-I, OIF-II, OIF 04-06, and OIF 05-07. 

The average number of new psychiatric contacts rose 

disproportionately higher than the average number of 

new combat stress contacts from OIF-I to OIF 05-07. 

(Only a rough estimate is possible as data collection 

during the early part of the conflict was obviously not 

the priority.) The reasons for the increase are not clear. 

Among possible explanations are improved workload 

reporting procedures, an increase in the population at 

risk or the number of soldiers deploying with psychotropic medications, or providers more willing to use 

medication to treat combat stress and thus convert 

what would have traditionally been a new combat 

stress contact into a psychiatric contact. Providers 

were likely more comfortable prescribing medication 

because the living environment was more stable and 

better follow up was available; thus soldiers would not 

need to be sent out of the theater for treatment. 

There was a very clinical feel to many of the services provided during OIF 05-07. (One benefit that 

comes from a longer conflict is that better working 

conditions develop.) During OIF-I, tents were the 

norm. By OIF 05-07 the tents had been replaced by 

buildings—working in buildings instead of working 

outside the same tent where one lives lends itself to 

a more clinical feel. Additionally, more combat stress 

control (CSC) units had teams collocated with a combat support hospital (CSH) compared to OIF-I.1 These 

teams would frequently provide primarily mental 

health services. Often times, this was out of necessity, 

as they were the only mental health providers on the 

FOB, or the CSH did not have the personnel due to 

split-base operations. Sometimes this was the choice 

of the provider, the combat stress control commander, 

or the CSH commander. 

This is not to say that COSC personnel were not 

providing preventive outreach services. As alluded 

to earlier, many of the division mental health personnel had a preventive focus, as did the mental health 

personnel from echelons above division beyond those 

in the CSC units. All teams from the CSC units did 

some form of outreach through classes, consultation, 

and education, as well as regular outreach by walking 

around and talking to the supported units. 

By OIF 05-07, theater mental health assets had 

learned the basics of their jobs in a combat environment 

and began to expand their roles into more forensic 

and administrative psychiatry services, which would 

not normally be associated with combat psychiatry. 

Sanity boards and mental status evaluations are not 

even mentioned in the COSC field manual2

 or the two 

psychiatry volumes in the Textbooks of Military Medicine 

series.3,4 It is unclear if the requests for these specialty 

services had any relationship to the fact that mental 

health services were being offered in more clinical 

environments, and thus providers were more able or 

prepared to fulfill these requests. 

The fact that commanders and soldiers were requesting these services while deployed to a combat 

zone merits discussion. The Mental Health Advisory 

Team (MHAT) IV found that soldiers who had deployed to Iraq more than once were more likely to 

screen positive for depression, acute stress, anxiety, 

or other mental health problems. It also reported that 

soldiers who screened positive for a mental health 

problem were twice as likely to engage in unethical 

behavior as those who did not screen positive.5 The 

number of moral waivers for felonies given to recruits 

increased from 459 in 2003 to 1,002 in fiscal year 2006.6

Thus, whether due to a mental health problem or a 

history of illegal behavior, it appears that the longer 

this conflict continues, the greater the chances are that 

soldiers will be acting out while deployed, and there 

will be an ever-increasing need for sanity boards or 

command-directed mental health evaluations performed in theater. 

Established mental health clinics during OIF 05-07 

also managed to work out logistical problems that 

plagued clinics at the start of the conflict. One of 

the biggest improvements was the formulary, which 

now contains a broader spectrum of antidepressant 

medication and stimulants, two concerns brought 

up by providers during OIF-I.7

 The formulary was 

frequently reevaluated, as the Multi-National Force–

Iraq (MNF–I) pharmacists held quarterly meetings that 

allowed providers to make suggestions for additions 

or substitutions. 

Despite great interest in knowing how many psychotropic prescriptions were written in theater, several 

mechanisms make this data difficult to accurately 

report. First, most established psychiatric patients 

deploy with a 90-day supply of medication from their 

home duty station or soldier readiness processing 

site. The TRICARE mail-order pharmacy was also 
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frequently used for established psychiatric patients 

and those stabilized on medication in theater. Theater 

pharmacies ordered their own stocks of medications 

and kept their own records of prescriptions written for 

each psychotropic. Thus, centralized order tracking 

would only reflect shipments to theater pharmacies, 

not how much of those shipments were actually being 

prescribed. 

Another advance that occurred in theater was the 

increased availability and usage of Composite Health 

Care System-Interactive Training Tool (CHCS-ITT), 

the deployment electronic medical record. Because 

CHCS-ITT is linked with the computerized medical 

record system utilized in garrison, provider notes written in the combat zone can be accessed at any military 

treatment facility in the world. This system greatly 

improved continuity of care between the Iraq Theater 

of operations and the medical facilities where soldiers 

were being treated and reduced the biggest risk of 

paper documentation—misplacement. Unfortunately, 

the only facilities that had reliable electricity, computer 

access, and CHCS-ITT trainers were the Level III CSHs 

and Level II battalion aid stations. Unless they were 

collocated in one of these facilities, the CSC teams did 

not have access to the CHCS-ITT system. 

The debate that had occurred in garrison mental 

health clinics was subsequently heard in theater. This 

debate centered on the inclusion of mental health notes 

in the general medical record and the lack of privacy 

of the computerized mental health record. The CHCSITT “sensitivity feature” was nonfunctional in theater. 

This sensitivity feature, also known as the “break the 

glass” feature, keeps record of all users accessing any 

clinical notes labeled as “sensitive.” Prior to accessing 

a sensitive note, medical providers are warned with 

a pop-up message that they are about to read sensitive data and they will be audited. For CHCS-ITT, 

in-theater providers could designate a note as sensitive, but there was no record created of who accessed 

a sensitive note and there was no warning pop-up 

message. To use the system while protecting patient 

privacy, some providers opted to keep all their records 

electronically unsigned, which kept the encounter in 

an “open” status and prevented other providers from 

being able to read the notes, but still allowed treating 

providers to write up a summary of their encounter 

with the patient and print it out. The disadvantage of 

this was that future mental health providers could not 

access these notes because they were never closed, and 

open encounters significantly downgraded the entire 

system so that all notes in all clinics on that particular 

network took longer to write. 

With more established FOBs offering more services, 

KBR (formerly Kellogg Brown & Root, the largest 

civilian contractor in Iraq at the time), and the Army 

and Air Force Exchange Service required more civilian 

employees during OIF 05-07 than in OIF-I. Problems 

arose when these employees, who were supposed to 

be psychiatrically cleared prior to their deployment, 

showed up at military mental health clinics in need of 

treatment. This put military providers in an uncomfortable position for several reasons: (a) military malpractice did not cover the care of contractors, (b) contractors 

were not eligible for care and so prescriptions would 

be difficult to fill, and (c) if the contract agency found 

out that an employee was receiving mental healthcare, 

the employee would be sent home, so when contractors presented to mental health clinics, they asked the 

providers not to report them. KBR brought its own 

employee assistance program counselors to Iraq, 

which was helpful when KBR employees were involved in a casualty-producing incident, because their 

own counselors could offer debriefings or counseling. 

However, KBR had no physicians or psychiatrists on 

staff. Because only physicians can initiate air evacuation requests, military psychiatrists were tasked with 

authorizing all KBR psychiatric emergencies requiring 

evacuation from theater.

Developed FOBs brought with them communication systems that were vastly improved from OIF-I. 

This had several implications for the mental health 

community. First, most FOBs now had widespread 

Internet access and phone centers, which enabled 

soldiers to call home more regularly. Mental health 

providers in theater considered this a mixed blessing—

soldiers could receive additional support or they could 

receive devastating news, yet they were still expected 

to perform the mission. 

Another consequence of improved communication, especially the ability to send US mail across 

FOBs fairly reliably, was that the design for MHAT 

IV could be simplified. Rather than having a team of 

researchers come into theater and travel across FOBs 

administering the surveys, the surveys were sent by 

express mail to the theater. They were then mailed to 

the mental health assets organic to the FOBs where the 

participating units were stationed. The surveys were 

administered by each unit’s mental health asset and 

then mailed back to the MNF–I surgeon’s office, where 

MHAT IV was housed. This new process allowed 

for a reduction in the number of researchers needed 

to deploy to theater. The mission now focused more 

on data analysis rather than survey administration. 

Although this expanded the mission of the theater 

mental health provider, it gave units an opportunity 

to interact with their own mental health assets, rather 

than with a group of outsiders. It also decreased the 

need for travel across FOBs by MHAT personnel, a 

process with its own inherent risks. Ultimately, there 

were delays in the mail system, so MHAT personnel 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

did more travel than was originally planned, but this 

was still far less than previous MHAT teams.

Increased Multiple Deployers

Clearly, with each additional year of the conflict, 

the chances increase that the population of deployed 

soldiers will contain greater numbers of multiple deployers. The increased number of multiple deployers 

during OIF 05-07 was not unique to soldier patients 

seeking mental healthcare. Many healthcare providers were also affected. It is not unusual to have COSC 

providers return from a deployment only to discover 

the need to prepare for the next deployment. They 

may not have had sufficient time to recover from the 

first deployment. The very nature of providing COSC 

services in a combat theater means repeated exposure 

to stress and hearing the tragedies of those being supported. Twenty-one percent of OIF 05-07 behavioral 

health providers reported high or very high levels of 

burnout.5

 It is unclear how many of these providers 

had had multiple deployments. An area of further 

research might be to look at the long-term effect of 

multiple deployments on behavioral health providers, 

especially with little time between each one. 

Ongoing provision of mental health service would 

have resulted in rotation through Army providers 

more quickly had it not been for the US Air Force and 

Navy contributing greater mental health assets than 

in previous OIF years. The Air Force deployed its 

mental health providers for 4 months at a time. They 

were placed in CSC teams or in the Air Force hospital 

in central Iraq. The Navy deployed its mental health 

providers in support of Marine line units, but also filled 

some of the rotating reservist slots of the CSC units. 

New Department of Defense Policies

As after-action reports and other reported difficulties from OIF-I and OIF-II made their way through 

the top levels of the military, new policies made their 

way down in an attempt to make needed improvements. One such policy concerned treating victims of 

sexual assault. This policy originated as a result of an 

inquiry made by the Secretary of Defense (then Donald 

Rumsfeld) in February 2004 over concerns of sexual 

assault allegations made by soldiers deployed to Iraq 

and Kuwait.8

 A task force that was formed to investigate these allegations found inconsistency in sexual 

assault prevention programs across the services. The 

task force reported that barriers to reporting sexual 

assault were significant in the military environment 

and that without an advocate looking out for the 

victim, it was easy to overlook a victim’s rights and 

needs. Among the task force’s recommendations was 

the establishment of a Department of Defense policy 

addressing sexual assault prevention and response, 

and the creation of a task force that would oversee this 

policy. After receiving congressional approval, Department of Defense Directive 6495.01, the Sexual Assault 

Prevention and Response Program, was published in 

October 2005. It outlined the treatment and care for 

victims of sexual assault and required that provisions 

be made for theater operations. The Army published 

its policy in Army Command Policy, Army Regulation 

600-20, which was first published February 1, 2006, and 

revised June 7, 2006. 

The Sexual Assault Prevention and Response Program affected theater mental health providers because 

it potentially added further missions. First, behavioral 

health personnel were often tasked with acting as the 

unit’s victim advocates due to their demonstrated 

ability to empathize. Even if they were not victim 

advocates, however, mental health personnel had 

the potential for greater contact with sexual assault 

victims, because the new policy required immediate 

availability of mental health services for all victims 

presenting to a medical treatment facility. Alternatively, 

a mental health visit could be the first contact a sexual 

assault victim had with the medical community. Thus 

providers had to know about the new reporting options, which were restricted reporting and unrestricted 

reporting. In restricted reporting, only the treatment 

community is authorized to know the victim’s identity 

(the victim’s chain of command is never told about the 

assault). In unrestricted reporting, the victim’s chain 

of command is informed and an official Criminal Investigation Division inquiry is opened. Finally, sexual 

assault review boards were now meeting in theater and 

behavioral health chiefs were a required component 

of these boards. 

The other policy that had a significant effect on the 

mental health mission during OIF 05-07 took effect 

June 1, 2006, when the Army revised its deployment 

drug testing procedures. The main changes involved 

giving more responsibilities to deployed units.9

 This 

included medical personnel because medical review 

officer (MRO) services now had to be available in the 

deployed environment. An MRO is a physician appointed to determine if a urinalysis positive for opiates, 

barbiturates, steroids, or stimulants is the result of a 

legitimate prescription or illegitimate use.10 In garrison, 

MROs are trained through a medical command course 

and are certified after passing an examination. 

An informal survey of division surgeons and the 

CSHs indicated that there were not enough certified 

MROs in theater to handle this new tasking. Ultimately, 

the decision was made to have two MROs appointed 

at each Level III CSH, two at the multifunctional medical battalion, and additional MROs as needed in the 
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divisions. The Army Forensic Drug Testing Program 

then distributed training CDs to theater. Commanders 

appointed MROs, the CDs were reviewed, and MROs 

took the certifying exam via e-mail. The majority of 

newly appointed MROs were psychiatrists, although 

some of the CSHs appointed family practice physicians. 

In addition to the MRO mission, the new drug 

testing policy also affected the mental health community by identifying more substance abusers in theater. 

Unfortunately, the Army Substance Abuse Program 

did not formally exist in theater, thus treatment and 

rehabilitation options for those identified were extremely limited. Some of the larger FOBs had Alcoholics Anonymous meetings, but for the most part, any 

drug and alcohol counseling was left to chaplains and 

the mental health community.11

Improvements in Command and Control of 

Echelon-Above-Division Stress Control Personnel

As the theater matured, so did the ability to command and control COSC personnel in the echelonabove-division units. At the start of combat operations, 

there were many changes in command structure, 

supporting units, who would support whom, and so 

forth.1 During OIF 05-07, not only was there only one 

medical headquarters in theater, but it was stationary. There was no longer a need to move north as the 

conflict progressed. 

Each rotation made improvements, and by OIF 05-

07 the medical headquarters had a firm foundation on 

which to build. The introduction of a mental health 

consultant at the Multi-National Corps–Iraq (MNC–I) 

level continued during OIF 05-07 as a dual role position with the TF30 Med mental health consultant. This 

permitted a single medical headquarters to coordinate 

plans with the divisions and other separate brigades, 

as well as ensure the MNC–I and MNF–I commanders 

and command surgeons were kept informed. The result 

was an enhanced ability for greater situational awareness and coordination of COSC/mental health needs 

and services. 

This enhanced situational awareness also assisted in 

planning for coverage. Because of improved communication systems, a stationary headquarters, and solid 

foundation from previous rotations, planning was 

able to be more deliberate and organized, obtaining 

input from multiple sources. As the theater changed, 

so did the method of estimating COSC coverage. In 

OIF-I, one CSC unit provided coverage to a specific 

division; there was one preventive team per brigade. 

By OIF 05-07, area support was the norm. COSC coverage was divided more by geographic location than 

strictly by division.

Situational Awareness

Managing and directing the COSC medical functional area in a theater of operations requires accurate 

and up-to-date situational awareness. This required 

verification of the location of COSC personnel in 

theater, by clinical specialty. Fortunately, a listing that 

included MH personnel from the divisions, KBR, the 

Air Force, the Navy, and the Marine Corps Operational 

Stress Control and Readiness (OSCAR) teams already 

existed. A database was developed, adding clinical 

specialties at each location, and updated regularly. 

This listing proved to be extremely helpful and provided the situational awareness required for optimal 

management of COSC resources. Not only did it 

help to identify the proper unit to task when specific 

missions were requested, but it also assisted in the 

planning process by ensuring minimal duplication of 

services among the various mental health resources 

on an FOB. 

Planning Process 

Even though the theater had evolved considerably 

since the start of the conflict, having the right number 

of people in the right place was always a challenge. Because planning did not have to occur as troops were on 

the move, as at the beginning, it was possible to use a 

very thorough planning process. TF30 Med developed 

a process that utilized a historical review of workload 

and operational tempo, COSC doctrine, and a staffing 

model. (The staffing model that was used was based 

very closely on one proposed by the second MHAT.12

It considered three primary categories of services: (1) 

clinical, (2) unit outreach, and (3) the restoration center. 

The clinical usage was calculated based on the average of the percentages that want help, need help, and 

use help. Some of the assumptions were corrected to 

reflect current processes, and items were modified to 

be applicable in the deployed environment.) 

This was the “science” of operational planning. The 

“art” of operational planning was then employed by 

comparing the requirements from the different methods, considering input from the CSC unit commanders, 

and applying the technical knowledge and expertise 

of the staff officer. The result was a proposed realignment plan. Mental health personnel in TF30 Med were 

always cognizant of their role as consultants, and 

not the final decision makers. Therefore, this recommended plan was presented throughout the chain of 

command and others involved in providing COSC/

mental health services. Because this process may be 

different from what is experienced by most mental 

health providers, it bears explanation. The plan was 

initially reviewed and approved within TF30 Med—
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

from clinical operations, through G3 (operations), to 

the commander/theater surgeon. It was then staffed 

through TF30 Med’s direct reporting units—the commanders, the operations officers (S3s), and of course 

the CSC unit leadership. The units being supported 

were part of the divisions, so the plan was briefed to 

the division surgeons and medical planners as well. 

Additionally, the equivalent personnel from the US 

Navy were included in the discussion. Changes were 

made at each step, based on input and needs identified. The final product was published in a fragmentary 

order. Even then, it specified only the minimal number 

of personnel at each FOB—by unit—and the location 

of the restoration centers. The CSC unit commanders 

were still responsible for determining the correct specialty and personnel to place at each location. 

Coordination and planning was continuous. Distribution of COSC personnel changed and adapted 

as situations changed or divisions made requests. 

This involved TF30 Med working in partnership with 

MNC–I mental health consultant, and coordinating 

closely with the senior mental health personnel of 

both divisions and Marine Expeditionary Forces on 

the placement of CSC units—fostering cooperation 

and minimizing duplication of services. 

As previously alluded to, provision of services involved planning and anticipating needs for the future 

as well. During OIF 05-07, this included coordinating 

with the US Air Force, which was compiling a CSC for 

a follow-on rotation. TF30 Med invited an Air Force 

representative to attend the COSC conference held 

in theater and meet other CSC commanders, discuss 

the mission, and get questions answered. The commander of the CSC unit that the Air Force team would 

be replacing also provided vital input to smooth the 

transition. After the visit, the utilization of the Air 

Force liaison officer in country proved invaluable in 

fine-tuning the coordination, planning, and preparation for the incoming team. 

Another manner in which command and control 

was improved was in the redistribution of the CSC 

units. After extensive mission analysis and communication with all involved, including the incoming 

medical headquarters, the CSC units were placed 

under the command and control of the newly formed 

provisional multifunctional medical battalion. One 

of the benefits to having all the CSC units under the 

same battalion was the enhancement of the ability to 

coordinate among all of these units. It was now easier 

to maintain situational awareness across the theater, 

task the most appropriate unit for any missions that 

arose, and simplify communication. An illustration 

of this was when the members of a specific brigade 

combat team (BCT) were told that they were going to 

be extended. The extension meant the BCT would need 

to relocate, and would involve a change in COSC team 

as well. Due to the ease in communication under one 

battalion, the efforts of each of the CSC units was wellcoordinated and they were able to ensure a minimal 

disruption of services and affect on the soldiers in the 

BCT. This also included TF30 Med coordination with 

the BCT’s organic mental health personnel. 

Challenges

As with previous rotations, the OIF 05-07 rotation 

faced several challenges. One of these was the rotation 

of the divisions midway through the tour of the combat 

stress control unit supporting them. When the new 

division arrived, it would sometimes want to change 

the number or specialty of the mental health personnel 

on different FOBs. Different mental health personnel 

may vary on how to implement COSC/mental health 

services. The challenge presented itself in that the 

CSC team had already established trust and rapport 

with the supported units. Changing COSC personnel 

would affect continuity of care. This was not a problem for the division soldiers as they were leaving, but 

the supported population included soldiers from the 

echelon-above-division units as well. It was easier to 

address this challenge because of the open lines of 

communication between the CSC units, their battalion 

headquarters, and the TF30 Med. 

Another challenge was in the coordination of who 

would provide services on a particular FOB. Because 

the method of team placement emphasized minimizing duplication of services, the only mental health support might be through the division team. This would 

often require the division mental health personnel to 

perform COSC and mental health activities to both 

echelon-above-division and division soldiers. Naturally, the reverse occurred when a CSC unit team was 

the only mental health asset at a location. 

Standardization of Practices 

The better-established theater provided the opportunity for the standardization of policies and procedures, and quality control. There are certain issues that 

seemed to be prevalent in providing COSC services, 

spanning the OIF rotations. Topics such as how to 

document contacts, how to measure workload, what is 

required to evacuate a soldier, and even interpretation 

of COSC doctrine were addressed. Standardization 

was difficult when personnel brought with them different levels of training in COSC and differing individual 

comfort levels with the prevention and outreach focus 

of COSC. COSC doctrine addressed these topics, but 

finding the answer was cumbersome at best. To alleviate this, TF30 Med simplified the search by addressing 
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these topics in the COSC annex to the operation orders 

for both TF30 and MNC–I. This annex established 

consistent policies and practices theater-wide. 

Documentation 

One of the main principles behind COSC is to maintain a nonclinical approach when managing soldiers 

with combat and operational stress reaction (COSR).2

However, COSC personnel perform interventions 

and activities not only for soldiers with COSR, but 

also those with diagnosable psychiatric conditions. 

What, constitutes appropriate documentation for a 

soldier with COSR? Does the documentation differ 

from that for mental health treatment of a psychiatric 

disorder? Where is this documentation kept, and for 

how long? Based on COSC doctrine found in Field 

Manual 4-02.51, a policy was established based on 

whether or not a soldier would be placed in a COSR 

restoration program. 

Care for a soldier participating in a restoration 

program for COSR was tracked from the initial contact until the soldier was released from the program. 

It included the COSC interventions and activities 

provided, soldier response, and a summary of COSC 

services provided. This record, or file, was kept separate from the soldier’s outpatient treatment record 

or deployment health record, and safeguarded on 

premises. As outlined by the Patient Administration 

Systems and Biostatistics Activity, this file was kept by 

the CSC unit for 5 years, and destroyed in December 

of the fifth year.13 Only a notation of the dates and the 

CSC unit providing the services was entered into the 

soldier’s official record. 

Care for soldiers with COSR, but not participating 

in a restoration program, was documented according to the level of intervention and severity of COSR. 

One level was a soldier who was experiencing normal 

stress reactions, and received only brief supportive 

“therapy,” skill acquisition, or “psychoeducation” 

to normalize the response. These contacts did not require documentation. However, the soldier who was 

experiencing a more severe, yet normal, stress reaction 

would require a notation in the outpatient treatment 

record. These reactions are described in Field Manual 

4-02.51 as “maladaptive stress behaviors.”2 Documentation was also required if the COSR was interfering 

with the soldier’s ability to function. The notation 

included the CSC unit, a statement that there were no 

safety issues, and no medication was needed. At the 

soldier’s request, the provider would document any of 

the above situations. Care for soldiers with psychiatric 

disorders was documented the same as if the care was 

provided in garrison. The standards outlined in Army 

Regulation 40-66 apply on deployment, too.14

Reporting Workload 

Keeping accurate records is important in identifying any potential trends in healthcare use, incidence 

of disease, and injury rates. Current methods in force 

health protection and healthcare include reporting 

disease nonbattle injuries, surgery hours, and hospital inpatient occupancy. The types of interventions 

and activities performed in COSC do not fit well into 

these types of reporting methods. As a result, the 

COSC-WARS was developed. Because the OIF units 

were the only ones using the COSC-WARS, permission 

was received to revise the form. During OIF 05-07, the 

COSC-WARS summary report was modified twice in 

an effort to ensure the data collected were sufficient 

to answer requests from a variety of sources. The final 

version contained data that allowed accurate responses 

to requests from the Government Accountability Office, Office of The Surgeon General consultants, and 

the command surgeons at all levels—MNF–I, MNC–I, 

and TF30. This form also provided data that proved to 

be invaluable in the planning process. It is important 

to note that this process also utilized input from the 

users of the form—the COSC personnel. The latest 

version of the COSC-WARS summary report was on a 

Microsoft Excel worksheet that was easier for the units 

to complete, and with nearly zero errors. The report 

was also easier for TF30 staff to collect and enter error 

free into the summary worksheet. Automatic totals 

made responding to inquiries and analyzing data 

almost effortless. Due to the elimination of specific 

identifying information, units could submit the report 

over nonsecured means. 

Completing the COSC-WARS summary report 

often seemed a daunting task because of the length. 

However, COSC personnel were provided with various methods of explanation that included a decision 

diagram and line-by-line explanations. The more 

problematic terms such as “walk-about” and “COSR 

contact” were also explained. 

Keeping Statistics

Psychiatric casualty statistics were frequently requested from all levels of leadership, from TF30 Med 

through MNF–I. Prior to OIF 05-07, most casualty 

statistics that were reported were based on the daily 

figures from the Level III hospitals, which included 

inpatient hospitalizations and inpatient and outpatient evacuations. This resulted in underreporting the 

number of evacuations, as outpatient evacuations also 

occurred from the divisions and Level II clinics. This 
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

realization led to the creation of a new database, the 

Mental Health Casualty Tracker for OIF (MHCTO) 

during OIF 05-07. The MHCTO utilized six sources of 

information: (1) the daily inpatient census report for 

theater, (2) the daily inpatient census report for garrison, (3) the US Transportation Command Regulating 

and Command and Control Evacuation System, (4) 

the Joint Patient Tracking Application, (5) the Command Critical Intelligence Requirements, and (6) the 

MNC–I casualty report. Combining these separate data 

sources into one database allowed for the tracking of 

all inpatient mental health admissions in theater, all 

inpatient and outpatient air evacuations, and all suicide completions and suicide attempts that resulted in 

hospitalization or air evacuation. Because all the notes 

were electronic and had to be read to fill in the data 

fields, this also served as a quality assurance measure 

for all air evacuations. 

Suicide statistics were also frequently requested. In 

addition to tracking the raw numbers, it became apparent that there was a lot of useful information available 

in the Army Suicide Event Reports (ASER) that had 

already been completed for suicide events occurring in 

Iraq. The TF30 Med mental health consultant was able 

to analyze the raw data on all ASERs submitted for the 

Iraq theater of operations. As a result of this analysis, it 

was clear that providers had different interpretations 

of certain questions, which resulted in lower quality 

data. The TF30 Med mental health consultant made 

the ASER a higher priority and took a more proactive 

stance toward completed ASER submissions for all 

suicide attempts. With the help of the MHCTO, suicide 

attempts were now easier to track, so corresponding 

mental health providers were now contacted and 

informed of the expectation that the ASER would be 

submitted. Certain providers even sent ASER drafts to 

the mental health consultant to ensure accuracy. With 

more providers submitting more accurate ASERs, the 

accuracy of the suicide statistics for OIF 05-07 was 

greatly improved over previous years. Additionally, 

in the clinical background information gathered from 

the MHCTO and the ASER it was possible to read 

about actual incidents in which buddy aid—the basis 

for Army suicide prevention programs—was successfully administered and resulted in a saved life. Every 

month, a new vignette was chosen and disseminated 

at the TF30 Med Battle Update Brief.

Quality Assurance 

Having standardized practices and theater-wide 

policies in place was the first step toward assuring 

that quality care was consistently being provided 

across theater. The next logical step was to devise 

a way to ensure these policies were available and 

understood by those to whom they applied. By OIF 

05-07 the electronic communication systems had been 

greatly improved and allowed wide dissemination of 

information. It was now possible to send the policies, 

through command channels, all the way down to the 

individual provider. Additionally, the TF30 Med chief 

of professional services held a regular teleconference 

in which the deputy chiefs of clinical services from all 

the CSHs and the multifunctional medical brigade, in 

addition to the division surgeons, were invited. The 

mental health consultant regularly disseminated new 

theater-wide mental health policies through this manner, which allowed for a dynamic discussion to take 

place prior to the implementation of new policies. 

One such policy that was initiated during OIF 05-

07 was the guidelines for psychotropic prescribing in 

theater. The purpose of the guidelines was threefold. 

First, they set a standard with which most psychiatrists 

should already be familiar, but primary care providers 

may not. Secondly, they clearly stated that psychiatrists 

and certain psychiatric advanced nurse practitioners 

were the only mental health providers credentialed 

to prescribe psychotropic medication. (Anecdotally, 

medical providers had asked social workers and psychologists to write prescriptions, unaware that this was 

not within their scope of practice.) Finally, the guidelines offered an information paper for commanders, 

who frequently asked providers which of their soldiers 

were taking psychotropic medications. There seemed 

to be a misperception that starting someone on an antidepressant would lead the soldier to be nonmission 

capable. (Also anecdotally, many soldiers reported 

feeling more mission capable once their depressive 

or anxiety symptoms were under better control from 

medication.) 

Another method used to support subordinate units 

in ensuring quality of care was the staff assistance visit 

(SAV). TF30 Med conducted SAVs to gain a first-hand 

awareness of “best practices,” make recommendations 

where indicated, and answer questions. It provided the 

valuable opportunity to get to know the combat stress 

control teams and COSC/mental health personnel, 

their locations, and so forth. A checklist was developed 

to standardize the questions asked during the visit and 

to help clarify TF30 Med’s priorities. The visit was not 

meant to be punitive, but rather to offer assistance in 

meeting expectations outlined in TF30 Med policies 

and procedures. The SAV was coordinated with the 

direct reporting unit commanders or deputy chiefs 

of clinical services, allowing a visit to each CSC unit 

headquarters and restoration center, mental health 

personnel at the CSHs, and some area support medical company mental health personnel. It also allowed 
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Combat and Operational Behavioral Health

the headquarters to obtain input from subordinates. 

In conjunction with these visits, TF30 Med personnel 

acted as an advocate for COSC/mental health at higher 

levels. A good example of this occurred after an SAV to 

one of the CSHs. Based on input from the mental health 

personnel, the TF30 Med mental health officer could 

ensure that the need of CSH mental health personnel 

for appropriate space was heard at brigade headquarters. This included current and future facility needs. 

Toward the end of its rotation, TF30 Med decided 

to institute more regular, formalized, quality control 

through the establishment of monthly mental health 

chart reviews. Up until this point, peer reviews were inconsistently being done and most were informally conducted, usually consisting of case discussions. The first 

question to be addressed was which encounters were 

to be reviewed: COSR, psychiatric mental disorder 

(PMD), or both. Because providers were presumably 

more familiar with the behavioral health standards of 

the Joint Commission, and because there was more ambiguity in the COSR charting requirements, it seemed 

reasonable to start with chart reviews on the PMD 

charts rather than the COSR charts. The next issue was 

determining a standard for mental health charting in 

theater. The MNC–I surgeon/TF30 Med commander’s 

directive was that the standards in theater be the same 

as those for garrison. Even though the Joint Commission would never visit the combat zone, its standards 

were based on patient safety issues, which still applied 

in theater. A garrison mental health chart review was 

then e-mailed to all the CSHs and CSC commanders 

for feedback on which standards did not apply to the 

theater. After a consensus was reached, the next step 

was to determine how isolated clinics could perform 

the review. It was decided that if there was only one 

provider at a certain location, that provider was expected to have another medical provider conduct the 

chart review. This only happened on rare occasions 

because of the frequency of CSC commander SAVs. 

The results of the reviews were then e-mailed to the 

mental health consultant, who could verify to the TF30 

Med commander that they were being done.

As a result of the mental health peer review, there 

was now one standard for mental health charting in 

the combat zone. This brought up some issues that 

were previously not being addressed. First, it became 

apparent that most reserve providers were unaware of 

the requirement for cosigning the notes of their mental 

health technicians. Not having a civilian equivalent of 

an outpatient mental health technician, this was understandable. Additionally, more questions were being 

asked about what was in a specific provider’s scope 

of practice, such as whether or not a psychiatric nurse 

practitioner was able to prescribe medications. Finally, 

as mentioned previously, with more forensic psychiatry requests, there was an increased likelihood that 

psychiatric charts could be subpoenaed. Chart reviews 

indicated that this, along with limits of confidentiality, 

was not always discussed with patients. 

Another quality assurance initiative developed by 

TF30 Med involved a review of the scope of practice of 

unlicensed providers, such as medics and other health 

technicians. Upon learning that there were unlicensed 

psychologists in theater who required regular supervision, the TF30 Med commander began discussions 

with the Office of The Surgeon General and Medical 

Command about this practice. Ultimately, the decision 

was made that no further unlicensed psychologists 

would deploy to the Iraq theater of operations. The 

mental health community was not prepared for this 

policy change. In the immediate aftermath of this, 

major changes had to be made in assignments. The 

result was an acute shortage of psychologists, which 

led to psychiatrists or psychiatric nurse practitioners 

being used to fill vacant deployment psychologist 

slots. According to the director, Behavioral Health 

Proponency, Office of The Surgeon General,15 training 

for psychologists in the last year has been extended to 

2 years to prevent unlicensed psychologists from being 

assigned to deployable positions. 

ROLE OF THE MEDIA 

The quality of information provided to the media 

is important and can have widespread effect on the 

mission. To this end, the TF30 Med COSC and mental 

health consultants worked closely with the task force 

in developing a Public Affairs Office policy as it related to COSC operations in theater. This ensured the 

protection of the service members being supported, 

and provided guidelines for the providers on releasing information. This policy also covered any articles 

or research requests from providers in theater. Headquarters has a broader awareness of events across the 

theater, is in a better position to ensure the information 

is consistent with the overall mission objectives of OIF, 

and that release of this information is compliant with 

operational security requirements. By having TF30 

Med answer incoming questions, it allowed providers in the field to focus on their mission of providing 

COSC/mental health services to the force. 

Although it is impossible to determine exactly how 

much the media influenced the daily operations of 

mental health providers during OIF 05-07, there were 

headlines that commanded the attention of soldiers 

and military leadership alike. These media reports 

ultimately translated into combat mental health prac-
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Provision of Mental Health Services in Operation Iraqi Freedom 05-07

tices being more carefully scrutinized and greater accountability of mental healthcare providers, neither of 

which is necessarily a negative result. In this section a 

closer look will be taken at some of the more significant 

headlines during OIF 05-07 and how they potentially 

impacted the mental health community. 

Reporting Increase in Suicide Rates

In April 2006, the 2005 Army suicide rate was released and became widely quoted in the press, the media, and on the Internet. The Associated Press reported 

that 83 soldiers killed themselves in 2005, the greatest 

number of Army suicides since 1993.16 The following 

month, The Hartford Courant ran a series entitled “Mentally Unfit, Forced to Fight.” In an article in the series, 

titled “Potent Mixture: Zoloft and a Rifle,” the authors 

discuss case reports of soldiers prescribed medication 

in a combat zone who later committed suicide. The 

article suggested that psychotropic medications were 

being prescribed too freely in theater and were related 

to suicides.17

The release of the 2005 suicide rate generated considerable interest in the topic of suicide and, specifically, how it applied to the conflict. In “Zoloft and a 

Rifle,” the authors used the increased suicide rate to 

criticize the combat effort and point out flaws with 

military mental health. The article sent a mixed message to soldiers in theater—the authors cared about 

soldiers and wanted to honor those who committed 

suicide, yet if they were having problems, health 

providers in theater would only make them worse. 

Little attention was paid to the theater suicide prevention programs already in existence, or the power 

of buddy aid. 

As the reporting of the increase in the suicide rate 

spread throughout the media, TF30 Med and MNC–I 

received additional inquiries related to suicide statistics. By April, the MHCTO was fully operational, 

which enabled the TF30 Med to support the requests 

for information. As mentioned previously, studying 

the ASERs also provided valuable information about 

theater suicides that was frequently requested by 

mental health providers and was presented at theater 

mental health conferences. 

Although dramatic, “Zoloft and a Rifle” did bring 

up a valuable point regarding how nonpsychiatrists 

were treating mental illness. An informal survey of 

physician assistants in theater demonstrated that comfort levels with the use of psychotropics varied greatly. 

This prompted the MNC–I surgeon to commission the 

psychotropic prescribing guidelines, which came out 

as a MNC–I fragmentary order during the summer of 

2006. The guidelines were meant to assist providers in 

better understanding psychotropic prescribing in the 

combat zone and included information about monitoring laboratory reports, side effects, drug interactions, 

standard of care for treating psychiatric disorders, 

and what to tell commanders requesting information 

about their soldiers.

Airing the Baghdad ER Special

Baghdad ER is a Home Box Office special that aired 

May 21, 2006. It is a graphic and emotional account 

of the realities of combat through the experiences of 

a CSH. Yet graphic documentaries also have other 

implications. They can serve as powerful reminders 

or “triggers” for soldiers who have been exposed to 

trauma. Baghad ER is indeed a harsh reminder of the 

brutal realities of combat. 

Lieutenant General Kevin Kiley, then the Army 

Surgeon General, directed Army mental health experts to prepare for the impact of Baghdad ER. Said 

Kiley, ”This film will have a strong impact on viewers 

and may cause anxiety for some soldiers and family 

members.”18 He suggested that mental health facilities 

should extend their treatment hours and reach out to 

the troops proactively. The Army recognized that it had 

to address the near-term implication of the program 

and also recognized that the families and soldiers who 

might be traumatized by this media event might also 

have on-going psychological issues.

The theater mental health consultant wrote the 

following talking points,which were disseminated in 

theater prior to the airing of the program.

1. Most soldiers returning from deployment 

seek to avoid images and media coverage related to the global war on terrorism. Soldiers 

in theater will have limited access to the HBO 

special. The greatest impact will likely be on 

soldiers’ families, brought about by fears 

raised from direct viewing or the publicity 

afterwards.

2. Technology has significantly altered communications with the home front, with increased 

accessibility and frequency. Mental health 

providers have noticed spouses who are coping poorly can significantly affect the morale 

of their deployed soldier.

3. In the days and weeks following the program 

airing, commanders should:

	 	 •	 Check in with their soldiers to see how their

spouses are coping.

	 	 •	 Consider limiting contact immediately

before a mission or have mental health assets or chaplains available during popular 

calling periods.

	 	 •	 Be aware of common warning signs of
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Combat and Operational Behavioral Health

increased stress, such as soldiers becoming isolated, becoming easily angered, or 

seeming distracted, and a change in work 

performance.

	 	 •	 Encourage soldiers to talk with their peers,

chaplains, or mental health providers if 

they start to feel more stressed after talking 

with family members.

4. There are assets available in stay-behind elements to assist family members coping with a 

soldier’s deployment, such as TRICARE and 

Military OneSource. Additionally, commanders should encourage active participation in 

family readiness groups, as this provides a 

unique opportunity for families with a common interest to support each other.19

Based on conversations with CSC providers, the 

aftereffects from Baghdad ER were not as intense in 

theater as was expected. Nevertheless, the event was 

a clear example of how the media influenced mental 

health providers in theater during OIF 05-07.

Media Coverage of Civilian Deaths in Haditha

In November 2005, Marines killed 24 Iraqi civilians 

in the town of Haditha, Iraq. Specifics of the story 

were not immediately available, but eventually it 

was reported that the killings were in retribution for a 

roadside bomb in which a Marine had been killed. The 

Washington Post wrote that “[t]wo US military boards 

are investigating the incident as potentially the gravest 

violation of the law of war by US forces in the 3-yearold conflict in Iraq.”20

Haditha was a complex media event because it 

lasted for months, as each new revelation had its turn 

in the media frenzy that followed. Mental health experts were often interviewed to try to make sense of 

the killings. The psychiatrist Robert Jay Lifton explains 

that “atrocity is a group activity.” Therefore, he writes 

at Editor & Publisher “[t]o attribute the likely massacre at Haditha to ‘a few bad apples’ or to ‘individual 

failures’ is poor psychology and self-serving moralism.”21 Lifton says that the Haditha incident can be 

understood as what he calls “an atrocity-producing 

situation,” which he defines as “one so structured, 

psychologically and militarily, that ordinary people, 

men or women no better or worse than you or I, can 

commit atrocities.” 

Interest in combat ethics grew substantially during OIF 05-07 as a result of the killings in Haditha. 

All subsequent war misbehavior was often presented 

in comparison to that event. MHAT-IV was commissioned by the MNF–I commander with the request to 

investigate combat ethics. The MHAT-IV accomplished 

this through survey questions and focus group discussions. The final report includes information about 

behaviors during deployment and discusses ideas for 

teaching ethics. Recommendations include incorporating battlefield ethics in all behavioral health counseling and anger management classes, especially when 

conducted in a combat zone.5

 These recommendations 

could substantially increase the scope of duties of 

deployed mental health providers.

SUMMARY

This chapter has explored how the provision of 

mental health services advanced during OIF 05-07 as 

a result of a more mature battlefield. Without having 

to worry about basic necessities or establishing new 

clinics, mental health providers were able to take 

on additional missions, such as serving as MROs or 

on sexual assault review boards, responding to the 

media, and meeting standards of care that were the 

same as garrison mental health clinics. The provision 

of mental health consultation to TF30 Med, MNC–

I, and MNF–I leadership was also able to advance 

because providers had become adept at mastering 

the basics. Although not mentioned specifically in 

this chapter, brevity, immediacy, contact, expectancy, 

proximity, and simplicity (BICEPS) remained as the 

cornerstone of mental health services in the combat 

zone during OIF 05-07. The fact that they did not 

require alterations speaks to their universality. As 

future battlefields will likely look as different from 

OIF as OIF does from World War II, it is reassuring 

to know that there will be at least one constant in the 

provision of mental health services. That constant 

is the BICEPS approach to combat and operational 

stress reactions.

REFERENCES

1. Caravalho J. 30th Medical Brigade After-Action Review for OIF-I. October 16, 2004. 30th Medical Brigade Lessons Learned 

Database. Accessed December 11, 2006.

2. US Department of the Army. Combat Stress Control. Washington, DC: DA; June 6, 2006. Field Manual 4-02.51.
149

Provision of Mental Health Services in Operation Iraqi Freedom 05-07

3. Jones F, Sparacino L, Wilcox V, Rothberg J, Stokes J, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbooks of 

Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995.

4. Jones F, Sparacino L, Wilcox V, Rothberg J, eds. Military Psychiatry: Preparing in Peace for War. In: Zajtchuk R, Bellamy 

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

Borden Institute; 1994.

5. Mental Health Advisory Team (MHAT) IV. Operation Iraqi Freedom 05-07. Office of the Surgeon, Multi-National 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.

6. Tan M. Gangs in uniform. Army Times. September 3, 2007:14.

7. Mental Health Advisory Team (MHAT). Operation Iraqi Freedom (OIF). Report. The US Army Surgeon General and 

HQDA G-1. December 16, 2003. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 

4, 2008.

8. United States Department of Defense Sexual Assault Prevention and Response Web site. Available at: http://www.

sapr.mil. Accessed September 9, 2008.

9. All Army Activity (ALARACT) Message No. 087/2006. Drug Testing During Deployments. April 26, 2006.

10. US Army Medcial Command Military MRO Information Pamphlet, May 30, 2006. 

11. Chagalis GP. Army Substance Abuse Program Guidance for Deployed Commanders. Information Paper, April 6, 2004. Available at: www.sbasap.com/files/deployed_cdrs.pdf. Accessed September 9, 2008.

12. Mental Health Advisory Team (MHAT-II). Operation Iraqi Freedom (OIF-II). Report. The US Army Surgeon General. 

January 30, 2005. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

13. Patient Administration Systems and Biostatistics Activity Memorandum. Consolidation of Deployment Medical Documentation. October 21, 2005. 

14. US Department of the Army. Medical Record Administration and Health Care Documentation. Washington, DC: DA; June 

17, 2008. Army Regulation 40-66.

15. Ritchie EC. Colonel, Medical Corps, US Army. Personal communication, February 2009.

16. Army suicides hit highest level since 1993. Associated Press. April 21, 2006. Available at: http://www.msnbc.msn.com/

id/12428185. Accessed September 9, 2008.

17. Chedekel L, Kauffman M. Potent mixture: Zoloft & a rifle. Hartford Courant. May 16, 2006:A1. 

18. Starr B. Army: HBO documentary could trigger stress disorder [transcript]. Entertainment. CNN television. May 15, 

2006.

19. Cooper MA. Major, Medical Corps, US Army. Personal communication, November 2008.

20. Knickmeyer E. In Haditha, memories of a massacre: Iraqi townspeople describe slaying of 24 civilians by Marines 

in Nov. 19 incident. Washington Post. May 27, 2006:A01. Available at: http://www.washingtonpost.com/wp-dyn/

content/article/2006/05/26/AR2006052602069.html. Accessed September 9, 2008.

21. Lifton RJ. The psychology of atrocity. Editor and Publisher. June 4, 2006. 
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151

Psychiatric Medications in Military Operations

Chapter 10

psychiatric medications in 

military operations

BRETT J. SCHNEIDER, MD*; JOHN C. BRADLEY, MD†; CHRISTOPHER H. WARNER, MD‡; and DAVID M. 

BENEDEK, MD§

INTRODUCTION

HISTORY OF PSYCHOTROPIC MEDICATION USE IN DEPLOYMENT

DOCTRINE AND POLICY

PREDEPLOYMENT ACTIONS

Psychiatric Medication Clearance for Deployment

Psychopharmacologic Planning for Deployment

DISPENSING PSYCHIATRIC MEDICATION IN THEATER

PHARMACOLOGIC TREATMENT OF MENTAL HEALTH CONDITIONS DURING 

DEPLOYMENT

Mood Disorders

Anxiety Disorders

Psychotic Disorders and Acute Agitation

Insomnia

ETHICAL ISSUES

Summary

*Lieutenant Colonel, Medical Corps, US Army; Deputy Chief, Department of Psychiatry, Building 61, Child and Adolescent Psychiatry Clinic, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307 

†

Colonel, Medical Corps, US Army; Chair, Department of Psychiatry, Borden Pavilion, Room 2022, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307; Psychiatry Consultant, North Atlantic Regional Medical Command and Vice Chair, Department of Psychiatry, 

Uniformed Services University of the Health Sciences, Bethesda, Maryland 

‡

Major, Medical Corps, US Army; Chief, Department of Behavioral Medicine, Winn Army Community Hospital, Building 9242, Room 20, 1083 Worcester 

Drive, Fort Stewart, Georgia 31324; formerly, Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

§

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814

A portion of this chapter has been published as: Benedek DM, Schneider BJ, Bradley JC. Psychiatric medications for deployment: an update. 

Mil Med. 2007;172:681–685.
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Combat and Operational Behavioral Health

INTRODUCTION

Until the mid-1990s, psychotropic medication use 

for the treatment of ongoing mental disorders during 

combat operations was uncommon. Stimulants and 

other psychotropic medications were used, at times, 

to enhance the vigilance and performance of fatigued 

service members. However, in the mid-1990s the introduction of medications with more favorable side-effect 

profiles—particularly the selective serotonin reuptake 

inhibitors (SSRIs)—revolutionized the role of medications in the practice of military operational psychiatry. 

The widespread incorporation of these medications 

into civilian and military garrison psychiatric practice 

has resulted in an evolution in operational practice 

such that medication use in combat operations now 

focuses on the capacity for soldiers with symptoms 

of psychiatric illness to return to their premorbid level 

of functioning, rather than on efforts to “enhance” 

baseline performance. 

Before the current conflicts in Iraq and Afghanistan, recent experiences either predated the current 

usage patterns of medications in psychiatric care, or 

were limited in duration (the Persian Gulf War) or 

scope (Bosnia, Kosovo, Somalia), so that few service 

members were affected. As a result, comprehensive 

experience and doctrine for the use of psychotropic 

medications consistent with current practice patterns 

in psychiatry were not feasible. This chapter will 

focus on the use of psychotropic medications during 

deployment. An overview of the history of the usage 

of medications will highlight the doctrinal evolution. 

Current practice guidance will be outlined and as yet 

unresolved questions addressed.

HISTORY OF PSYCHOTROPIC MEDICATION USE IN DEPLOYMENT

The ancient Assyrians, Egyptians, and Greeks 

reportedly used opiates before and during battles to 

sustain or enhance bravery and courage.1

 Other drugs 

studied or used to enhance combat performance include ergot alkaloids, cannabis, amphetamines, and 

other stimulants; Dramamine (McNeil-PPC Inc, Morris 

Plains, NJ) and other antihistamines; benzodiazepines; 

and l-tryptophan.1 The most extensive modern use of 

performance-enhancing drugs occurred during World 

War II by German, Japanese, and English soldiers.2 Amphetamines were noted to be useful not only to stave 

off fatigue and drowsiness but also to improve memory, 

concentration, physical strength, and endurance.3–5

During the Vietnam conflict, methylphenidate (Ritalin [Novartis AG, Basel, Switzerland]) and sometimes 

dextroamphetamine (Dexedrine [GlaxoSmithKline, 

Philadelphia, Pa]) were standard-issue drugs carried 

by long-range reconnaissance patrol soldiers, who 

reported the drugs’ usefulness when they developed 

fatigue at the end of missions and had to return rapidly 

to base camp. Mild rebound depression and fatigue 

after discontinuation were the only reported adverse 

effects.1

 Sedatives were also explored as a method to 

improve performance in anxiety-producing situations, 

such as paratroopers making low-altitude jumps, or to 

reduce the emotional tension of young soldiers when 

guns were fired.6

Although the concept of using medications for 

performance enhancement remains an area of ongoing research, the documented usage of psychotropic 

medications to treat symptoms associated with current 

psychiatric diagnoses in soldiers actively involved in 

combat is limited. In earlier conflicts, limited experience using psychotropic medications to treat anxiety 

symptoms has been reported. These conditions have 

been treated with sedatives ranging from chloral hydrate and bromides in World War I to barbiturates in 

World War II and self-prescribed alcohol, cannabis, 

and heroin in Vietnam.1

 However, discussions of usage commented mostly on the medications’ unwanted 

side effects, such as sedation, and the concern that their 

usage would lead to the fixation of a sickness role suggested by taking medication.

In 1978 Datel and Johnson7 reviewed the usage of 

psychotropic medications by physicians deployed to 

Vietnam in 1967. They surveyed a group of mostly 

primary care physicians about how they prescribed 28 

different psychotropic medications, including “major 

tranquilizers,” “minor tranquilizers,” antidepressants, stimulants, and sedatives for a 30-day period 

during the summer of that year. The most commonly 

utilized “psychotropic medication” was Compazine 

(GlaxoSmithKline) for gastroenteritis, and anxiety 

and insomnia were the most frequent mental health 

reasons for prescribing medications. Minor tranquilizers such as Equanil (Wyeth, Madison, NJ); Librium 

(Hoffman-LaRoche Inc, Nutley, NJ); Valium (HoffmanLaRoche Inc); and Vistaril (Pfizer Inc, New York, NY) 

were most frequently prescribed for symptoms of 

anxiety, with Librium accounting for the majority of 

prescriptions (65%) and Thorazine (GlaxoSmithKline) 

accounting for most of the major tranquilizer prescriptions (86%).The authors noted that a “surprisingly low 

frequency” of depression was an indication for the usage of psychotropic medications. In general, the drugs 

that were utilized were perceived by the prescribing 

physicians as being quite efficacious.7 Six medications (Prolixin [Bristol-Myers Squibb, Princeton, NJ]; 
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Psychiatric Medications in Military Operations

Vesprin [Bristol-Myers Squibb]; Nardil [Pfizer]; Parnate [GlaxoSmithKline], Taractan [Hoffman-LaRoche 

Inc]; and desipramine) were not prescribed by any of 

the reporting physicians.

The first Israeli reports of operational use of tricyclic 

antidepressants in combat soldiers occurred during the 

1982 war with Lebanon. Belenky noted that in 1973 

the Israelis created a policy prohibiting forward use 

of medications and even hypnosis, expressing concern about the potential effect of this policy on battle 

fatigue return-to-duty rates.8,9 Belenky advocated for 

longer-term military treatment facilities in theater, but 

cautioned against placing soldiers on psychotropic 

medications in forward deployed areas because of 

the possibility of side effects that might interfere with 

psychomotor performance or impair judgment in 

dangerous situations. He also noted potential medical 

risks from side effects in the field environment and 

problems with resupply.8

No reports have been published on the utilization 

rates or rationale for usage of psychotropic medications during the Persian Gulf War (1991), possibly 

because of the lack of prolonged combat exposure, or 

possibly because the military stress control doctrine 

at the time emphasized triage and normalization, 

discussing the use of psychotropic medications only 

in emergency situations. Staudenmeier and Bacon10

reviewed the history and role of combat stress units 

during deployments and noted that one unit, the 

528th, conducted 514 psychiatric evaluations during 

the Persian Gulf War. Of those evaluated, 24% were 

held for treatment and 3.5% were evacuated. Although 

this information demonstrated that combat stress units 

were being utilized, no data were given on the usage 

of medications among service members identified for 

treatment or evacuation.10

Ritchie11 described a decision-making process for 

choosing which psychotropic medications to bring 

and use in Somalia during Operation Restore Hope 

(1993). Ritchie recommended considering two broad 

categories: emergency and maintenance medications. The former group included benzodiazepines 

(diazepam and lorazepam) and neuroleptics (haloperidol). The latter included antidepressants (“one 

tricyclic antidepressant and one SSRI”); anxiolytics 

(buspirone, benzodiazepines, or antidepressants); and 

sedatives (temazepam, triazolam, and trazodone). The 

rationale for bringing just one tricyclic antidepressant 

and one SSRI mirrored clinical practice at the time, 

which suggested that patients being treated by one 

antidepressant could be switched to another with little 

problem. Subsequently, practitioners have recognized 

that frequently patients only respond to a particular 

antidepressant or have side effects with one SSRI but 

not another. Ritchie recommended that medications 

such as lithium, carbamazepine, valproic acid, and 

all monoamine oxidase inhibitors be avoided during 

deployment because of problems with safety and 

monitoring.11

Pincus and Benedek12 summarized the integrated 

use of combat stress detachments and division mental 

health (DMH) assets during Operation Joint Endeavor 

in Bosnia during 1995. The article does not specifically 

discuss medication usage in detail, but it considered 

the mission, a year-long peacekeeping operation, as 

more similar to the practice of garrison mental health 

than to other deployment environments.12 Garrison 

mental health in 1995 typically consisted of a DMH 

team providing routine outpatient mental healthcare, 

including using psychotropic medications as indicated 

for the treatment of disorders seen in routine outpatient 

clinics. This practice suggests that mental health assets 

deployed during Operation Joint Endeavor utilized 

psychotropic medications routinely during the more 

than 3,000 outpatient contacts made over the year-long 

deployment. The authors acknowledged use consistent with garrison psychiatric practice in subsequent 

descriptions of their deployments.12

Warner et al13 reviewed the utilization of one DMH 

activity during deployment to Operation Iraqi Freedom (OIF) in 2005. The authors noted 5,542 clinical 

contacts, of which 29.8% were for psychiatric mental 

disorders and the other 70.2% were for combat operational stress reactions. The top two psychiatric mental 

disorders in theater were generalized anxiety disorder 

(42.4%) and major depressive disorder (33.4%). The 

authors defined a “mature theater” as permitting the 

ongoing management of psychiatric disorders with 

psychotropic medications, although personnel were 

generally restricted to the use of SSRIs and mild hypnotics in theater. The article did not report rates of how 

many soldiers were prescribed or took the medications in theater; however, the account demonstrated 

the incorporation of practice patterns established in 

more recent peacekeeping operations (Bosnia) into 

psychiatric practice in the combat environment, with 

service members receiving treatment for ongoing 

mental health issues beyond the scope of combat operational stress.13

In July 2007, Schneider, Bradley, and Benedek14

revisited the question of a rationale for choosing a 

psychotropic formulary for military operations. Recommendations were based on a combined 18 months of experience by the authors as psychiatrists deployed with 

combat stress control detachments during the first and 

third rotations to Iraq. The authors discussed the evolution of treatment of combat operational stress casualties 

from triage and nonpharmacologic, treatment-forward 

psychiatry principles to a role more consistent with 

contemporary outpatient psychiatric practices, noting 
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Combat and Operational Behavioral Health

some caveats related to environmental and operational 

concerns. From their perspective, the nature of combat 

had changed. The idea that soldiers could be removed 

from the front lines and treated in the rear echelons no 

longer worked, because no true rear echelons exist in 

Iraq. It was now important to treat some mood and 

anxiety disorders as far forward as possible.14

Schneider and colleagues also noted that the increased dependence on National Guard and Reserve 

soldiers meant that the Army was receiving personnel 

who were treated according to civilian community 

standards rather than military readiness standards 

concerning prescriptions for SSRIs, atypical antidepressants, and antianxiety medications. This resulted 

in an increased requirement for available medications 

in theater. They suggested that most routine outpatient psychiatric conditions might be managed with 

medications and therapy in the combat zone, with 

the caveat of factoring in the “limitations inherent in 

the operational environment,”14(p685) such as military 

occupation, travel limitations for follow-up, and the 

restricted ability to educate the soldier and command 

about the medications’ potential risks, benefits, side 

effects, and possible effect on mission requirements. 

They proposed a psychotropic formulary of at least 24 

medications under the categories of antidepressants/

antianxiety medications, benzodiazepines, antipsychotics/antimanics, sleep medications, adrenergic 

agents, and attention deficit hyperactivity disorder 

medications (Table 10-1).14

The level of comfort with the use of psychotropic 

medications in combat has mirrored trends in the 

larger US society. The change in psychotropic medication use from the last major extended US conflict (Vietnam) to current operations in Afghanistan and Iraq is 

well illustrated by a comparison between Datel and 

Johnson’s questionnaire and the recent recommended 

psychotropic formulary for OIF by Schneider, Bradley, 

and Benedek. The only medications common to both 

documents are Ritalin and Dexedrine.7,14

DOCTRINE AND POLICY

US Army doctrine on the use of psychotropic medication has evolved significantly in the last 20 years. The 

initial Army field manual (FM) on combat stress control, Combat Stress Control in a Theater of Operations (FM 

8-51),15 published in 1994 and updated in 1998, focused 

on triage and nonpharmacologic interventions aimed 

at normalizing and minimizing combat stress. Little 

guidance was provided on the role and usage of psychotropic medications. The word “medication” occurs 

25 times in this document, which contains 9 chapters. 

Most of these references discuss the use of medications 

in emergency situations when medication might be 

needed to calm an agitated service member. Chapter 

3, section 8, states that “medication is prescribed sparingly and only when needed to temporarily support 

sleep or manage disruptive symptoms.”15(p3-8) Chapter 

6, section 3, discusses how to manage a service member who deploys after having been “diagnosed with 

psychiatric disorders by a civilian physician,” advising 

the clinician as follows:

These soldiers may hide the fact that they are taking 

psychotherapeutic medication to keep the diagnosis 

off their military record. Once in the theater they may 

experience a relapse or self-refer themselves to an 

MTF [medical treatment facility] when their medication supply is exhausted. The evaluating psychiatrist 

must determine if the soldier can function without 

the medication. If the soldier requires medication, can 

he be re-stabilized on a drug which can be provided 

in the theater? Can the drug be given without risk of 

harmful side effects? If the alternatives are not feasible, 

the soldier must be evacuated out of the theater.15(p6-13)

During the spring and summer of 2004, the Army 

mental health community recognized, based on experience in the first year of OIF, that the FM required 

some revisions based on the changes in overall Army 

doctrine and lessons learned from the first long-term 

sustained conflict in more than 30 years. In the new 

manual, Combat and Operational Stress Control (FM 

4-02.51),16 published in 2006, the word “medication” 

occurs 30 times in an 11-chapter manual. Although the 

overall number of times medication usage is discussed 

barely eclipses the number of times it was mentioned 

in the previous manual, a change in the accepted role 

of medications can be seen. Three sections in the new 

manual highlight the gradual move towards acceptance of psychotropic medication usage in a combat 

zone. Section 8-21 discusses how a service member 

may have both a combat stress reaction and a mental 

disorder, and directs clinicians to use clinical judgment 

and consultation to help “distinguish among these 

sometimes overlapping conditions.”16(p8-6) When a 

service member presents with reemerging symptoms 

of a previously diagnosed mental disorder or for refill 

of previously prescribed psychotropic medication, 

“deferral of diagnosis is preferred, but diagnosis can 

be considered.”16(p8-6) Sections 9-8 and 11-1 outline 

doctrinal changes in the role of medication in treating 

service members diagnosed with mental disorders 

while deployed. Section 9-8 states:

Ongoing treatment and/or therapeutic modalities are essential to improving a Soldier’s chances 

to RTD [return to duty] whether in theater or af-
155

Psychiatric Medications in Military Operations

Table 10-1

Example Psychiatric Formulary for Deployment 

Medication Amount

Antidepressants/Antianxiety Medications

Citalopram 20 mg 15 bottles

Sertraline 100 mg 30 bottles

Prozac* 10 mg 5 bottles

Paroxetine 20 mg 5 bottles

Venlafaxine XR 37.5 mg 10 bottles (good for initiating treatment)

Venlafaxine XR 150 mg 10 bottles

Bupropion XL 150 mg 10 bottles (more if planning to do smoking cessation)

Bupropion XL 75 mg 10 bottles (good for initiating treatment)

Mirtazapine 20 mg 10 bottles

Benzodiazepines

Lorazepam 1 mg tablets 30 bottles

Clonazepam 1 mg tablets 30 bottles

Lorazepam 2 mg injectable 30 dosages (must be refrigerated)

Antipsychotics/Antimanics

Risperidone 1 mg tablets 10 bottles

Quetiapine 100 mg tablets 30 bottles (can be used off-label for PTSD, insomnia)

Olanzapine 5 mg tablets 10 bottles

Haloperidol injectable 30 dosages

Sleep Medications

Trazodone 100 mg tablets 30 bottles

Zolpidem 10 mg tablets 30 bottles

Adrenergic Agents

Clonidine 0.1 mg tablets 10 bottles (may be better for startle, flashbacks in PTSD)

Prazosin 1 mg tablets 10 bottles (may be better for nightmares in PTSD)

Propranolol 20 mg tablets 10 bottles

ADHD Medications

Atomoxetine 20 mg tablets 10 bottles

Methylphenidate or Dexedrine† 10 bottles (may want to have combination of long-/short-acting forms)

*Eli Lilly and Company, Indianapolis, Ind

†

GlaxoSmithKline, Philadelphia, Pa

ADHD: attention deficit hyperactivity disorder

PTSD: posttraumatic stress disorder

Reproduced from: Schneider BJ, Bradley JC, Benedek DM. Psychiatric medications for deployment: an update. Mil Med. 2007;172:683.

ter evacuation. Therapeutic modalities are similar 

to those used on inpatient units, but must remain 

consistent with COSC [combat operational stress 

control] principles. These modalities include medication, individual psychotherapy, group psychotherapy, and appropriate therapeutic occupations.16(p9)

Section 11-1 states:

Behavioral health treatment is provided for Soldiers with behavioral disorders to sustain them 

on duty or to stabilize them for referral/transfer. This is usually brief, time-limited treat-
156

Combat and Operational Behavioral Health

ment as dictated by the operational situation. 

Behavioral health treatment includes counseling, psychotherapy, behavior therapy, occupational therapy, and medication therapy.16(p11) 

Despite this subtle but real evolution of the role of 

psychotropic medications, in the fall of 2006—only 4 

months after the FM was released—the Department of 

Defense developed criteria for psychiatric medications 

use in deployment. The policy was initially released 

in November 2006 in a memorandum titled Policy 

Guidance for Deployment-Limiting Psychiatric Conditions 

and Medications,

17 in response to a congressional directive18 after several media reports of deployed mentally 

ill soldiers who were unstable or taking medications 

without follow-on care. The memorandum outlined 

the restrictions and minimum mental health deployment criteria for all soldiers. Exhibit 10-1 lists key 

factors related to medications in the policy. Although 

the policy does not address how long a soldier on a 

medication for anxiety, depression, or insomnia should 

be monitored, at least 1 month prior to deployment is 

a good time frame for consideration.

Current military operations in war zones such as 

Iraq or Afghanistan no longer have true “rear” areas 

to which soldiers can be evacuated and treated away 

from the threat of attack. The ability to provide more 

definitive treatment to soldiers with certain mood or 

anxiety disorders as far forward as possible is increasingly important in these operations. For most soldiers, 

this means that a battalion aid station, DMH element, 

or a combat stress team is the most easily accessible 

location for treatment that could allow the soldier to 

remain mission capable. 

EXHIBIT 10-1

KEy POints in the NOvember 2006 

Policy Guidance for deploymentlimiting psychiatric conditions 

and medications

•	 Soldiers currently being treated for psychosis or

bipolar disorder are not deployable. 

	 •	 Soldiers who are taking medications that require

laboratory monitoring, such as lithium or valproic 

acid, are not deployable.

	 •	 Soldiers who are taking antipsychotic medications

to control psychotic, bipolar, or chronic insomnia 

conditions are not deployable. 

	 •	 The continued use of psychotropic medications

that are clinically and operationally problematic 

during deployments, including short half-life benzodiazepines and stimulants, should be balanced 

between the necessity for successful functioning in 

the theater of operations and the ability to obtain 

the medication, the potential for withdrawal, and 

the potential for abuse. 

	 •	 If a soldieris placed on a psychotropic medication

within 3 months of deployment, then he/she must 

be improving, stable, and tolerating the medication 

without significant side effect to deploy.

Data source: Assistant Secretary of Defense. Policy Guidance 

for Deployment-Limiting Psychiatric Conditions and Medications. 

Washington, DC: Department of the Army; 2006.

PREDEPLOYMENT ACTIONS

It is imperative that all military primary care and 

mental health providers know where a soldier under 

treatment is in the deployment cycle. The stage of the 

deployment cycle can play a major role in the selection of particular medication choices. Communication 

among the soldier, medical and mental health providers, and the brigade surgeon and brigade behavioral 

health officer is essential to ensure that treatment plans 

are developed without creating additional unnecessary 

limitations for the soldier. Two key actions required 

before deployment are (1) determining if soldiers currently taking psychotropic medications meet the minimum mental health fitness standards for deployment, 

and (2) choosing the medications to make available 

during deployment. 

Psychiatric Medication Clearance for Deployment

To determine if soldiers meet the minimum mental 

health standards for deployment outlined in Exhibit 

10-1, units have added mental health medication 

screening to the predeployment medical screening 

process. In one recently deploying brigade combat 

team, screening questions were added to the face-toface interview by a primary care provider; all soldiers 

taking psychotropic medications were required to meet 

with a behavioral health provider to ensure they met 

deployment requirements. 

Case Study 10-1: A deploying brigade combat team of 

3,312 soldiers implemented the process described above. 

The brigade identified 143 soldiers (4.3%) who were or had 

recently been under the care of a mental health provider, 

and 86 (2.6%) who were currently taking a psychotropic 

medication. Of those taking psychotropic medications, 53 

(1.6%) used antidepressant medications; 11 (0.3%) used 

medications other than antipsychotics for chronic insomnia 

or sleep disturbances; 11 (0.3%) used stimulants for attention 

deficit problems; 8 (0.2%) used antipsychotic medications 
157

Psychiatric Medications in Military Operations

for chronic insomnia; 2 (0.06%) used benzodiazepines for 

chronic anxiety symptoms; and 1 (0.03%) used Depakote 

(Abbott Laboratories, Abbott Park, Ill) for bipolar disorder. Of 

the group on medication, 68 (2.1%) required mental health 

clearance for deployment; of the 68, 4 (0.1%) were delayed 

1 to 2 months before deploying for medication stabilization, 

and 3 (0.09%) were not cleared for deployment because of 

their medications (a tricyclic antidepressant, an antipsychotic, 

and a mood stabilizer). An additional 19 soldiers (0.6%) were 

deemed unqualified for deployment because of their current 

medication even though they were stable and performing 

required duties without impairment.19

For soldiers who are stable but on medications that 

disqualify them from deployment, such as a stimulant 

for attention deficit hyperactivity disorder or a lowdose antipsychotic for chronic insomnia, a waiver 

may be requested. The process is instituted through 

unit medical channels and is requested through the 

combatant command surgeon—the senior ranking 

command surgeon in theater. In most cases, if a unit 

provides a justification, plan for continuation of treatment, and safety assessment, the waiver is likely to be 

granted. Medications generally eligible for a waiver 

are benzodiazepines used for anxiety, stimulants for 

treatment of attention deficit disorder, nonlaboratory 

monitoring mood stabilizing agents for impulse control and nonbipolar mood management, and low-dose 

antipsychotics for sleep and anxiety symptoms. In 

deciding whether to request a waiver, a unit should 

consider the duties and responsibilities the soldiers 

will hold and ensure that they will have ongoing access to mental healthcare throughout deployment. The 

final decision on the waiver is at the discretion of the 

combatant command surgeon. 

Case Study 10-2: The 19 soldiers deemed unqualified 

from the brigade combat team in Case Study 10-1 were 

eligible for waivers. Many were taking stimulants for attention 

deficit problems or low doses of atypical antipsychotics for 

chronic insomnia. The unit leadership deemed that most of 

the soldiers were critical to the mission, and waivers were 

requested for all of them. The waiver requests outlined 

length of time on the medication and how the soldier would 

be followed by mental health services during deployment. 

All soldiers received waivers and deployed. The DMH team 

and the brigade surgeon ensured that each of the soldiers 

was seen on a regular basis (monthly), and after 6 months of 

deployment, all remained in theater, stable, and functioning 

well in their duties.19

Psychopharmacologic Planning for Deployment

A psychiatrist assigned to a DMH or combat stress 

control (CSC) unit must determine what type of psychotropic medications, and how much of each, to obtain for use in a deployment. For most brigade combat 

teams, the individual who makes these decisions is the 

brigade surgeon; the surgeon often acts on the advice 

of the brigade behavioral health officer or the division 

psychiatrist. Factors to be considered are the current 

medications used by soldiers within the unit, the availability of medications in theater, and the maturity of 

the theater. Medications are class VIII in the military 

supply classification system, and most medical/mental 

health units deploy with an initial supply stock.

The brigade surgeon can determine which medications soldiers are currently taking by asking them 

during the predeployment screening program or consulting the local medical treatment facility pharmacist. 

Medication availability is determined by the local theater. The brigade medical supply officer can provide a 

standard formulary for the region in which the unit is 

deploying. For example, in the current conflicts in Iraq 

and Afghanistan, the medications available for resupply are determined by the central command pharmacy 

review committee. In preparation for deployments, 

brigade surgeons should ensure that local home station 

providers have the theater formulary, and that they 

utilize the listed medications as the first choice.

The maturity of theater plays a key role in the 

amount of medications a unit needs to take with it. 

An important finding of the original mental health 

assessment team (MHAT) in the first year of OIF was 

that psychotropic medications were not adequately 

available in theater and resupply was not effective.20

However, the theaters in Iraq and Afghanistan have 

now become more mature, and resupply channels are 

clearly established and effective. The formulary provided by Schneider et al14 (see Table 10-1) delineates 

initial planning guidance, but it should be modified 

based on the factors outlined above.

DISPENSING PSYCHIATRIC MEDICATION IN THEATER

Multiple factors affect the dispensing of medications 

in the deployed environment. Providers must be able 

to support follow up for individuals who are started 

on medications and ensure that resupply is available. 

A number of options for resupply of medications are 

available in theater. DMH units are generally located 

with Level-II aid stations, and CSC units may have 

relationships with local unit medical clinics. CSC units 

can also establish medication resupply channels with 

medical logistics units. Psychiatrists must maintain 

ongoing communication with their resupply sources 

to ensure availability as well as to report utilization 

trends, which allows medical supply officers to effectively maintain supplies.

Once medications have been obtained, their storage 

and security are the next consideration. Although most 
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Combat and Operational Behavioral Health

medications are stable compounds, checking package 

inserts or asking the pharmacist or pharmaceutical 

company about any problems with keeping the specific 

compounds in the deployment environment is advisable. Deploying behavioral health units that intend to 

maintain their own medication supply should consider 

obtaining a small refrigerator for storage, taking into 

account the availability and source of power in theater. 

Medications such as benzodiazepines and stimulants 

are controlled substances with the potential for abuse. 

These medications must be securely maintained under 

clear standard operating procedures that fall within 

military regulations for maintenance of controlled 

substances. 

Methods for dispensing psychotropic medications 

in theater will be determined by several factors, including the soldier’s access to mental health services, 

the soldier’s reliability, and the proximity of other 

pharmacy services. In current operations in Iraq, multiple methods have been utilized, including providing 

soldiers with a supply of medication, providing a 

starting dose and a prescription to take to the local aid 

station or pharmacy, or providing only a prescription 

for the patient to have filled locally. In general, soldiers 

should be provided no more than a 1-month supply of 

medication. Additionally, in 2006 the Army opened the 

TRICARE mail order pharmacy program, which allows 

soldiers to have refills shipped directly to them. 

PHARMACOLOGIC TREATMENT OF MENTAL HEALTH CONDITIONS DURING DEPLOYMENT

Clinicians must make decisions regarding the extent 

of services they can safely and effectively provide within their units. Potential pharmacological interventions, 

such as medication for posttraumatic stress disorder 

(PTSD), attention deficit hyperactivity disorder, or 

smoking cessation fall into a “gray area” of in-theater 

treatment considerations. The decision to continue 

treatment or evacuate patients with these conditions 

depends on which medications are available, how 

significant the symptoms are, how the soldier initially 

responds to treatment, and how significantly the symptoms interfere with the soldier’s assigned duties. 

Mood Disorders

Bipolar Disorder

Bipolar disorder requires evacuation from the 

combat zone, especially if the soldier presents in the 

midst of a manic or hypomanic episode. Because the 

number of manic or hypomanic patients likely to present during military operations is minimal, psychiatrists 

should select medications useful for multiple situations. Because only acute and emergent management 

are conducted in theater, the most practical course of 

action is to stock at least two atypical antipsychotic 

agents, such as olanzapine, quetiapine, risperidone, 

aripiprazole, and ziprasidone. All of these medications 

are effective in treating acute mania and have multiple additional indications (mood instability, anxiety, 

agitation, psychosis, and augmentation strategies for 

depression).

 Major Depressive Disorder and Dysthymic Disorder 

In planning for the treatment of new-onset depressive disorders, clinicians should request a considerable 

quantity of the SSRI they are most comfortable prescribing. They should request the largest amount of an 

SSRI that is also indicated for new-onset anxiety disorders. Zoloft (sertraline [Pfizer-Roerig, New York, NY]) 

and Celexa (citalopram [Forest Pharmaceuticals, Saint 

Louis, Mo]) are reasonable first choices because neither 

interacts significantly with other medications through 

the cytochrome P450 enzyme system, and both are 

usually well tolerated by both depressed and anxious 

patients.21,22 The long half-life of fluoxetine offers an 

advantage; however, its tendency to be more activating 

than other medications makes its use for both anxiety 

and depressive disorders less favorable.23 Paroxetine’s 

potential for a discontinuation syndrome if doses are 

missed could prove problematic in a combat zone.24

Additionally, paroxetine’s anticholinergic properties 

may prove problematic in Iraq, where temperatures 

often reach 140°F. Nonetheless, a small supply of all of 

the SSRIs mentioned above should be secured, because 

these medications are so commonly prescribed that 

clinicians will surely encounter patients who either are 

currently receiving them or have responded favorably 

to them in the past. 

Clinicians should also consider keeping at least two 

non-SSRI antidepressants in the formulary (see Table 

10-1). Some deployed psychiatrists have selected bupropion and venlafaxine because they have different 

mechanisms of action than the SSRIs and both can be 

used for more than treatment of depression (bupropion for attention deficit hyperactivity disorder and 

smoking cessation, and venlafaxine for generalized 

anxiety disorder), allowing for maximal flexibility and 

economy.25,26 Other potential choices include Cymbalta 

(duloxetine [Eli Lilly and Company, Indianapolis, 

Ind]) and Remeron (mirtazepine [Organon USA, West 

Orange, NJ]). The recently released Cymbalta has a 

mechanism of action similar to that of venlafaxine 

with less reported risk of causing hypertension, and 

Remeron treats insomnia, which is nearly ubiquitous 
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Psychiatric Medications in Military Operations

during deployments.27,28 Not recommended are tricyclic antidepressants, which have anticholinergic properties, and nefazadone, because of the potential need 

for laboratory monitoring with liver function tests. 

Anxiety Disorders

SSRIs are the mainstay of treatment for various anxiety disorders because they have demonstrated efficacy 

in panic disorder, PTSD, obsessive-compulsive disorder, and generalized anxiety disorder.29–31 Clinicians 

should consider having one SSRI in large quantities 

to be used for both depressive and anxiety disorders. 

Benzodiazepines may be helpful for panic disorder 

and acute stress disorder because they improve sleep 

and decrease general anxiety symptoms, although 

they may increase the severity of PTSD, especially if 

used for long periods.29 Venlafaxine may be useful in 

treating generalized anxiety disorder. A useful adjunct 

in the treatment of acute stress disorder and PTSD is 

an α-adrenergic or β-adrenergic receptor antagonist 

to target the autonomic symptoms and nightmares 

that may be associated with these disorders. Prazosin 

is a medication in this group with preliminary data 

supporting its usefulness in treating trauma-related 

nightmares.32

Psychotic Disorders and Acute Agitation

Injectable haloperidol and lorazepam remain excellent choices for management of acutely agitated, 

violent, or psychotic patients.33 Although injectable 

forms of both Geodon (ziprasidone [Pfizer-Roerig]) 

and Zyprexa (olanzapine [Eli Lilly and Company]) are 

now available that may have better side-effect profiles, 

including decreased risk of extrapyramidal symptoms, 

both require preparation (being mixed with sterile 

water for 1–5 minutes) before use.34,35 Additionally, 

DMH sections and CSC units have a limited number of 

psychiatrists and psychiatric clinical nurse specialists. 

Physician’s assistants, general medical officers, flight 

surgeons, and others who transport soldiers between 

echelons of care often have limited experience with 

these medications and may be more comfortable with 

Haldol (haloperidol [Ortho-McNeil Inc, Titusville, NJ]) 

as the antipsychotic agent for treating acute mania, 

agitation, or psychosis in a combat zone.33

The authors recommend that deploying psychiatrists’ formulary include two orally administered 

atypical neuroleptic agents, one injectable typical neuroleptic agent (most likely haloperidol), one injectable 

benzodiazepine (most likely lorazepam), and injectable 

Benadryl (diphenhydramine [Pfizer]). The latter is useful to treat agitation and some acute side effects (such 

as dystonic reactions) of neuroleptic agents. 

Insomnia

Insomnia was the most common symptom reported 

by soldiers presenting for care at the 528th CSC during 

the first year of OIF.14 Clinicians treating soldiers with 

insomnia must initially decide whether the problem 

is part of a major psychiatric disorder, a symptom of 

operational stress, or an adjustment disorder. In the 

absence of other symptoms, behavioral interventions 

such as education on sleep hygiene may be the preferred initial intervention because of the possibility that 

prescribed medications will cause drowsiness during 

missions or difficulty awakening during times of peril. 

The decision to use medications should include consideration of the soldier’s military occupational specialty, 

current duties, comorbid symptoms, substance use 

history, and estimated ability to adhere to instructions 

and the recommended dosing schedule. Potential 

deployment formulary medications for the treatment 

of insomnia include trazodone, zolpidem, lorazepam, 

clonazepam, prazosin, and quetiapine.14

Trazodone is particularly useful for patients with 

difficulty staying asleep throughout the night.36 To 

maximize its successful use, clinicians must spend 

extra time educating patients about how to take this 

medication in a field environment. One disadvantage 

of trazodone is its tendency to cause morning sedation or sluggishness, particularly if the dose is too 

high. Frequently, the standard dosage (50 or 100 mg 

with subsequent 50- to 100-mg increments) leaves 

a patient either undermedicated or overmedicated. 

Because the 528th CSC prescribed this medication 

only for sleep, patients there were given a range of 

pill strengths (usually between 25 and 200 mg) and 

flexible dosing instructions. They were encouraged 

to take the initial moderate dose to assess their individual response and then titrate the dosage up or 

down within the predetermined dosage range until 

they could (a) fall asleep within 1 hour of taking 

the medication, (b) sleep all night, and (c) wake up 

without feeling groggy. 

Lorazepam and clonazepam proved most useful 

in treating patients at the 528th CSC with prominent 

anxiety symptoms in addition to insomnia. These 

medications were practical for patients who presented 

with panic attacks and insomnia because they could be 

taken in divided doses to treat both problems, sparing 

the soldier a more complicated treatment regimen. 

However, clinicians must carefully evaluate a patient’s 

need to take these medications for extended periods to 

prevent physiological dependence, which could lead 

to withdrawal if refills are unavailable. Patients who 

have a history of substance abuse or are thought to be 

at risk for abuse should generally not be prescribed 

benzodiazepines in theater. Clinicians must use care 
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Combat and Operational Behavioral Health

to ensure that patients taking benzodiazepines are 

closely monitored. It is prudent to inform someone 

in the soldier’s chain of command (with the soldier’s 

consent) when sleep medications are prescribed because they may affect the soldier’s ability to perform 

duties during the first few days while the dosage is 

being adjusted. 

Ambien (zolpidem [Sanofi-Aventis, Bridgewater, 

NJ]) is particularly useful for treating patients with 

initial insomnia as an isolated symptom or in the 

context of a mood disorder.37 Prazosin, although not 

yet extensively studied, has received increasing attention for helping to alleviate nightmares brought 

on by traumatic experiences.32 Seroquel (quetiapine; 

AstraZeneca US, Wilmington, Del) may also be useful 

in this population, as well as for patients with bipolar 

II disorder, both as a treatment for insomnia and as a 

mood stabilizer. 

ETHICAL ISSUES

The conflicts in Iraq and Afghanistan present for 

the first time since the advent of “biological psychiatry” a situation in which a large part of the military is 

forward deployed for extended periods. In addition, 

many service members are returning to combat zones 

for second or third tours of duty. The risks of keeping 

service members diagnosed with psychological problems in theater, or redeploying these patients a second 

or third time, presents a worrisome ethical question. 

Medication use may inform this discussion. 

The most prevalent disorders in theater are anxiety and depressive disorders. Most of the disorders 

in these two categories respond to treatment with 

psychotropic medications. If a soldier has a mood or 

anxiety disorder and a desire or duty to deploy to a 

combat zone, and a provider believes medication will 

help resolve the symptoms and contribute to successful performance, then perhaps the ethical decision is 

to provide the treatment. Historically, large numbers 

of service members who required evacuation for psychiatric symptoms never returned to their units and, 

unfortunately, developed chronic dysfunction and 

guilt.38 Although mere presence in a combat zone is a 

risk factor for psychological sequelae, experience has 

shown that failing to successfully negotiate, process, 

and come to proper closure with an experience as 

emotional as a deployment may also present longterm challenges.6

 Modern psychotropic medications 

can clearly reduce psychiatric symptoms of many 

disorders in the combat theater. The extent to which 

medication and treatment may facilitate successful 

negotiation and processing of combat experience and 

thus reduce long-term morbidity, however, remains 

an open question. 

SUMMARY

The use of psychotropic medications in combat 

has evolved significantly, mirroring changes in 

psychiatric practice and use of these medications in 

the military garrison environment and the civilian 

sector. Many disorders are now being successfully 

treated with medications in theater. Psychiatrists must 

prepare a deployment formulary before departure, 

and consider the individual circumstances as well 

as guidelines for pharmaceutical usage in theater. 

Factors such as the nature of the conflict, duration of 

deployment, size of deploying force, and guidance of 

military doctrine and policy will continue to inform 

and shape the use of psychotropic medications in 

combat zones. 

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32. Raskind MA, Peskind ER, Kanter ED, et al. Reduction of nightmares and other PTSD symptoms in combat veterans 

by prazosin: a placebo-controlled study. Am J Psychiatry. 2003;160(2):371–373.

33. Haldol (haloperidol) [product information]. Raritan, NJ: Ortho-McNeil Pharmaceuticals; 2001. Available at: http://

www.ortho-mcneil.com/products/pi/pdfs/haldol.pdf. Accessed January 19, 2007. 

34. Olanzapine (zyprexa) [product information]. Indianapolis, Ind: Eli Lilly and Company; 2007. Available at: http://

pi.lilly.com/us/zyprexa-pi.pdf. Accessed February 14, 2008.

35. Geodon (ziprasidone) [product information]. New York, NY: Pfizer-Roerig; 2005. Available at: http://www.pfizer.

com/brands/geodon.jsp. Accessed November 18, 2008. 

36. Schwartz T, Nihalani N, Virk S, et al. A comparison of the effectiveness of two hypnotic agents for the treatment of 

insomnia. Int J Psychiatr Nurs Res. 2004;10(1):1146–1150.

37. Ambien (zolpidem) [product information]. Bridgewater, NJ: Sanofi-Aventis; 2008. Available at: http://products.sanofiaventis.us/ambien_cr/ambiencr.html. Accessed February 14, 2008.

38. Jones FD. Lessons of war for psychiatry. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol 

6. New York, NY: Plenum; 1985: 515–519.
163

The Role of Chaplains in the Operational Army

Chapter 11

THE ROLE OF CHAPLAINS IN THE 

OPERATIONAL ARMY

PETER FREDERICH, MDiv*; THOMAS C. WAYNICK, MDiv†; JASON E. DUCKWORTH, DMin, MDiv‡; and

JEFF VOYLES, MDiv§

INTRODUCTION

THE CHAPLAIN AS PASTORAL COUNSELOR

Pastoral Care and Counseling in the Chaplain Corps

Chaplains and Confidentiality

The Chaplain as Facilitator of Religious Strength

Dynamics of Faith in Soldier Resilience and Recovery

CHAPLAINS AS PARTNERS IN OPERATIONAL PSYCHOLOGY

SUMMARY

*Lieutenant Colonel, Chaplain Corps, US Army; Family Ministries Officer, Directorate of Ministry Initiatives, US Army Chief of Chaplains Office, 1421 

Jefferson Davis Highway, Suite 10600, Arlington, Virginia 22202; formerly, Director, US Army Family Life Chaplain Training Center, Fort Benning, 

Georgia 

†

Lieutenant Colonel, Chaplain Corps, US Army; Command Chaplain, Family, Morale, Welfare, and Recreation Command, 4700 King Street, Alexandria, 

Virginia 22301; formerly, Director and Clinical Supervisor, US Army Family Life Chaplains’ Training Program, Fort Benning, Georgia 31905

‡

Lieutenant Colonel, Chaplain Corps, US Army; Garrison Chaplain, Religious Support Office, US Army Garrison, Heidelberg, Germany, CMR 419 

Box 1876, APO AE 09102; formerly, Training Developer, Chaplain Basic Officer Leader Course, US Army Chaplain Center and School, Fort Jackson, 

South Carolina 29207

§

Lieutenant Colonel, Chaplain Corps, US Army; Director and Clinical Supervisor, Chaplain Family Life Training Program, Building 2606 Collins Loop, 

Fort Benning, Georgia 31905
164

Combat and Operational Behavioral Health

INTRODUCTION

In the US Army’s current care structure, chaplains are frequently first responders to the personal 

and psychological problems of soldiers. This is a 

long tradition. Long before mental health providers existed in the ranks, chaplains were available 

to soldiers as pastors, lending a listening ear and 

wise counsel. Today, maintenance of the soul of 

the soldier is the primary mission of the military 

chaplaincy. Wherever faith and life intersect, the 

chaplain is present. Chaplains, like their civilian 

counterparts, play a defined role in rites and rituals celebrating the meaningful passages of life from 

birth to the grave. Their calling is to the development and growth of the soul, both temporally and 

eternally. These activities inherently support the 

mental health of soldiers and their family members, 

and make the chaplain a natural partner to military 

psychiatric caregivers.

THE CHAPLAIN AS PASTORAL COUNSELOR

Vignette 11-1: Private Sam Jones doesn’t really know 

what to do or think. Four months into his first Iraq deployment, 

he’s afraid his marriage is falling apart—he feels helpless and 

desperate. Married just over a year to Sarah, his high-school 

girlfriend, he thought they were the picture of a great young 

Army couple. Sarah had written him faithfully while he was in 

basic and advanced individual training, and when he proposed 

during the Christmas break she’d said yes. They had a wonderful holiday, showing family and friends her engagement ring 

and making plans for the future. There wasn’t a lot of time or 

money, no big wedding or a honeymoon, but by summer they 

had moved into a small apartment outside Fort Bragg, North 

Carolina. Sarah started taking classes at the local community 

college, got pregnant, and made some friends. 

And then came Iraq. They both put on a brave face, but 

both were scared. The baby would be born while he was in 

Iraq. She had friends, but not necessarily the kind to help 

when a baby comes, so they decided she would move back 

home until he returned. And so, a month before his departure, 

Sam took a week’s leave, loaded up a rented trailer, and 

drove Sarah home. As he watched her waving goodbye, he 

knew this was going to be a long haul. But he was confident 

they’d get through this, raise kids, and grow old together. 

They were so in love.

But things didn’t go as planned. With perverse precision, 

Sarah miscarried the baby on the last day of the first trimester 

while Sam was actually in the air, flying to the Middle East. 

It was 4 days before he got the news, and even though his 

commander found him a phone and a quiet place to call right 

away, it was days late for Sarah. The call didn’t go well. To 

Sam, it seemed like Sarah blamed him for the miscarriage, 

and couldn’t understand why Sam’s unit didn’t send him 

home. What was supposed to be a loving call of support 

turned into a frustrating exchange that was mercifully cut off 

by a break in the lines.

Somehow the phone just didn’t work for them. Calls were 

characterized more by silences and anger than by love and 

affection. E-mail, while better, couldn’t patch it up. Then, it 

seemed like he could never find her at home. He’d wait in line 

an hour for a phone, only to leave a message on an answering 

machine. Worse, e-mails stopped being regularly answered. 

Before long, weeks passed with no contact between them. 

Now Sam is sitting staring at his computer screen in despair. A well-intentioned friend just sent an e-mail telling Sam 

he’d seen Sarah at a movie with her old boyfriend, a week 

after he saw the pair sitting in a car outside the Denny’s she 

and Sam used to frequent as a couple. He’s telling Sam this 

because he “doesn’t want to see you get hurt.”

Suddenly it all makes sense to Sam and it seems hopeless 

and more than he can bear. In his mind he sees some really 

ugly pictures of Sarah with her new friend. And it seems like 

there’s nothing he can do—how can he win her back when 

she doesn’t even answer his calls? Sam doesn’t know what 

to think, but he knows this: he doesn’t want to live if he can’t 

be with Sarah. Looking over his shoulder, Sam sees his M4 

rifle: clean, loaded, and ready for action. Just three steps, 

pick it up, pull the charging handle, rotate, and fire. All this 

pain would be over, and Sarah would be so sorry . . .

In the future Sam would always look back to that moment 

and wonder if it was just coincidence, or the hand of God. 

But as the thoughts of suicide came through his mind, so 

did the sound of a knock at the door of the squad “hooch” 

where Sam was sitting. A moment later Chaplain Watson 

walked through the door. Strange thing. The chaplain didn’t 

come every day, but more than once a week he’d come 

through, handing out candy, care packages, or something 

else. Sometimes he seemed out of his element in the rough 

atmosphere of the forward operating base, but he came by 

anyway. And whether it was his jump shot (he’d played NCAA 

Division-III basketball in college and was a solid addition to 

any platoon’s pick-up team) or his insistence on regularly, 

voluntarily joining squads on patrols, he was a respected 

member of the battalion, even among soldiers who couldn’t 

find the chapel. 

It didn’t take the chaplain long to pick up the cues from 

Sam’s feeble answers to his standard “How’s it going?” questions. He sat down on the bed next to the computer desk, 

and asked for more information. Before he knew it, Sam was 

roughing out the details of his situation and finding someone 

who’d heard it before, cared, had hope, and had a plan. “Let’s 

go find out what’s happening and figure out what to do.” The 

chaplain invited Sam back to the chapel, where there was 

a class-A line (a line that connects to phones outside the 

military installation) and plenty of privacy to start the process 

of pulling things back together.

With only simple changes to the details, Sam’s story 

could be retold tens of thousands of times every decade. In the Western world soldiers for centuries have 
165

The Role of Chaplains in the Operational Army

looked to clergy to help them sort through problems 

and answer the deeper existential questions of the soul. 

The US Army’s Chaplain Corps was established at the 

Army’s inception by General George Washington.

Pastoral Care and Counseling in the Chaplain 

Corps

Chaplains draw from a centuries-old tradition of 

pastoral care. Historically, and throughout the first 

centuries of American colonial and national history, 

pastors of various denominations lived or sometimes 

“circuit rode” between tiny, agrarian communities, 

leading worship, caring for the sick, and often burying the dead. With college and frequently seminary 

degrees, these clergymen were often the most highly 

educated and widely experienced in their communities, and were called on to perform many helping tasks, 

sometimes even including medical care, for their isolated charges. “Pastoral care” developed a very wide 

range of activities during this period.1

Following this historic pattern, today’s clergy often see the role of pastoral counseling as part of their 

scriptural injunction to take oversight of the flock by 

caring for one another’s burdens.2 Chaplains do their 

trade well when they follow recognized principles of 

spiritual leadership regarding the care of another’s 

soul—personal concern, faith in the value and meaning of life, and hope.3

 These values are typically shared 

by most counseling modalities—pastoral or not.

Although chaplains collectively represent many 

faiths, each individually comes from one particular 

faith group.4 Each chaplain is endorsed by a specific 

denomination, but the task is to minister to every soldier in the command. Consequently, chaplains have 

diverse responsibilities. Besides conducting the rituals, 

rites, and sacraments (referred to above) and public 

worship services (their most common responsibility), 

chaplains also provide pastoral care and counseling. It 

is in the pastoral relationship that the work of chaplains overlaps most closely with military psychiatry. 

As a result, military mental health workers commonly 

find that they are partnered with chaplains in areas 

such as resiliency in preparation for combat, stress 

control in combat, suicide prevention, wounded soldier recovery, soldier reintegration, trauma recovery, 

family issues, and care for the caregiver.

All chaplains have rudimentary training in care 

and counseling. However, skill and education levels 

cover a broad range. Actual training in counseling may 

vary from a couple of seminary courses to a doctorate 

in clinical psychology. Recognizing this range, and 

attempting to ensure that every chaplain has a basic 

workable skill set, the Chaplain Corps has been proactive in raising the standard of care in pastoral counseling. The heart of this effort is focused on the family life 

chaplain and hospital chaplain programs.

For over 30 years, the Chief of Chaplains has 

sponsored an advanced civilian schooling program 

for midcareer chaplains. Chaplains selected for this 

program attend a 15-month masters degree course 

in pastoral counseling and, upon graduation, are assigned to Family Life Centers spread throughout the 

Army in garrisons and divisions. Many graduates from 

this program become licensed as marriage and family 

therapists or professional counselors.

The chaplaincy has also continued to raise the level 

of pastoral care through its clinical pastoral education 

programs. Located in major medical centers, these 

programs train chaplains to do ministry in the hospital environment where the basic skills of listening 

and self-awareness are tantamount to quality care. 

Once in positions in Family Life Centers or military 

hospitals, these chaplains provide care as well as 

training in pastoral counseling for unit chaplains. 

Under a new initiative, both family life and hospital 

chaplains will be used to mentor young chaplains in 

“battlefield pastoral education”—a program designed 

to raise the quality of care and counseling across the 

Chaplain Corps. 

The ministry of care and counseling to the greater 

community begins with the chaplain and chaplain assistant. They make up the unit ministry team (UMT) 

in the Army and the religious support team in joint 

environments. UMTs are assigned down to battalion 

level, so there is typically one UMT for every 600 soldiers. Because the UMTs are assigned to the unit, there 

is generally a very close relationship between the team 

and the unit. That close relationship makes chaplains 

and their assistants ideal “first responders.” Because 

soldiers trust the UMT, they are likely to respond 

positively when its members advise them to talk to 

someone else in the helping professions, such as mental 

health providers. Additionally, because chaplains and 

assistants live and work closely with soldiers, they 

make ideal follow-on caregivers for soldiers and family 

members who are in parallel treatment with military 

medical providers. A time-honored best practice is for 

UMTs and military mental health practitioners to build 

and maintain robust relationships in order to facilitate 

early recognition and integrated treatment for military 

constituents.

Chaplains and Confidentiality

One unique aspect of the chaplain–penitent relationship is the nature and extent of confidentiality. In 

order to best partner with chaplains, mental health 
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Combat and Operational Behavioral Health

providers must become comfortable with this unique 

aspect of the chaplain–soldier–family-member relationship. Society has long recognized the need for 

certain relationships, such as marriage, to be protected 

by confidential communication. The main reason for 

protecting communication within a marriage is to 

promote absolute trust in the marital bond. Society 

has decided that a husband and wife should be able 

to communicate freely about even the most sensitive 

issues without the threat of that communication being 

used against them in a legal setting. 

Similarly, the communication between an attorney 

and a client has also traditionally been protected by 

confidential communication so that the client can receive accurate legal advice. The conversations between 

patients and their healthcare providers have also been 

protected, most recently in the 1996 Health Insurance 

Portability and Accountability Act. Patients need to 

know their conversations with healthcare providers 

are protected so they can make a full disclosure of their 

history and symptoms without fearing that others will 

have access to this information.

As for these other relationships, long tradition has 

held that conversations between a member of the 

clergy and a parishioner or penitent have also been 

protected so that the matters of soul and conscience 

can be fully and freely discussed without fear of these 

conversations becoming public. The concept of the 

privilege of confidential communication between a 

member of the clergy and a penitent has been around 

for almost two centuries. It was first introduced in the 

United States in New York in the early 19th century. 

Every state and the District of Columbia have enacted 

laws that protect this relationship.5

 On the federal 

level, in Trammel v US (1980),6 the US Supreme Court 

recognized “the human need to disclose to a spiritual counsel, in total and absolute confidence, what are 

believed to be flawed acts or thoughts and to receive 

priestly consolation and guidance in return.” In a case 

5 years later, the court stated that 

[t]he privilege regarding communications with a 

clergyman reflects an accommodation between the 

public’s right to evidence and the individual’s need to be 

able to speak with a spiritual counselor, in absolute 

confidence, and disclose the wrongs done or evils 

thought and receive spiritual absolution, consolation, 

or guidance in return.7

The US military also has regulations that govern 

confidential communications. Military rule of evidence 

(MRE) 503 covers confidential communications to 

members of the clergy.8

 The general rule of privilege 

in MRE 503 states:

A person has a privilege to refuse to disclose and 

to prevent another from disclosing a confidential 

communication by the person to a clergyman or a 

clergyman’s assistant, if such communication is made 

either as a formal act of religion or as a matter of 

conscience.8(pIII-23)

It is significant that the privilege belongs to the 

declarant. The chaplain is bound by this privilege, 

and is not free to waive it. It also states that a chaplain 

assistant is bound by the privilege. Thus, if an individual is speaking to a chaplain or chaplain assistant, 

and believes the conversation is in confidence, it is 

a protected communication. As used in this rule, a 

“clergyman” is a minister, priest, rabbi, chaplain, or 

other similar functionary of a religious organization, 

or an individual reasonably believed to be so by the 

person consulting the clergyman. MRE 503 also states 

that a communication is “confidential” if made to a 

clergyman in the clergyman’s capacity as a spiritual 

advisor or to a clergyman’s assistant in the assistant’s 

official capacity. MRE 503 makes all communications 

to a chaplain in this role privileged. As such, they 

are not admissible in court. Further policies interpret 

this privilege broadly, making chaplain–parishioner 

privilege “nearly absolute.” As a result, the chaplain 

is often viewed as a safe place to go by both soldiers 

and the command. Soldiers can go to the chaplain to 

have their problems addressed without the matter 

being made known to their units. 

This relationship has been repeatedly tested in 

court, and as recently as 2007 was clarified by the 

chief of chaplains. The term that has typically been 

connected to this relationship is “absolute confidentiality.” The bottom line guidance given to chaplains 

and their assistants is this: the privilege that soldiers 

and family members own as a result of the relationship is absolute. It cannot be waived for any reason 

(to include threat of harm) unless the soldier or family 

member waives it.

Although this absolute privilege has been viewed 

with angst by many professionals, in practice the 

safety that soldiers thereby attach to the relationship 

is virtually always positive. The hypothetical situations of danger (eg, a chaplain remaining quiet in the 

case of child abuse or some other heinous situation) 

are grist for interesting legal discussions, but virtually 

never come to reality. In fact, a multiyear search done 

by the chiefs of chaplains across the Department of 

Defense did not find a single instance where harm 

ensued as a result of a chaplain or assistant holding 

confidence. However, the search uncovered many instances where the perceived safety of the relationship 

enabled chaplains and assistants to gain early access 
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The Role of Chaplains in the Operational Army

to dangerous situations and prevent harm. The bottom 

line for mental health professionals is this: the privilege 

attached to the soldier–chaplain relationship makes 

the chaplains and chaplain assistants in the military 

extremely valuable partners in the care of soldiers and 

their family members.

The Chaplain as Facilitator of Religious Strength

The free exercise of religion has been the source 

of the chaplain’s ability to be a facilitator of religious 

strength. This has 

corresponded well with the intent of the Founding 

Fathers and the Constitution of the United States. . . 

. Long before the Constitution was framed, a distinct 

tradition of free exercise of religion developed within 

the army by necessity. The pattern for chaplain ministry to soldiers of different religious backgrounds was 

set in the seventeeth century, from the time of the first 

militia units drilled at Jamestown, Plymouth, Boston, 

and New York.9

Today’s Army maintains a Chaplain Corps for the 

primary reason of ensuring a soldier’s free exercise of 

religion. However, the motivation at the operational 

level may be different. In the Army, everything must 

support the soldier on the front line. Logisticians ensure that the infantry on the front have beans and bullets. The Signal Corps supports the fight by providing 

clear means of communication. The Medical Command 

attends to the health of the soldier. The chaplain is seen 

as a force health contributor by supporting the spirit 

of the individual soldier, enabling the soldier to be 

resilient in the fight. 

But how does religion support the soldier? The 

answer to that question is threefold. It has to do with 

the nature of belief systems, which bring meaning to 

life. First, belief systems support soldiers throughout 

combat. Before the battle, belief systems aid the process 

of convictions in just and right causes. In the midst of 

the chaos and horror of combat a belief system can 

sustain an individual. After the battle the application 

of meaning to the traumatic event can help restore 

not only a sense of order and meaning, but also a 

renewed calling to life. Secondly, belief systems offer 

rites, rituals, and sacraments that provide healing, 

cleansing, and restoration that can be very important 

to the wounded soul of the warrior. Thirdly, chaplains 

perform a symbolic role, referred to by the Chaplain 

Corps as the “ministry of presence.” The chaplain is 

perceived by some as the embodiment of God’s presence in the midst of soldiers. 

Some commanders feel that a chaplain accompanying troops during the mission is more important than 

the current doctrine of locating chaplains at the aid 

station. These commanders believe that a chaplain’s 

presence, a symbol of God’s closeness with the troops, 

is an encouragement to soldiers in the field. These officers are not alone in their convictions that belief in 

God sustains a person in combat. In an address at Trinity College in Hartford, Connecticut, in 1941, General 

George C Marshall said these words: 

The soldier’s heart, the soldier’s spirit, the soldier’s 

soul, are everything. Unless the soldier’s soul sustains 

him he cannot be relied on and will fail himself and 

his commander and his country in the end. . . . It is 

morale that wins the victory. . . . The French never 

found an adequate “dictionary” definition for the 

word. . . . It is more than a word—more than any one 

word, or several words, can measure. Morale is a state 

of mind. It is steadfastness and courage and hope. It 

is confidence and zeal and loyalty. . . . It is élan, esprit 

de corps and determination. It is staying power, the 

spirit which endures to the end—the will to win. With 

it all things are possible, without it everything else, 

planning, preparation, production, count for naught. 

I have just said it is the spirit which endures to the 

end. And so it is.10

Dynamics of Faith in Soldier Resilience and Recovery 

The chaplain may or may not be a symbol of God’s 

presence to the individual soldier. The greater question is how does individual belief, religion, or faith 

promoted and supported by the chaplain enable 

soldiers first to stay in the fight and then return to the 

fight after being wounded in body or spirit? Anecdotal 

accounts and folk wisdom have supported the belief 

that religious faith adds a profound dimension to the 

emotional resilience and recovery capabilities of people 

under stress. One example comes from World War II 

in this report of the country’s response to the invasion 

of Normandy:

The whole country knew on June 6 that something 

dire, something that might fail, was taking place . . . 

in a Brooklyn shipyard, welders knelt on the decks of 

their Liberty ships and recited the Lord ’s Prayer. At the 

opening, the New York Stock Exchange observed two 

minutes of silent prayer. All over America church bells 

tolled, and the Liberty Bell was rung in Philadelphia. 

In Columbus, Ohio, at 7:30 in the evening, all traffic 

stopped for five minutes while people prayed in the 

streets.11(p37)

Another example is the nation’s spiritual reaction to 

the attacks of September 11, 2001. In the days after the 
168

Combat and Operational Behavioral Health

fall of the World Trade Center, church prayer services 

were well attended, crosses and other religious symbols were erected, and memorial events such as Oprah 

Winfrey’s grand prayer service at Yankee Stadium to 

commemorate the victims were celebrated. Even years 

later it is not uncommon for a soldier to tell a chaplain 

that God called him or her into the military in response 

to September 11.

A growing amount of empirical research supports 

the concept that for many individuals faith is a resource 

for resiliency and recovery. Pargament’s seminal work, 

The Psychology of Religion and Coping, encapsulates 

much of the research on religion and resiliency of the 

previous decade. He writes: 

A number of studies have compared the frequencies of 

religious and nonreligious forms of coping and found 

that religion looms large. For example, McCrae (1984) 

studied the coping mechanisms reportedly used by 

a community sample of men and women faced with 

events categorized as losses, threats, or challenges. 

Of the 28 coping mechanisms, “faith” was the second 

most frequently used for dealing with threats (72%), 

and the third most frequently used for dealing with 

losses (75%). Faith was less frequently used in coping 

with challenges (43%). Conway (1885–1986) interviewed black and white urban elderly women who 

had experienced stressful medical problems in the past 

year. Asked how they coped with their medical problems, prayer was selected by 91% of the sample; it was 

the most frequently reported of all coping mechanisms 

including seeking information, resting, treatment, prescription drugs, and going to a doctor.12(pp137–138)

In a more recent work, Learning from Resilient People: 

Lessons We Can Apply to Counseling and Psychotherapy, 

Glicken refers to the following studies:

Gartner, Larson, and Allen reviewed over 200 psychiatric and psychological studies and concluded 

that religious involvement has a positive impact on 

both health and mental health, while Ellison and colleagues indicate that “there is at least some evidence 

of mental health benefits of religion among men and 

women, persons of different ages and racial and ethnic 

groups, and individuals from various socioeconomic 

classes and geographical locations. Further, these 

salutary effects often persist even with an array of 

social, demographic, and health-related statistical 

controls.”13(p23)

If there is, as the research and recent history indicate, 

a connection between faith resources and a soldier’s 

ability to be resilient and recover from the traumas of 

military life, then the role of the chaplain as pastoral 

counselor is an important resource to be accessed by 

those involved with operational psychology. (For 

further discussion, see Waynick and colleagues, “Human Spirituality, Resilience, and the Role of Military 

Chaplains.”14)

CHAPLAINS AS PARTNERS IN OPERATIONAL PSYCHOLOGY

Chaplains are partners with other military helping 

personnel in the overall psychological well-being of 

soldiers. Because they are typically assigned at battalion level, chaplains often handle the day-to-day bulk 

of basic issues faced by soldiers. This often consists of 

straightforward “problem solving” related to professional issues, relationships, life choices, and spirituality. Chaplains provide proximity, immediacy, and 

expectancy in their basic counseling services—they 

have the ability to work with soldiers within the unit 

and meet their needs quickly. This is an important 

operational concept because when soldiers are sent 

away for help, there is a reduced expectancy of their 

return. 

Because chaplains are an integral part of their units, 

they are often familiar with the home situations of the 

soldiers. Chaplains can provide a “reach-back” capability to soldiers, contacting other chaplains who are 

collocated with family members. Thus the deployed 

chaplain often bridges the gap on issues caused by 

family separations. Rear detachment chaplains often 

find themselves tasked by command to react to family 

crises and provide crisis intervention counseling.

It is important to reiterate that chaplains are not 

mental health professionals (the exception being 

licensed family life chaplains); their primary role is 

that of pastor. As such they do pastoral counseling, 

which includes serving as first responders to crisis 

events as well as making good and timely referrals to 

mental health and other agencies for the well-being 

of the soldier. After some initial counseling a chaplain 

may decide that the combat stress control team (CSCT) 

or other professionals may be better suited to help a 

particular individual. At this point the chaplain will 

often refer the person to the CSCT. Depending on the 

nature of the issue, the chaplain may personally escort 

the person, have a noncommissioned officer escort the 

person, or suggest the person seek additional help 

from the CSCT unaccompanied. It is important for 

the mental health team to know that chaplains do not 

perceive this as a “hand off.” Chaplains are typically 

eager to continue the pastoral relationship and play 

an adjunct role in the healing of the soldier. Some past 

tension between mental health professionals and the 

chaplaincy resulted from a perceived message that 

once the soldier is in the medical chain there is no 
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The Role of Chaplains in the Operational Army

need for the pastoral role, as if mental health somehow 

trumped all other care giving. Chaplains as a whole 

come from theological communities that believe human beings function best when they have multiple 

supportive resources.

A prime example of chaplains partnering with 

mental health personnel is occurring during critical incidents in both Iraq and Afghanistan. Unlike chaplains, 

the CSCT is usually assigned at brigade level, although 

sometimes at forward operating bases controlled by 

a single battalion. Typically both the CSCT and the 

chaplain respond to the same client during the same 

events, such as a significant amount of combat loss, 

but each in their own role. Chaplains often respond 

immediately to a critical incident with a pastoral 

presence on the scene. The CSCT often follows up by 

triaging those involved and treating the emotional aftermath of the traumatic experience. Chaplains trained 

in crisis processing often perform critical incident 

stress ministry shortly after the event. Mental health 

professionals respond in similar fashion. Chaplains 

then continue follow-up care by checking in with the 

soldiers while living and working with them on a daily 

basis. Chaplain assistants can also participate in the 

contacting, assessing, and referral process. Unit leaders 

recognizing the teamwork of UMTs and CSCTs often 

advise or direct soldiers to talk with personnel in one 

or the other group.

Another area where mental health practitioners and 

chaplains work hand in hand is in suicide prevention. The 

Army suicide prevention program has four elements: (1) 

primary prevention through life and relationship skills 

training, (2) awareness training, (3) intervention training, and (4) treatment for suicidal soldiers.15 Whereas 

mental health providers have the task of diagnosis and 

treatment, chaplains are the primary vehicle for prevention and awareness education. UMTs are often the first 

to identify a soldier in need of psychological evaluation 

for suicidal or homicidal ideations. This is particularly 

important downrange, where perceptive chaplains can 

expedite, on the basis of their position, a soldier being 

taken to receive mental healthcare.

In March 2007, the US Army Center for Health 

Promotion and Preventative Medicine released a new 

suicide awareness program for soldiers and Army 

leaders. Urging soldiers to “get help” if needed and 

“protect your buddy,” this training emphasizes practical protective steps. This program is now the Army 

standard for suicide awareness training.16 UMTs train 

their units in suicide awareness under the Deployment 

Cycle Support program, as well as providing periodic 

retraining of soldiers and leaders. 

A less talked about role chaplains play in operational psychology is serving as a personal resource 

for mental health providers. Being connected, but not 

in the same professional community, many mental 

health providers find chaplains to be safe friends and 

confidants to process their own experiences. Mental 

health providers also play this role for chaplains. Both 

professions speak a similar language and have similar 

goals in ensuring the well-being of soldiers. Mental 

health providers enjoy the same “absolute privilege” 

as chaplains, which can be very advantageous in the 

close quarters of deployments.

Chaplains and CSCTs should work together and 

be aware of the workloads each is carrying. Equitable distribution of work is part of taking care of the 

caregiver. Chaplains have been, and will continue to 

be, available as a resource to all those who work in 

operational psychology. Chaplains also must take care 

of themselves and each other if they are going to take 

care of the soldier. Consequently, for many chaplains 

and CSCTs, it has become a best practice to maintain 

mutually supportive relationships in which each tracks 

the physical and emotional fitness and workload of the 

other, and which provide informal support and care. 

The nuanced nature of both spiritual and psychiatric 

care requires providers to remain emotionally sound. 

For many deployed chaplains and mental health professionals, the personal relationships they share and 

the supportive interactions they sustain in the midst 

of the struggle have become a keystone of their ability 

to stay healthy and effective through the trials of long 

deployments.

SUMMARY 

Today’s military Chaplain Corps is an expression 

of millenia-long traditions of pastoral practice that include the practice of worship and sacramental rites as 

well as a tradition of personal soul care. Responding 

to this tradition, US military chaplains are ubiquitous 

among soldiers and their family members, leading 

worship and prayer, and listening, comforting, and 

providing guidance. In support of this tradition, 

military chaplains receive extensive training in supportive counseling, personal resilience, and family 

health promotion. Consequently, chaplains support 

the mission of military healthcare providers and are 

natural partners in pursuit of soldier and family 

mental health. Additionally, as a caring professional 

functioning outside normal medical channels, the 

chaplain is a “safe resource” for mental health providers and a good fit for providers seeking a means 

to support their own personal emotional health. As 
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Combat and Operational Behavioral Health

a result of this alignment and shared mission, many 

mental health providers find it a best practice to 

build and maintain rich, supportive relationships 

with chaplains in their area of action. This partnership has for many been a source of increased effectiveness, durability, and, ultimately, better health 

for the soldiers and family members whose welfare 

they support.

REFERENCES

1. Schuetze AW, Habeck IJ. The Shepherd Under Christ–A Textbook for Pastoral Theology. Milwaukee, Wisc: Northwestern 

Publishing House; 1974. 

2. Galatians 6:2. Available at: http://scriptures.lds.org/gal/6. Accessed April 20, 2009.

3. Nouwen HJM. The Wounded Healer. Garden City, NY: Image Books; 1979: 70–76.

4. US Department of the Army. Chaplain Activities in the United States Army. Washington, DC: DA; 2004. Army Regulation 

165-1.

5. Broyde M, Reiss Y, Diament N. Confidentiality and rabbinic counseling: an overview of Halakhic and legal issues. 

Jewish Law Articles. Available at: http://www.jlaw.com/Articles/RabbinicCounseling1.html. Accessed December 16, 

2009.

6. Trammel v US, 445 US 40 (1980). 

7. US v Moreno, 20 MJ 623, 626 (ACMR 1985).

8. US Department of Defense. Military rules of evidence, section 503, communications with clergy. Manual for CourtsMartial, United States. Washington, DC: DoD; 2000: III-23. 

9. Brinsfield JW. Our roots for ministry: the Continental Army, George Washington, and the free exercise of religion. Mil 

Chaplain’s Review. 1987;Fall:25.

10. The Marshall Papers. Speech at Trinity College, June 15, 1941. The George C Marshall Foundation. Available at: http://

www.marshallfoundation.org/Database.htm [Note: search for “zeal”; select #2-484]. Accessed September 15, 2009.

11. Fussell P. How the leaders led. Newsweek. May 23, 1994:36–38.

12. Pargament KI. The Psychology of Religion and Coping. New York, NY: Guildford Press; 1997. 

13. Glicken D. Learning From Resilient People: Lessons We Can Apply to Counseling and Psychotherapy. Thousand Oaks, Calif: 

Sage Publications; 2006. 

14. Waynick T, Frederich P, Scheider D, Thomas R, Bloomstrom G. Human spirituality, resilience, and the role of the military chaplain. In: Adler A, Castro C, Britt T, eds. Operational Stress. Vol 2. In: Military Life—The Psychology of Serving in 

Peace and Combat. Westport, Conn: Praeger Security International; 2006: 173–199.

15. US Department of the Army. Army Health Promotion. Washington, DC: DA; 2004. Army Regulation 600-63, Chapter 

5.

16. US Department of the Army, Chief of Chaplains. The New Army Standard Suicide Awareness Program. Information paper 

to all Army Chaplains, April 27, 2007. 
171

Psychiatric Consultation to Command

Chapter 12

PSYCHIATRIC CONSULTATION TO 

COMMAND

CHRISTOPHER H. WARNER, MD*; GEORGE N. APPENZELLER, MD†; JILL E. BREITBACH, PsyD‡; JENNIFER T. LANGE, MD§

; ANGELA MOBBS, PsyD¥; and ELSPETH CAMERON RITCHIE, MD, MPH¶

INTRODUCTION

ORIGIN AND HISTORY OF PSYCHIATRIC COMMAND CONSULTATION

FACTORS ASSOCIATED WITH COMMAND CONSULTATION

PERFORMING THE CONSULTation

DETERMINING FITNESS FOR DUTY AND DEPLYOMENT CLEARANCE

COMMAND-DIRECTED EVALUATIONS

RISKS TO THE CONSULTANT AND ETHICAL ISSUES IN CONSULTATION

NOTABLE CONSULTATIVE POSITIONS IN THE ARMY

SUMMARY

*Major, Medical Corps, US Army; Chief, Department of Behavioral Medicine, Winn Army Community Hospital, Building 9242, Room 20, 1083 Worcester 

Drive, Fort Stewart, Georgia 31324; formerly, Division Psychiatrist, 3rd Infantry Division, Fort Stewart, Georgia

†

Lieutenant Colonel, Medical Corps, US Army; Commander, US Army Medical Activity, Alaska, 1060 Gaffney Road #7400, Fort Wainwright, Alaska 

99703-7400; formerly, Deputy Commander for Clinical Services, Command Group, Winn Army Community Hospital, Fort Stewart, Georgia 31314 

‡

Major, Medical Service Corps, US Army; Neuropsychologist, Department of Psychology, Evans Army Community Hospital, USAMEDDAC, 1650 

Cochrane Circle, Fort Carson, Colorado 80913; formerly, Group Psychologist, 1st Special Warfare Training Group, Fort Bragg, North Carolina 

§

Lieutenant Colonel, Medical Corps, US Army; Medical Director, Behavioral Health Clinic, Department of Psychiatry, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307-5001

¥

Captain, Medical Service Corps, US Army; Special Forces Assignment and Selection Psychologist, Special Warfare Center and School, Rowe Training 

Facility, Building T-5167, 1500 Camp Mackall Place, Marston, North Carolina 28363; formerly, Brigade Psychologist, 3rd Brigade Combat Team, 3rd 

Infantry Division, Fort Benning, Georgia 

¶

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

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

NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

The psychological effects of warfare have been well 

documented throughout history. Since World War I, the 

US Army has been deploying behavioral health assets to 

the front line for treatment of combat operational stress 

and to advise unit commanders about combat stress 

and its effects on soldiers. Currently, commanders of 

combat units are being encouraged to attend to the overall health of their soldiers, including consulting with 

behavioral health professionals about the psychiatric 

well-being of their soldiers. One of the many challenges 

that behavioral health professionals are confronted with 

is the need to educate commanders about the role of 

psychiatric command consultation. This chapter outlines the many responsibilities of this role. 

ORIGIN AND HISTORY OF PSYCHIATRIC COMMAND CONSULTATION

Whereas mental health evaluations are typically 

thought of in terms of an encounter between a provider and a patient, a psychiatric command consultation occurs when a military commander desires to 

know mental health information or factors about an 

individual, unit, or command, and how to improve 

overall behavioral health. Historically, psychiatric 

command consultation has occurred in two different 

capacities: (1) attempts to screen for vulnerability 

and determine fitness for duty, and (2) preventive 

psychiatry. Previous overviews have described the 

history related to these components in depth. It is 

important to know how these roles have developed 

when outlining the future of psychiatric command 

consultation.1

 Additionally, although “psychiatric 

consultation” will often be performed by psychiatrists, other behavioral health professionals will also 

perform these consultations, thus, the term “behavioral health professionals” is used in discussion of 

consultations. For guidance regarding the specific 

roles of psychiatrists, psychologists, social workers, 

and technicians, the reader is encouraged to explore 

their individual discipline regulations. 

Screening for Vulnerability and Determining 

Fitness for Duty

For individuals desiring to enter the military, their 

first encounter with medical personnel will generally 

be at the Military Entrance Processing Station. Here 

new recruits complete a thorough medical evaluation 

that includes answering questions regarding mental 

health. Certain individuals may be barred from entry to 

service or require further evaluation prior to entering 

the military. This process, a reflection of the recognized 

need to screen military personnel for psychiatric vulnerabilities, dates back to the mid-18th century. 

“Nostalgia,” which was the recognized ailment 

defined by Aurenbrugger in 1761, was the term used 

to describe the “disease” where soldiers lost hope, 

became sad, isolative, inattentive, and apathetic—what 

today is commonly termed “combat stress.”2

 French 

physicians of the Napoleonic era recognized factors 

associated with producing and preventing nostalgia, 

and began screening soldiers accordingly.2

The US military began psychological screening 

in the early 20th century. During World War I, the 

famous Army Alpha and Beta testing and psychiatric 

interviews were applied to screen the massive influx of 

military recruits needed to fight the war.3 At that time, 

the personality and estimated intellectual functioning 

of each individual was assessed, and recommendations regarding suitability for military service and 

service specialties were made. The decisions made 

concerning suitability largely reflected the belief that 

psychiatric symptoms and illnesses reflected a “weak 

personality”; individuals with psychoneurotic illness 

were not normal, and thus not capable of marshalling 

defenses needed to serve during war.3 This method 

of screening military soldiers for service is largely 

viewed by historians as a failure.4 However, as a consequence of the efforts, the perception of psychology 

as a valuable science capable of producing results of 

immediate and practical significance to command was 

substantially bolstered.5

In 1941, Harry Stack Sullivan was appointed as a 

psychiatric consultant to the Selective Service Program 

and helped develop a more comprehensive system that 

incorporated screening interviews.6 However, over the 

course of World War II, attitudes changed about the 

effectiveness of these screening methods and many began to view them as excessive, ineffective in accurately 

predicting the resilience of individuals to withstand the 

risks of war, and resulting in a substantial and excessive loss of potential soldiers.6–8 After World War II, 

psychiatric screening methods were modified to focus 

on identifying and disqualifying only gross psychiatric 

disorders. This process has remained in place since 

then, with varying modifications over time. 

Although the screening purpose has remained 

relatively unchanged, the debate continues over the 

role that preexisting medical and psychiatric conditions have in making individuals more vulnerable to 

negative outcomes in times of stress. Conflicting data 
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Psychiatric Consultation to Command

continue to exist as to whether preexisting psychological conditions are a contributing factor to psychiatric 

attrition in a combat zone.9–18 This debate is especially 

salient given the estimated rates of depression, anxiety, 

and posttraumatic stress disorder in returning Operation Iraqi Freedom and Operation Enduring Freedom 

veterans.19

What remains unclear is what number of service 

personnel experiencing psychiatric problems upon 

return from combat had preexisting mental health 

conditions before deployment and, more specifically, 

what number had conditions that existed prior to 

entry into the service. The psychiatric conditions that 

should perhaps preclude service because of vulnerability under stress, which may only have minimal 

effects on the well-being of soldiers in combat, are not 

yet understood. 

Since the establishment of the Office of Strategic 

Services in World War II, screening processes have 

also been conducted in soldiers seeking special duties. Through the years, the role of behavioral health 

professionals has evolved with expansion of special 

operations and special missions. Not only do psychologists screen applicants for suitability for special 

operations, they also monitor progress throughout 

special operations training.20 After training has been 

completed, psychologists screen soldiers for special 

missions, which requires these behavioral health 

professionals to carefully assess the “biopsychosocial 

fit” of individuals to their specified mission tasks. 

Mental health providers must become familiar with 

the demands that will be placed on the soldier (ie, 

isolation from others, exposure to extreme conditions), and work intimately with command regarding the establishment of desired competency for the 

mission. This aspect of command consultation is 

unique in that the commander of the mission will 

often dictate aspects of required competencies. It 

is the job of the mental health professional to apply these principles in a psychiatric framework for 

screening. Assessments are presently performed for a 

variety of special missions (special operations service 

members) or specialty job requirements (security 

clearance evaluations, intelligence positions, nuclear 

weapons specialists). 

Preventive Psychiatry

Military psychiatrists were the first to focus on the 

total social environment of the individual in establishing programs not only for the treatment, but also the 

prevention, of mental illness.11 This shift in focus came 

in 1944, when the Army began using psychiatrists in 

a preventive fashion, morphing the role of psychiatry 

from overseeing straight disposition of personnel into 

recommending how to use marginal personnel and 

implementing mental hygiene training programs.21

Furthermore, the Vietnam War provided a unique 

opportunity to understand combat, from which significant understanding of the individual’s response 

to extreme conditions was gained.11 Thus, the role 

of psychiatry in providing primary, secondary, and 

tertiary prevention training based on understanding 

the biopsychosocial influences on behavior was established. The effectiveness of preventive psychiatry 

was later shown by the Group for the Advancement 

of Psychiatry when it reported that preventive psychiatry could reduce combat ineffectiveness through 

early recognition and prompt outpatient treatment of 

emotional difficulties during combat and noncombat 

situations.22

Much of what is understood about prevention of 

psychiatric casualties comes from the work of William 

C Menninger, who identified the failure to meet basic 

needs (such as food, water, sleep, social interaction, 

and recreation) as a significant contributor to the incidence of psychiatric casualties in combat.7

 Likewise, 

unit cohesion and morale have repeatedly been found 

important in supporting individual coping behavior 

and unit performance, both in wartime and in peacetime.23,24 Although morale remains difficult to operationally define, it may be considered to represent the 

general sense of unit cohesion, confidence in ability, 

and overall well-being of a unit. Failure to experience 

positive morale in a group (because of a lack of order 

and security, a lack of fusion with the group, having 

insufficient leadership, or lack of absorption into the 

unit’s work) has been associated with increased psychiatric referral, at least upon initial deployment.23

Morale and unit cohesion are often synonymous; one 

of the greatest defenses against breakdown in combat 

is the development and reinforcement of group cohesiveness.25

Additionally, it has been well documented throughout history that the time spent exposed to combat correlates with the number of psychiatric casualties.21–26

This was perhaps most salient in the Vietnam War, 

where soldiers knew that if they could survive for 12 

months, their removal from combat was assured. The 

rest-and-recreation policy, which sought to reduce continued exposure, was also widely implemented. The 

effect of time on psychiatric visits has also been seen 

in recent conflicts, where multiple studies have noted 

an increase in combat operational stress reactions after 6 months of deployment.26,27 Understanding these 

factors, as well as their historical context, provides a 

framework for application of current principles and 

avoidance of prior pitfalls.
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Combat and Operational Behavioral Health

FACTORS ASSOCIATED WITH COMMAND CONSULTATION

As the consultant prepares to perform an evaluation, there are several factors that must be considered. 

These include the environment, the nature of the request, and the proximity of the consultant to the unit 

or individual being evaluated.

Deployed Versus Garrison

Consultations can vary significantly depending 

on the environment. In a garrison environment, commanders are generally looking for risk reduction 

methods and to determine if a soldier is fit for duty 

or deployment. During deployment, commanders 

are more focused on interventions for maintaining 

their combat power and assessing the levels of unit 

cohesion and soldier quality of life to maintain soldier 

readiness. 

Level of Preventive Consultation

Preventive consultative advising involves using the 

threats identified during the planning and oversight 

phases of operations and making recommendations 

to the medical staff and command on measures to be 

taken and areas requiring command emphasis. Three 

categories of prevention can generally occur both in 

the garrison and deployed environment: (1) primary 

prevention, (2) secondary prevention, and (3) tertiary 

prevention. These prevention activities are especially 

critical in the deployed environment given that resources may be limited.

Primary Prevention

Primary prevention generally comes in the form 

of education. Most units regularly employ periodic 

training on topics such as prevention of sexual assault, 

suicide, and substance abuse. These training sessions 

allow behavioral health professionals an opportunity 

to gain visibility with command and soldiers alike. 

Furthermore, behavioral health professionals can play 

key advisory roles in preparation for deployment, as 

well as during deployment, in such areas as training 

(including training schedules), personnel issues, discipline, crosscultural issues, and, most importantly, the 

morale of the unit. All preventive services provided in 

garrison and during deployment establish credibility 

with the command. 

Recently, in response to evolving technology and 

the recognition that soldiers and commanders are 

presented with differing stressors throughout the 

deployment cycle, the Army Medical Department 

designed an educational series called “Battlemind” 

training.28 These modules were designed for specific 

portions of the deployment cycle, to build upon a 

soldier’s strength, help soldiers develop resiliency in 

stressful situations, and to teach soldiers how to utilize 

their strengths during times of transition. Modules 

for both soldiers and their families were designed for 

predeployment, reintegration (immediate return from 

a deployment), and reconstitution (90–180 days after 

return from deployment).28 Initial research on the effectiveness of “Battlemind” training appears promising; 

this effectiveness will continue to be explored.26,29

Secondary Prevention

Secondary prevention involves identifying as early 

as possible those soldiers who are at risk to develop 

mental health problems and intervening to prevent 

the development or worsening of symptoms after exposure. These types of procedures are accomplished 

both through individual and unit-level screening and 

also through traumatic event management.

Postdeployment psychological screening has been 

growing in importance since Operation Desert Storm 

in 1991 and became mandatory in 1997.30,31 Shortly 

thereafter, the Department of Defense introduced the 

Post-Deployment Health Assessment, which screened 

soldiers for physical and mental health problems 

upon return from deployment. It was a method for 

early identification of problems and for decreasing 

the stigma associated with behavioral healthcare. 

However, few studies have looked at validating the 

postdeployment screening instrument against other 

measures or functional outcomes.32,33 Furthermore, 

experiences from other samples of returning soldiers 

indicate that rates of reported deployment-related 

symptoms increased with time after returning from 

deployment.19,34,35 This led to an extension of the PostDeployment Health Assessment program to include 

a reevaluation (the Post-Deployment Health Reassessment) at 3 to 6 months after return from a combat 

zone.36 These programs allow for early identification; 

however, there has been notable criticism that effective 

follow-up of the concerns identified has not occurred.37

It is important that consultants be engaged throughout 

these screening processes and that commanders be 

very involved. Both occurrences will increase soldier 

participation and help decrease the potential for soldiers to “fall through the cracks.”38

Other assessment methods allow for broad unitwide assessments rather than individual screenings. 

An example of this type of method is the Unit Behav-
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Psychiatric Consultation to Command

ioral Health Needs Assessment. This tool allows the 

consultant to take a sampling of a unit, employing a 

standardized survey that assesses areas such as morale, 

cohesion, ongoing stressors, and soldier concerns, as 

well as current levels of need and barriers to care. 

This allows the consultant to provide the commander 

with clear objective findings and provide customized 

recommendations specific to the unit. Additionally, the 

Unit Behavioral Health Needs Assessment has comparison data that have been collected from multiple 

units at varying stages throughout Operation Iraqi 

Freedom to serve as a gauge.39

Another area of secondary preventive psychiatric 

consultation is that of traumatic event management 

(TEM). TEM involves intervening after a potentially 

traumatic event has occurred, with the purpose of 

seeking to decrease the effect of the event and prevent 

long-term negative consequences. Considerable debate 

continues between both military and civilian behavioral health providers about the utility and efficacy of 

debriefings (which are traditionally part of an overall 

TEM strategy) as preventative interventions. Traditionally, the TEM process is conducted at the request of a 

unit supervisor to begin the process of integrating a 

traumatic experience into the individual and group 

experience. Debriefings involve a structured meeting 

of all parties directly involved with a traumatic event. 

Members of the group tell their individual stories 

about what happened in the presence of trained behavioral health providers or chaplains, followed by 

processing of the cognitive and emotional components 

of the event. 

Currently there are many different models for 

debriefings. Most evolved out of Marshall’s work in 

World War II when he attempted to record accounts of 

unit operations for historical purposes.40 Interestingly, 

these initial sessions were not for the expressed purpose of psychological benefits to the involved parties. 

Marshall noted, however, that during the process of 

debriefing many misperceptions were corrected by 

other individuals involved in the traumatic event, 

and the debriefing appeared to render social support 

and decrease the development of combat stress reactions.40

Although debriefings have been used throughout 

military conflicts, their effectiveness has not been 

well documented in research studies and they have 

not been proven to prevent posttraumatic stress disorder.41–44 Part of the problem in examining the utility 

of debriefings is the evolution of what TEM actually 

entails. In fact, “debriefings” are now thought to take 

many forms commonly used by all military personnel, to include after-action reviews, which are now a 

standard operating procedure for all US Army teams 

and small units following any training exercise.40

Other forms of debriefings include defusing, critical 

event debriefing, critical incident stress debriefing, 

psychiatric debriefing, historical debriefing, and intelligence debriefing. Thus, one of the inherent problems 

in determining the effectiveness of TEM is the lack of 

consistent standardized protocols across providers and 

across organizations. Furthermore, what constitutes a 

debriefing, or what form of a debriefing to use for a 

particular circumstance, often varies. 

Despite all of the inherent problems in TEM definition, standardization, and demonstrable utility, TEM 

nonetheless remains a common consultation task that 

is expected of behavioral health providers, and thus it 

is imperative that behavioral health providers be proficient in TEM. US Army Field Manual 4-02.51, Combat 

and Operational Stress Control,

45 provides a standardized 

outline and structure for current TEM operations. The 

Army has recently introduced Battlemind psychological debriefings.46 These debriefings take into account 

military rank and structure and incorporate resiliency 

based educational principles that help to build upon 

the soldier’s strengths during the process. As with 

other debriefing methods, the effectiveness of this 

process is not known at this time.

Tertiary Prevention

Disease nonbattle injuries—specifically combat operational stress and psychiatric casualties—have long 

accounted for vast numbers of non–mission-capable 

soldiers. Indeed, one of the defining principles of history’s victorious commanders has been to “break the 

enemy’s will to fight,” and thus produce combat stress 

and psychiatric casualties in the opposing force. History has revealed consistent themes in soldiers who 

persevere in combat compared with those who break 

down in combat, with the difference in outcome often 

being reduced to adaptability and cohesion.23,24 Tertiary 

prevention involves the treatment of those who have 

ongoing issues, with the goal to return soldiers to duty 

and to advise commanders on who should be removed 

from the combat operations. 

Internal (Division Mental Health) Versus External 

(Combat Stress Detachment) Resources

The primary resources responsible for preventive 

psychiatry missions and the control of combat operational stress during both garrison and deployment are 

the combat stress control (CSC) and division mental 

health (DMH) units. These units establish a diplomatic 

relationship with command to earn credibility in the 

consultative role. Preventive missions of both of these 
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Combat and Operational Behavioral Health

units are defined by US Army doctrine as the following: consultation-liaison services; reorganization and 

reconstitution support; proximate neuropsychiatry 

triage; and stabilization, restoration, and reconditioning and retraining.23

Although the mission is the same, the two units 

have notable differences that present varying challenges. DMH units are organic to the organization and have 

been deploying in that structure since World War II.47,48

Recently, the transformation of the US Army from a 

division-centric focus to one in which the brigade combat team is the primary unit of action has resulted in the 

expansion of the DMH organization and mission. (In 

this volume, Chapter 6, The Division Psychiatrist and 

Brigade Behavioral Health Officers, discusses DMH 

and the positions within it at much greater length.) 

DMH units are with the larger organization both in 

garrison and during deployment and thus have the 

ability to establish long-term relationships with commanders and implement long-term prevention plans. 

These units, however, tend to be smaller and more 

limited in capability than CSC units. 

Like DMH units, CSC detachments have been 

evolving for quite some time in the US Army. They 

first appeared during the Korean War when Colonel 

Albert Glass established these teams to augment 

existing DMH assets.47 Glass, drawing on his own 

experiences from World War II, organized what were 

called “KO” teams (the “KO” designation refers to 

one in a series of hospital augmentation detachments). 

They provided mobile consultation throughout the 

corps and US Army areas.47 The first KO teams were 

deployed to Korea; CSCs have augmented organic 

mental health assets in every major conflict since that 

time. They officially became known as CSCs in the 

mid-1980s. Presently, the CSC model remains largely 

unchanged from that originally established by Colonel 

Glass; however, the mission has expanded to include 

additional preventive psychiatric care and restoration 

capabilities. Today, CSC detachments and companies 

traditionally provide US Army Echelon II or III care 

during deployed operations and are external to the 

brigade, division, or other unit.45

Local Versus Remote Behavioral Health Resource

The type of consultation may dictate the use of a 

local versus a remote behavioral health resource. For 

issues that will require ongoing follow-up and will 

require a relationship with a commander, it is best to 

use local resources. These individuals are more apt to 

have some familiarity with the systems, personnel, and 

processes involved and can develop ongoing relationships with the commanders and provide follow-up. 

An excellent example of this process is the use by a 

brigade behavioral health officer of a unit behavioral 

health needs assessment within a battalion. The officer 

may have only a limited relationship with that commander but has some familiarity with the brigade. The 

officer performs the assessment and informs the command of the key findings and recommendations. As 

a local resource, the brigade behavioral health officer 

is then able to follow up with the unit and continue 

to both monitor and reassess the situation to provide 

continued feedback to the leadership. These processes 

allow for identification of such items as barriers to care, 

stigma about using mental healthcare, and leadership 

issues.

In contrast, remote consultations will generally require mobilization of a team to conduct an evaluation, 

make recommendations, and then return to its home 

station, likely not to follow up again or with limited 

follow-up. These types of consultations tend to occur 

in units that have minimal mental health contacts 

or desire an independent assessment from someone 

who has minimal to no knowledge of the unit or its 

experiences. 

Examples of these types of consultation can be seen 

in the site assistance visit or with the epidemiologic 

consultation team evaluations of suicide behaviors that 

have occurred at several sites throughout the Army in 

the past several years. In these cases, the team arrives, 

does a thorough analysis of potential factors, interviews individuals from the unit, and then provides a 

report of its findings and recommendations. It is left 

to the unit and local personnel to enact and follow up 

those recommendations. 

PERFORMING THE CONSULTation

Forming a Consultative Team

A consultation can be completed by either an 

individual clinician or by a team. If forming a team, 

the lead consultant should seek individuals who 

either have areas of expertise that will be needed to 

answer the consultation question, or with similarities 

in experience or background to the group requesting the consult. When assembling a team, it is also 

important to ensure it can work cohesively. The lead 

consultant must make clear the roles and duties of 

each team member. This can be especially difficult if 

the members have not worked together before and 

are coming together solely for the purpose of a consultation. It is often immediately evident if a team is 

or is not working together. Team cohesion will often 
177

Psychiatric Consultation to Command

determine success of the consultation process and 

whether the consultation is performed adequately, 

effectively, and efficiently.

Formulating the Consultation Question

Prior to performing the consultation, the clinician 

should ensure that the question being asked has been 

clarified. For instance, the consultative question can 

concern clinical care requirements or the deployability of a particular soldier, or it may include a broader 

question of unit policy, behaviors, or actions. The consultative team needs to ensure that it focuses its efforts 

to meet the needs of the requesting commander. The 

team should only give additional information about individuals on a need-to-know basis. Once the nature of 

the request is determined, specific goals of the consultation must be established. Often command and other 

military personnel are unclear of their desired “goals,” 

and are best able to describe a “desired end state.” 

Setting specific goals at the onset of the consultation 

will ensure that expectations are met. It will also help 

prevent any misperceptions of what the consultative 

team is doing or its capabilities. In addition to setting 

goals, it is also important to explain the limitations of 

the consultative team. One specific difficulty can arise 

if the requesting commander believes that a consultation also provides treatment. An illustration of this 

misperception is discussed below. 

Case Study 12-1: A company commander came to the 

brigade behavioral health office during a deployment in Iraq. 

He stated that one of his route clearance platoons was recently having behavioral problems. It was also failing to find 

as many improvised explosive devices as it had on previous 

missions. After the brigade behavioral health officer went on a 

route clearance mission with the platoon members, it became 

evident they were fatigued—arguing with each other instead 

of focusing on the mission—and frustrated about not having 

had a day off in weeks. When this information was shared 

with the company commander, the command expressed 

confusion with regards to the outcome of the consultation. 

Specifically, the command in this instance had expected the 

brigade behavioral health officer would “fix” the soldiers by 

just spending time with them. Instead, the behavioral health 

officer had taken the consultative question and developed 

recommended changes in the soldiers’ schedules. This 

example highlights the need for the consulting provider to 

clarify the request, set clear goals, and explain the limitations 

of the consultation services. Attention to these processes 

can ensure both parties are clear about the goals of the 

consultation and satisfied with its outcome. 

Gaining Entry to the Unit

A consultation generally occurs at the request of the 

unit’s commander. First and foremost, an appropriate 

member of the chain of command must request the 

consultation. During deployments, this can be difficult, 

because many individuals, especially those in combat 

stress detachments, want to assist the unit. However, 

if their participation is not invited, the “consultation” 

may develop into a confrontational relationship with 

the commander. 

Additionally, the consultation team must establish 

rapport with the soldiers being evaluated. It should be 

clear that the team is there to help the unit, not to blame 

or hold certain members responsible for any problems 

that the unit may have. Demonstrating that the team 

cares and wants to make improvements will increase 

the willingness of the unit to disclose factual as well 

as emotional material, thus providing information that 

may assist in answering the consultation question. 

It is important that the unit views the consultant 

as someone who is genuine; available not only in the 

moment, but for future involvement; supportive of 

their needs; and perceived as someone recognized in 

the field in which the consultant is asked to evaluate. 

Additionally, being someone who has provided assistance previously or spent time with members of the 

unit helps to establish an early rapport. By ensuring the 

behavioral health consultant possesses these qualities, 

there is an increased likelihood of being asked into the 

unit, as well as ensuring the consultant will be used 

again in the future. 

In Case Study 12-1, concerning the evaluation of the 

route clearance platoon, the consultant had previously 

gone on a few route clearance missions with the soldiers for no other reason than to understand what their 

mission was and experience what it was like. Not only 

did this permit the consultant to earn the respect of the 

soldiers, it also solidified the consultant’s credibility 

with command and led to numerous consultations in 

which the consultant was able to assist the unit.

Explaining the Purpose of the Consultation

Before gathering information from soldiers, it is 

necessary to explain the purpose of the consultation, 

including who requested it, what information is being 

gathered, and what will be done with that information. 

It is imperative for all parties in the evaluation to be 

clear about all the issues involved, including legal and 

ethical ones, and potential consequences. Knowing the 

basic legal rights of the individuals undergoing the 

process, as well as to whom to refer service members 

if issues arise, is also important. Furthermore, walking 

the involved parties through a step-by-step overview 

of the process and then performing a “back brief” will 

also ensure that command understands the consulta-
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tion process. Finally, clarifying the scope of the consultation process as it is occurring is essential. 

Cross-Service Consultations

In some cases, individuals may be required to perform consultations for another US military service. The 

consultative team should review the doctrine, regulations, and mission-specific goals for sister services and 

their units because there may be significant differences 

in how information is gathered, what documents are 

used, and how information is shared. Additionally, 

consultants should take time to learn about the differences in a particular service’s systems, as well as 

the differences in unit functions. Consultants can 

demonstrate interest by explaining what information 

they have already learned, then asking questions that 

may assist in better understanding the sister branch. 

This process will likely guide the consultation while 

building rapport. 

Uniform

One of the greatest challenges for a consultative 

team is to establish trust and mutual respect with the 

leadership requesting the consultation. To further this 

end, team members should determine the current uniform status of the unit to which they are consulting and 

dress accordingly. For example, if the consultative team 

was meeting with a number of line commanders in a 

field environment, the Army Class B uniform would 

not be appropriate. 

Additionally, members of the consultative team 

need to ensure that they display the proper wear, fit, 

and appearance of the uniform. Commanders may 

see it as a sign of disrespect and lack of concern about 

their military mission if consultative team members 

do not pay attention to what is the proper uniform; 

this can have a negative effect on the relationship 

developed between the team and the command. In a 

deployment setting, knowing what the proper uniform is and wearing it appropriately may also be a 

safety concern because some locations are at high-risk 

for attacks, therefore requiring more extensive gear 

and protective wear. Moreover, it can provide yet 

another segue in building rapport with the unit by 

showing interest in how it operates, while decreasing 

the psychological distance between the consultant 

and unit members. 

Language 

The consultative team members should identify the 

common terminology, slang, and descriptive terms that 

are frequently used by the organization requesting the 

consult and adapt their own language to those with 

whom they are speaking. Not only does this require 

adapting to the language of the command, but also to 

that of the members of the unit. Speaking in simple 

language, minimizing medical jargon, and not using 

“psychobabble” are recommended. However, when 

trying to adapt one’s own communication style to that 

of the group, do not use obscene or coarse language 

that may jeopardize professional credibility. 

Understanding Unit Structures and Functions 

Prior to providing a unit with recommendations 

for intervention and ideally prior to beginning the 

consultation, consulting clinicians should educate 

themselves about the unit or organization requesting 

the consultation. Understanding the unit and its mission will guide how the consultant engages with the 

participating soldiers and the interventions that might 

be recommended. It is helpful to know the formal and 

informal structure of the unit and how it directly and 

indirectly affects the unit. Relying solely on an organizational chart of the unit would be remiss. Many 

subgroups and personalities frequently play a significant role in how the unit runs and operates. Gaining 

knowledge on how communication is relayed and who 

has the power in the unit is also of utmost significance. 

Making assumptions due to rank (enlisted or officer) 

and branch could lead to false or inappropriate conclusions. Additionally, the consultant must be cognizant 

of the limitations that these functions place on their 

recommendations; otherwise, it may set the unit up 

for failure or not have the intended result. 

Case Study 12-2: A company commander at a patrol base 

in Iraq stated that morale was down and he wasn’t exactly 

sure why. He asked the brigade behavioral health officer if 

she could assess the situation and give him some feedback 

and recommendations. After surveying the unit and talking 

to the soldiers at length, the consultant determined that the 

soldiers were frustrated with their leadership because they 

felt they were not receiving information on missions and they 

were doing missions that were not necessary, thus putting 

them in harm’s way. This information was back briefed to the 

commander. When the situation was reassessed a week 

later, nothing had changed; the soldiers continued to be 

frustrated and unmotivated. During the reassessment, the 

behavioral health officer determined that the first sergeant 

was failing to provide information to the soldiers, leading 

to a breakdown in information flow within the unit. Until the 

first sergeant was briefed directly, none of the feedback 

from the consultation had been discussed or implemented 

at his level. Once he fully understood the recommendations, 

he began making changes on the patrol base and morale 

began improving. 
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Engaging With Soldiers 

Consultants need to be cautious about how they 

begin a visit. Many times the participating soldiers 

will decide within the first 5 minutes whether they 

feel the effort of talking with a consultant is relevant 

to them and if they will participate. It is the job of 

the consultant to get service members to “buy in” to 

the consultation process. Many times it is effective 

to begin by opening with a question and seeking the 

participants’ responses and input rather than talking to 

them at length. Zeroing in on key leaders and getting 

them engaged in the process will lower the barriers and 

intimidation of other soldiers who may be reluctant to 

get involved. Consultants should inform the unit of 

how they want to help the unit and the soldiers, while 

telling the soldiers that they are the true experts and 

allowing them to inform the consultant. Taking the 

time to sit back and listen to them in their element (ie, 

motor pool, guard towers, etc) will assist in making 

soldiers feel comfortable and further reinforce how 

the consultant values their opinions and knowledge. 

Soldiers are trained and conditioned to listen and take 

orders, so when somebody sits back and genuinely 

listens, a lot of valuable information and insight can 

quickly and easily be gathered. 

Interventions 

The consultant must consider realistic interventions 

that are not only applicable to the current conditions, 

mission, operational tempo, and resources available, 

but also with realistic implementation strategies. As 

one division commander in combat expressed to a 

visiting consultation team, “Don’t tell me it’s hard 

here or that conditions suck, we all know that. Don’t 

give me platitudes, give me clear and specific guidance that my commanders can actually use to help 

my soldiers.”

To meet these goals, the consultant must consider 

realistic interventions that will address function as 

opposed to pathology. These include educating the 

unit as well as the command on how the intention 

of the intervention is to keep soldiers ready to fight 

and make them more productive for the mission; 

briefing the commander with simple, objective, and 

clear-cut ways that the situation can be improved 

using clearly defined recommendations that can 

be easily implemented; and reinforcing in a stepby-step method how the recommendations will be 

executed and how they will ultimately improve the 

unit’s ability to accomplish its mission. Once the 

interventions have been made, it is imperative that 

the consultant remains available to clarify any ambiguities or address any questions that arise during 

the implementation process. 

Terminating the Consultation 

The type of consultation determines the number of 

sessions required. Some consultations will be over after 

one visit, others might last several months. As part of 

terminating the consultation, a final report should be 

provided to the requestor, the participants should be 

thanked, and those who may have developed relationships during the consultation experience should have 

an opportunity to say goodbye. Consultants must 

ensure all of their questions have been addressed, and 

make certain they have provided information for future contacts while imparting other resources that may 

be of assistance. It is preferable that the consultants 

talk to all parties involved in the consultation process 

to close all the loops of communication. Consultants 

use valuable unit resources such as time, energy, and 

information. Therefore, it is important to include the 

contributing parties in the termination process. 

A good consultation can be ruined by a poor 

termination. If consultants leave the group feeling 

“used” or “no longer important” then they will lose 

credibility. It is probable that the long-term benefit of 

their interventions will fail because they are likely to 

lack unit acceptance. Additionally, it can make it more 

difficult to gain access to future groups for establishing 

consultative relationships. 

Reporting the Consultation 

As part of the termination process, a report should 

be given to the requestor. This may not initially be in 

written form, but should at least be via a back brief 

and then followed at a later date by a written brief 

with recommendations. A formal out brief should 

always be offered to the commander who has allowed 

access into the unit. This not only shows respect and 

understanding of the command relationship, it also 

provides access to the person who can implement the 

recommendations and programs suggested. Furthermore, it is an opportunity to gain insight into areas 

that may have been missed or may require further 

study. This should be followed by sending a written 

brief subsequent to the back brief, which guarantees 

that consultants have had time to reflect and consider 

all aspects of the group; think things through more 

carefully; and consult with a trusted colleague if any 

reservations have arisen.49 It will also provide the consultant with an opportunity to ensure that the consultation question has been answered clearly and concisely 

while ensuring the commander’s objectives were met. 
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Additionally, if the consultant intends to use the information from this report for any other endeavor, such as publication or report to any outside agencies, then 

permission should be gained from the unit.

DETERMINING FITNESS FOR DUTY AND DEPLOYMENT CLEARANCE 

At times, consultants are requested by commanders 

to determine if a soldier is fit for continued military 

service or deployment. There are several aspects associated with determining fitness for duty and deployment clearance. 

Disqualifying Conditions 

The first step is to have a thorough and detailed 

understanding of Army Regulation 40-501, Standards 

of Medical Fitness, particularly Chapters 3 and 7.50

Chapter 3 outlines the standards for medical fitness 

and separation. Chapter 7 provides guidance on profiling.50 Current Army regulations require soldiers 

with disorders with psychotic features not caused by 

organic pathology or toxic substances to undergo a 

medical board to determine fitness for continued service in the military. This includes bipolar disorder and 

schizophrenia or any other mental disorder that causes 

gross impairment in reality testing. There is further 

guidance regarding other diagnoses and the criteria 

for referral to a medical board. In general, mood, 

anxiety, somatoform, and dissociative disorders are 

disqualifying if they necessitate recurrent hospitalization, persistently limit duty, or interfere with effective 

military performance.50

Personality, substance-related, and adjustment 

disorders are generally not disqualifying through 

the physical disability system, but may be cause for 

administrative separation. Before recommending administrative separation for these conditions, a detailed 

exploration for potential posttraumatic stress should 

be performed, particularly in previously deployed 

soldiers with changes in behavior patterns, because 

the outcome of the evaluation may significantly affect postseparation benefits and access to ongoing 

medical care.

Medical Profiling 

Army Regulation 40-501, Chapter 7, details physical 

profiling and is an area of ongoing confusion and contention among soldiers, providers, and commanders.50

A thorough knowledge of the regulations will enable 

providers to clearly articulate both the limitations of 

the profile and the regulatory responsibilities of command, and ensure expectation management on the part 

of the profiled soldier.

The profile serial system (P-U-L-H-E-S, which 

stands for Physical capacity or stamina; Upper extremities; Lower extremities; Hearing and ears; Eyes; 

and pSychiatric) is used to define the effects of a 

soldier’s medical condition in relation to the performance of duties. Psychiatric disorders are denoted 

in the “S” section and rated from 1 to 4. This rating 

is to provide an assessment of overall functioning 

and is not based on the diagnosis itself. When determining the rating, the provider must consider the 

type, severity, and duration of symptoms, amount of 

external stressors, predisposition, intelligence, prior 

psychiatric history, and current duty performance. 

Additionally, the regulation provides some specific 

guidance for conditions that require a particular rating to be given, including when (a) no psychiatric 

pathology is evident; (b) there is a history of recovery of an acute psychotic reaction from external but 

non–substance-abuse-related cause; (c) there has been 

remission of a mental health disorder that is not otherwise disqualifying, but requires either limitations of 

assignments or duties; and (d) a rating of “3” cannot 

be met.50 Assignment of a permanent S3 or S4 rating 

requires a medical board to be performed.

The specific limitations recommended on the profile 

are as important as the profile designator. According 

to Army Regulation 40-501, the condition itself should 

not be the sole consideration when recommending 

limitations. The profiling officer must also consider 

the prognosis, the possibility of aggravation, and the 

effects the profile will have on the soldier’s ability to 

perform required duties.50 The regulation states specifically that profiles “must be realistic.”50(p73) Profiles are 

required to be specific and written in lay terms.50

It should be clearly articulated to a soldier being 

profiled that determination of duties, assignments, and 

deployment are command matters. Given this, profiles 

such as no deployment, no field duty, or no overseas 

duty are “not proper medical recommendations”50(p73)

to be written on a profile. It is incumbent upon the 

profiling officer to provide adequate and clear recommendations so the commander can make an informed 

decision based on medical limitations and capacities, 

duty requirements, assignment limitations, mission 

requirements, and duties of the soldier among other 

command and mission-related issues.

If the commander does not feel the soldier can 

perform within the profile, reconsideration can be 

requested. If requested, reconsideration must be accomplished and will either amend the profile or re-
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validate it. This can be requested for both temporary 

and permanent profiles. 

Deployment Clearance 

In the fall of 2006, the Assistant Secretary of Defense 

for Health Affairs and The Surgeon General, US Army, 

provided guidance on the minimum mental health 

standards for deployment.51 This policy was outlined 

in a memorandum, “Policy Guidance for Deployment 

Limiting Psychiatric Conditions and Medications.” This 

guidance came in response to a congressional directive52 after several media reports stated that mentally 

ill soldiers were being deployed who were unstable or 

taking medications without follow-on care. Additionally, some media reports cited soldiers being started on 

medications shortly before deployment and receiving a 

year supply of medication without monitoring. 

Key factors in the policy related to mental health 

conditions and medications included: (a) soldiers currently being treated for psychosis or bipolar disorder 

were not deployable; (b) soldiers who were taking 

medications that require laboratory monitoring, such 

as lithium or valproic acid, were not deployable; (c) 

soldiers who are taking antipsychotic medications to 

control psychotic, bipolar, or chronic insomnia conditions were not deployable; (d) the continued use of 

psychotropic medications that are clinically and operationally problematic during deployments, including 

short half-life benzodiazepines and stimulants, should 

be balanced between the necessity for successful functioning in the theater of operations and the ability to 

obtain the medication, the potential for withdrawal, 

and the potential for abuse; (e) soldiers with significant 

mental health conditions require 3 months of stability 

prior to deployment; and (f) if a soldier is placed on a 

psychotropic medication within 3 months of deployment, then that soldier must be improving, stable, 

and tolerating the medication without significant side 

effects to deploy.51 Although not articulated in the 

policy, consideration should be given to monitoring, 

for at least 1 month prior to deployment, any soldier 

on medication for anxiety, depression, or insomnia.

Screening for conditions that preclude deployment 

as part of the predeployment health process enables 

identification of soldiers not meeting minimum criteria 

for deployment. The screening process in one deploying unit prior to Operation Iraqi Freedom in 2007 

consisted of an initial survey that was filled out concurrently with the predeployment health assessment. 

This process identified any soldier who was currently 

on any psychiatric medication, under psychiatric care, 

or experiencing significant stressors. Soldiers who 

screened positive were referred to mental health services for an evaluation for deployability based on the 

outlined minimum standards for deployment. Those 

who met standards were cleared. Those who did not 

were either referred to a medical board or the provider 

met with command to discuss limitations. Soldiers 

were then either left on rear detachment (delayed in 

deployment until stable on medications [typically 1–2 

months]) or a waiver was granted through the combatant command surgeon. In general, the number of 

soldiers requiring clearance was minimal (less than 

20/3,500 soldiers) because the majority who were unable to deploy were identified prior to beginning the 

predeployment screening process. However, this is 

an important safety mechanism that is recommended 

to all deploying units, and it is likely that a standardized procedure and survey will be implemented in 

the near future.53

Separation From the Military 

At times soldiers may have mental health conditions 

that make them unfit for duty, although they do not 

require a medical board per se. These conditions are 

defined in Army Regulation 635-200, Enlisted Separations.

54 Although these separations are primarily a 

command function, an evaluation and diagnosis by 

an appropriately credentialed provider is required. 

Functional knowledge of these chapters and the 

separation process will enable consultants to counsel 

commanders—who may be junior or facing other more 

pressing issues—regarding the appropriate and judicious use of these actions, thus avoiding unnecessary 

delays, misdiagnoses, inappropriate separations, and 

potential procedural errors.

Mental health providers will predominantly be 

involved with Chapter 5-13 (personality disorders) 

and Chapter 5-17 (other mental or physical disorders).54 Both of these chapters require that the soldier 

not have a condition that amounts to disability, and 

both require that the soldier be formally counseled 

and afforded “ample opportunity to overcome those 

deficiencies.”54(p56) These mechanisms should not be 

used in lieu of judicial actions or other administrative 

separations.

Chapter 5-13 states that a soldier can be separated 

for personality disorder if the condition severely impairs the soldier’s ability to function in the military environment. It further states it must be a long-standing 

and deeply ingrained condition.54 This is particularly 

important when dealing with the postdeployment 

soldier who may have confounding posttraumatic 

stress issues, mild traumatic brain injury, or acute 

situational issues. 

Chapter 5-17 deals with physical or mental is-
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sues that “potentially interfere with assignment to 

or performance of duty”54(p57) and are not covered 

under other areas of the separation regulations. 

This includes conditions such as claustrophobia; 

disturbances of perception, emotional control, or 

behavior; dyslexia; sleepwalking; or other disorders 

that may significantly impair the performance of 

military duties.

COMMAND-DIRECTED EVALUATIONS

Command-directed mental health evaluations 

are defined in DoD Instruction 6490.4,55 DoD Directive 6490.1,56 and US Army Medical Command 

Regulation 40-38,57 which outline rules for both discretionary and nondiscretionary command-directed 

referrals. Nondiscretionary evaluations are those 

required by regulation to include the positions of 

drill sergeant, recruiter, and sniper. Additionally, 

all soldiers undergoing certain chapter separations 

require mental status evaluations. However, when 

commanders request evaluations for soldiers who 

do not require assessment by regulation, they use 

their discretionary authority to request evaluation 

and feedback. 

When performing a command-directed evaluation, 

commanders should be provided a formal “Report of 

Mental Status” outlining feedback and recommendations. At a minimum, the report should address if a 

diagnosis exists, a prognosis for the soldier’s condition, any limitations, a review of soldier safety and any 

safety interventions required, and the soldier’s fitness 

for duty. Regulations require that the commander receive that report no later than 24 hours after completion 

of the evaluation. 

Additionally, evaluating providers must be familiar 

with the restrictions that their level of professional 

degree places on their ability to perform and sign command-directed evaluations. In general, non–doctorallevel social workers are able to perform and sign nondiscretionary evaluations. Discretionary evaluations 

and those recommending a Chapter 5-13 (personality 

disorder) or Chapter 5-17 (failure to adapt) discharges 

require a doctoral-level social worker, a psychologist, 

or a psychiatrist. If there is a condition in which the 

only available mental health provider does not have 

signing authority, such as during a deployment or in 

a remote location, then a physician may serve as the 

signing authority. 

RISKS TO THE CONSULTANT AND ETHICAL ISSUES IN CONSULTATION

As previously mentioned, serving in the role of a 

command consultant is very different from a typical 

doctor–patient encounter. The role of the consultant 

can at times present ethical challenges and difficult 

situations. 

Double Agency 

In command consultation, the military mental health 

provider is frequently called upon to simultaneously 

address the needs of both the unit and the soldierpatient. This dual responsibility is termed “double 

agency.” Sometimes in command consultation, the 

only “patient” is the unit, and there is not an identified 

soldier of concern. In other cases, a soldier is identified 

as the patient, and the provider has a responsibility to 

provide treatment and, at the same time, to advise the 

commander regarding the military’s most favorable 

course of action. The two are synchronous a majority of the time: that is, what is good for the soldier is 

also good for the military. For example, a soldier with 

permanent cognitive impairment from a brain injury 

should not remain in the military, because it would 

not be safe for that soldier to function in combat. Thus, 

the soldier is recommended for a medical evaluation 

board to determine the level of disability and ensure 

that this individual receives the appropriate long-term 

medical and financial benefits. Additionally, the unit’s 

needs are met because having an impaired soldier in 

combat poses greater risk for fellow soldiers, and by 

medically boarding such a soldier, the unit is able to 

receive a healthy replacement. 

However, a mutually beneficial course of action 

does not always exist. Such is the case when a dysfunctional soldier will suffer financial hardship, or the 

family will lose needed medical benefits due to separation from the military. When making recommendations concerning treatment, limitations, or separation/

evacuation, the behavioral health officer must keep in 

mind the soldier’s ability to perform assigned tasks in 

a combat environment. This becomes more difficult in 

the case of soldiers who are struggling with the psychological effects of combat. The provider may find 

it very difficult to determine when is the proper time 

to remove a soldier from continued combat exposure 

while also keeping in mind the unit’s mission and 

current needs.

These situations must be carefully examined and, as 

with many ethical issues, there is no single correct answer. Discussion with colleagues or senior behavioral 
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Psychiatric Consultation to Command

health providers, including the theater mental health 

consultant, can be helpful in processing these issues 

and is recommended.

Confidentiality 

The commander has a right to know a soldier’s 

diagnosis, prognosis, treatment plan, and duty limitations. Beyond these concise details, the behavioral 

health providers must be very careful concerning what 

information is provided to the commander. However, 

the commander is under no such restriction and can 

provide a great deal of information to the behavioral 

health provider, including reports about the soldier’s 

ability to function at work, relationships with peers 

and supervisors, past occupational counseling, and 

the “other side” of the story. If viewed as partners 

on a team, rather than as adversaries, the consulting 

relationship between behavioral health providers and 

commanders can be mutually beneficial to each party, 

as well as to soldiers. Frequently, both the commander 

and the behavioral health provider can work together 

to help a soldier function better.

Thus, even though a commander has a right to 

know a soldier’s diagnosis, prognosis, treatment plan, 

and duty limitations, behavioral health providers 

certainly do not contact every patient’s commander 

with that information. If soldiers have mild symptoms 

that neither impair their functioning at work nor 

require duty limitations, there is no need to contact 

the commander. However, if there is risk to the unit, 

mission, or soldier, it is incumbent upon the provider 

to be certain that command is aware to ensure the 

ongoing safety and treatment of the patient, as well 

as that of the unit.

Objectivity Versus Intimacy 

When the mental health provider is closely integrated into the unit, ongoing relationships are established with commanders that significantly improve 

the effectiveness of the consultative process. However, 

because of this intimacy, some objectivity may be lost. 

The behavioral health provider needs to continually 

ask the question, “What is my role in this situation?” 

to ensure that appropriate impartiality is being maintained. As a result of the intimacy, the provider is also 

vulnerable to the same stressors and tragedies as the 

unit. Closely aligned behavioral health providers can 

still be able to help the unit during times of crisis, 

but also need to be aware of their own stressors and 

limitations. In some circumstances, behavioral health 

providers may need their own treatment or intervention as a part of the unit.

Short Versus Long Consultations and the Development of Relationships 

Some consultation relationships exist over an extended period of time, such as that of DMH officers 

with the commanders in their division. Others by 

nature are of a limited or one-time duration, such as 

a soldier who is seen for a command-directed mental 

health evaluation. Although a behavioral health provider may only plan to see a particular soldier for a 

single evaluation, frequently the provider ultimately 

has further contact with the command regarding 

other soldiers. This fosters the long-term consultative 

relationship. 

Every interaction with a commander has the potential to help a particular soldier, but also to “take the 

pulse” of the unit’s climate, to cultivate future cooperative relations, and to educate commanders about 

leader actions for decreasing combat operational stress 

within their units. The behavioral health provider’s 

conscious grooming of this relationship allows commanders to begin to feel more comfortable accepting 

behavioral health interventions for their soldiers, as 

well as for themselves.

Investigation Verus Consultation 

It can be easy for commanders to feel that they 

or their practices are being investigated during the 

information-gathering portion of a consult. This can 

feel intrusive and cause anxiety. For example, a commander in Iraq referred a soldier who had allegedly 

assaulted the unit’s first sergeant. The soldier reported 

having assaulted the first sergeant only after the first 

sergeant had pushed him against the wall in a chokehold. This situation required a careful consultative approach to balance advocating for the soldier, defusing 

tension at the unit, and promoting future consultation. 

Generally, approaching the situation from a shared 

problem-solving stance, rather than seeking to find 

blame, is more productive. 

Impact of HIPAA on Command Consultation 

Aspects of the Health Insurance Portability and 

Accountability Act (HIPAA) address safeguarding 

the security and privacy of protected health information, including names, Social Security numbers, dates 

of birth, and other patient identifying data. Soldiers 

are commonly designated on military records by 

this information. Military hospitals and clinics are 

required to comply with HIPAA, and generally have 

the required safeguards in place. Providers need to 

ensure that any protected health information sent 
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Combat and Operational Behavioral Health

electronically to commanders is either sent over a 

closed network, or that some form of encryption 

is used. Routine measures for HIPAA compliance 

ensuring patient privacy include placing computer 

workstations out of the public view and locking them 

when not in use, securing charts behind locked doors, 

and protecting identifying information on charts from 

being seen by others during an office visit.

NOTABLE CONSULTATIVE POSITIONS IN THE ARMY

Most military behavioral health providers will be 

placed in a command consultative role at some time 

in their careers, whether it is simply to evaluate one 

soldier or to provide an overview of a large unit. Three 

particular consultative roles merit further discussion: 

(1) Consultant to The Surgeon General of the Army; (2) 

member of a Mental Health Advisory Team (MHAT); 

and (3) division psychiatrist/brigade behavioral health 

officer. 

Consultant to The Surgeon General, US Army 

This assignment is generally a 4-year tasking, which 

the consultant undertakes in addition to usual assigned 

duties. In behavioral health, these consultant positions 

include research and clinical psychology, social work, 

psychiatric nursing, and occupational therapy. There 

are four consultant positions in psychiatry: general, 

child, forensics, and addiction. There is also a consultant for the Exceptional Family Member Program, 

which usually is either a pediatrician or a psychiatrist. 

Functionally, the consultant positions in general and 

child psychiatry, research and clinical psychology, 

social work, and psychiatric nursing contribute to 

assignment determinations for personnel in these 

specialties. 

For the last 20 years, these behavioral health consultants have been located throughout the United 

States, although principally at the US Army Medical 

Command Headquarters in San Antonio, Texas. After the attacks on September 11, 2001, the respective 

behavioral health consultants spent numerous weeks 

and months at the Office of The Surgeon General in 

Washington, DC. In 2007, a new Proponency for Behavioral Health was established, solidifying a requirement 

for a behavioral health consultant at the Office of The 

Surgeon General.

Key functions of the behavioral health Consultants 

to The Surgeon General of the Army include assignments, taskings for deployment, review of records, and 

strategic communications. 

Assignments 

The most important function of a Consultant to 

The Surgeon General is the task of assignments. The 

consultant recommends assignments to the specialty 

branch manager who makes the assignment decision. 

In general, the recommendations of the consultant are 

followed. The assignment process, however, involves 

several matrices. The current psychiatry consultant, for 

instance, asks graduating residents and staff who are 

eligible to move for a list of ten desired assignments as 

well as any family considerations. The consultant then 

generates a list of potential assignments. Additional 

related issues, such as whether candidates are medically deployable, are also considered. (It is essential 

to put deployable psychiatrists and other behavioral 

health assets in divisions and CSC units.) Following 

the Graduate Medical Education Selection Board and 

the Officer Distribution Plan conference (where Board 

decisions are made and announced), the draft assignments can be distributed. Request for orders and the 

actual orders subsequently follow. These orders may 

be modified in the event of unanticipated personnel 

changes or in the event of new, emergent missions.

The priorities for assignment are: first the needs of 

the Army and second the needs of the soldier. Army 

needs include the two graduate medical education 

programs (National Capital Area and Tripler Army 

Medical Center) and power projection platforms, 

such as Fort Hood, Texas; Fort Benning, Georgia; Fort 

Riley, Kansas; Fort Stewart, Georgia; and Fort Bragg, 

North Carolina.

Many assignment choices are dominated by family 

needs. Those couples with small children usually want 

to live as close as possible to their extended families. 

Spouses who are employed usually want to be able to 

find good career-related jobs. Some have aged parents 

or ill siblings to tend for. The consultant works to take 

all these needs into account, but the needs of the Army 

are still paramount.

Tasking for Deployment 

For “Tier I specialties,” including psychiatry, 

psychology, and social work, the consultant is now 

intimately involved in deciding who will be tasked 

to deploy. The “cardinal rule” for the Medical Command is that no one should go twice until all have gone 

once. The deployment decisions are now made at the 

Professional Officer Filler Information System support 

conference, with the input of the regional medical consultants. However, it is not infrequent that last-minute 
185

Psychiatric Consultation to Command

taskings will arise due to unforeseen illness, injury, or 

other factors that make a projected officer unable to 

deploy, requiring the consultant to review the entire 

provider inventory and adjust priorities of need.

Review of Records 

Another function of the psychiatry consultant is 

to review mental health records. These are received 

for a multitude of purposes, including: (a) waivers 

for accessions to both the officer and enlisted ranks; 

(b) determinations on line-of-duty investigations, 

especially following suicides; (c) review of completed 

investigations; and (d) review of cases where there is a 

question as to whether someone should have received 

a medical board or chapter. 

Strategic Communications 

The consultant functions in numerous roles to 

include reviewing scientific papers, answering media inquiries, advising on the suitability of others 

to participate in media interviews, and advising the 

public affairs officer. The position presents numerous challenges. A major one is that of recruiting and 

retaining medical personnel with the Army’s current 

operation tempo. 

Mental Health Advisory Team Member 

Since 2003, the Army Surgeon General has annually 

deployed an MHAT at the request of the US Central 

Command commanding general to evaluate the behavioral health needs of soldiers during deployment. 

The initial team performed their evaluation during 

Operation Iraqi Freedom 1 after there were reports of 

elevated suicide rates in theater. More recently, MHAT 

teams have focused on the quality of care provided and 

the behavioral healthcare system of delivery within the 

theater of operations. 

The MHATs have varied in their composition, at 

times consisting of large multidisciplinary mental 

health teams while more recent MHATs have only 

had a few research psychologists. The MHAT teams 

utilize methods of paper surveys and focus groups, 

and each year issue a report of findings with recommendations. Key recommendations have included 

the establishment of a theater suicide prevention 

program, implementation of “Battlemind” training, 

institution of unit behavioral health needs assessments, 

and battlefield ethics training. The MHAT teams and 

their recommendations are discussed in greater detail 

in Chapter 5, Walter Reed Army Institute of Research 

Contributions During Operations Iraqi Freedom and 

Enduring Freedom: From Research to Public Health 

Policy, in this volume.

Division Psychiatrist/Brigade Behavioral Health 

Officer 

Chapter 6, The Division Psychiatrist and Brigade 

Behavioral Health Officers, in this volume details the 

role of these mental health specialists. However, this 

unique position places a behavioral health officer 

within a combat unit working directly as an ongoing 

consultant to a combat commander rather than working for the medical command. This position entails 

continuing responsibilities to the command as a consultant on issues such as how and where to deploy behavioral health resources, methods and techniques for 

controlling combat operational stress, and determining 

plans for prevention of behavioral casualties.

SUMMARY

Military mental health professionals provide critical 

consultation to command when psychiatric casualties 

are seen in garrison or during deployment. The challenge to the mental health consultant is to balance the 

need of the unit with what is in the best interest of 

the soldier’s short-term and long-term mental health. 

Commanders have the utmost concern for their soldiers; it is therefore imperative that they trust the 

judgment of their consulting behavioral health officer 

in the decisions that they are making on the treatment 

of their soldiers. In addition, these same challenges exist in garrison because the consultant has to determine 

if a soldier is no longer fit to continue in service and 

requires a medical evaluation board or if this soldier 

might have a more favorable prognosis for recovery 

and continued military service. 

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23. Tischler GL. Patterns of psychiatric attrition and of behavior in a combat zone. In: Bourne PG, ed. Psychology and 

Physiology of Stress. New York, NY: Academic Press; 1969: 19–44. 

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26. Mental Health Advisory Team IV. MHAT IV Operation Iraqi Freedom 05-07 Final Report. Washington, DC: US Army 

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combat team structure. Part 1: Predeployment and deployment. Mil Med. 2007;172:907–911. 

28. Walter Reed Army Institute of Research. Psychiatry and Neuroscience. Battlemind training. Available at: http://www.

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seeking care upon return from combat. Mil Med. 2008;173(6):563–569.

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applying lessons learned since the Gulf War. Clin Infect Dis. 2002;15:S208–S214.

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DD Form 2900. Walter Reed Army Institute of Research-Europe: Heidelberg; Research Report #2005-003. Available at: 

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2009.

33. 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;295:1023–1032.

34. Southwick SM, Morgan CA 3rd, Darnell A, et al. Trauma-related symptoms in veterans of Operation Desert Storm: a 

2-year follow-up. Am J Psychiatry. 1995;152(8):1150–1155.

35. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163:1777–1783.

36. Secretary of the Army. Post Deployment Health Re-Assessment. Washington, DC: Department of the Army; January 23, 

2006. 

37. US Government Accountability Office. Post Traumatic Stress Disorder: DoD Needs to Identify the Factors Its Providers Use 

to Make Mental Health Evaluation Referrals for Servicemembers. Washington, DC: GAO, Report to Congressional Committees; 2006: 1–34. GAO-06-397. 

38. Appenzeller GN, Warner CH, Grieger T. Post deployment health reassessment: a sustainable method for brigade 

combat teams. Mil Med. 2007;172:1017–1023.

39. Mental Health Advisory Team III. MHAT III Operation Iraqi Freedom 04-06 Final Report. Washington, DC: US Army 

Surgeon General; May 29, 2006. 

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Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbooks of Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995: 271–290.
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41. Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). 

Cochrane Database Syst Rev. 2002;2:CD000560.

42. MacDonald CM. Evaluation of stress debriefing interventions with military populations. Mil Med. 2003;168:961–968.

43. Jacobs J, Horne-Moyer HL, Jones R. The effectiveness of critical incident stress debriefing with primary and secondary 

trauma victims. Int J Emerg Ment Health. 2004;6:5–14.

44. Mitchell SG, Mitchell JT. Caplan, community, and critical incident stress management. Int J Emerg Ment Health.

2005;8:5–14.

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

Manual 4-02.51. 

46. Alder AB, Castro CA, McGurk D. Battlemind Psychological Debriefings. Heidelberg, Germany: Walter Reed Army Institute of Research-Europe; 2007. Research Report 2007-001. 

47. Rock NL, Stokes JW, Koshes RJ, Fagan J, Cline WR, Jones FD. US Army combat psychiatry. In: Jones FD, Sparacino LR, 

Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbooks of Military Medicine. 

Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 1995: 149–175.

48. Jones E, Wessely E. “Forward psychiatry” in the military: its origin and effectiveness. J Trauma Stress. 2003;16:411–419.

49. McCarroll JE, Ursano RJ. Consultation to groups, organizations, and communities. In: Ritchie EC, Watson PJ, Friedman MJ, eds. Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. New York, NY: 

Guilford Press; 2006: 193–205.

50. US Department of the Army. Standards of Medical Fitness. Washington, DC: Headquarters, DA; 2007. Army Regulation 

40-501.

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and Medications. Washington, DC: Department of the Army; November 7, 2006. Memorandum. Available at: http://

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2010.

52. National Defense Authorization Act for Fiscal Year 2007. Pub L No. 109-364, Section 738.

53. Warner CH, Appenzeller GN, Mobbs A, Grieger T. Division mental health through the deployment cycle. Paper presented at: Force Health Protection Conference; August 13, 2008; Albuquerque, NM. 

54. US Department of the Army. Active Duty Enlisted Administrative Separations. Washington, DC: Headquarters, DA; 2005. 

Army Regulation 635-200.

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Defense; October 1, 1997. Directive 6490.1.

56. US Department of Defense. Requirements for Mental Health Evaluations of Members of the Armed Forces. Washington, DC: 

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57. US Army Medical Command. Command Directed Mental Health Evaluations. Fort Sam Houston, Tex: Headquarters, 

MEDCOM; 1999. US Army Medical Command Regulation 40-38.
191

The Aeromedical Evacuation

Chapter 13

THE AEROMEDICAL EVACUATION

ALAN L. PETERSON, PhD, ABPP*; KELLY R. MCCARTHY, MA†; DANIEL J. BUSHEME, MA, LCDC‡; RICK 

L. CAMPISE, PhD, ABPP§; and MONTY T. BAKER, PhD¥

INTRODUCTION

EVOLUTION OF MILITARY MEDICAL EVACUATION

A Brief History of Military Medical Evacuation

Aircraft Used for Aeromedical Evacuation

THE DEPARTMENT OF DEFENSE PATIENT MOVEMENT SYSTEM

Aeromedical Evacuation Movement Precedence

Patient Classification Codes for Aeromedical Evacuation

Completion of Patient Movement Records

AEROMEDICAL STAGING FACILITIES

Contingency Aeromedical Staging Facilities

The Ramstein Air Base Contingency Aeromedical Staging Facility

The Andrews Air Force Base Aeromedical Staging Flight

AEROMEDICAL EVACUATION OF PATIENTS IN SUPPORT OF OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM

BEHAVIORAL HEALTH CONSULTATION FOR MEDICAL PATIENTS

SUMMARY

*Professor, Department of Psychiatry, Mail Code 7792, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, 

Texas 78229; formerly, Chair, Department of Psychology, Wilford Hall Medical Center, San Antonio, Texas

†

Captain, Nurse Corps, US Air Force; Historian, Peterson Air Force Base, 150 Vandenberg, Suite 110S, Peterson Air Force Base, Colorado 80914; formerly, 

Chief, Behavioral Health Nursing Management, Life Skills Center, United States Air Force Academy, Colorado Springs, Colorado

‡

Lieutenant Colonel, Nurse Corps, US Air Force; Chief, Mental Health Nursing, US Air Force Medical Operations Agency, 485 Quentin Roosevelt 

Road, Suite 400, San Antonio, Texas 78226-2017; formerly, Deputy Squadron Commander and Inpatient Mental Health Flight Commander, Travis 

Air Force Base, California

§

Colonel, Biomedical Sciences Corps, US Air Force; Commander, 559th Medical Group, 1920 Biggs Avenue, Lackland Air Force Base, Texas 78236; 

formerly, Commander, 1st Medical Operations Squadron, Langley Air Force Base, Virginia

¥

Major, Biomedical Sciences Corps, US Air Force; Director of Clinical Research, Warrior Resiliency Program, San Antonio Military Medical Center, 

2200 Bergquist Drive, Suite 1, Lackland Air Force Base, Texas 78236; formerly, Element Leader, Mental Health Clinic, 59th Military Health System, 

Lackland Air Force Base, Texas
192

Combat and Operational Behavioral Health

INTRODUCTION

Aeromedical evacuation is the movement of patients under medical supervision to and between 

medical treatment facilities by air transportation.1

 The 

global war on terror has been the largest sustained 

combat operation by the US military since the Vietnam 

War. Almost 2 million US military personnel have 

deployed to support Operation Iraqi Freedom (OIF) 

and Operation Enduring Freedom (OEF). The current 

aeromedical evacuation system used in support of 

OIF/OEF is one of the factors that is credited for the 

greatly improved survival rate for combat-wounded 

personnel in Iraq.2 The current survival rate is approximately 90%, and it is the highest in recorded history; it 

is a significant increase from the 74% to 75% survival 

rate of wounded personnel in the wars in Korea, Vietnam, and the Persian Gulf.2

This chapter will review the aeromedical evacuation 

of patients from military battlefield locations and other 

operational locations, to include the types of aircraft 

used, the functioning of contingency aeromedical staging facilities (CASFs), guidelines and principles for 

evacuation of medical and psychiatric patients, and 

the pertinent military regulations and instructions that 

guide the evacuation process. A particular emphasis 

of the chapter is on aeromedical evacuation in support 

of OIF and OEF.

EVOLUTION OF MILITARY MEDICAL EVACUATION

A Brief History of Military Medical Evacuation

Throughout history many different approaches 

have been used to evacuate combat casualties from the 

battlefield to receive medical care. In the United States, 

the earliest recorded reports of the need for a military medical evacuation system occurred during the 

American Revolutionary War.3

 In April of 1777, the US 

Congress passed a bill recommending that “[a] suitable 

number of covered and other wagons, litters, and other 

necessaries for removing the sick and wounded, shall 

be supplied by the Quartermaster or Deputy Quartermaster General; and in case of their deficiency, by the 

Director or Deputy Director General.”3(p36) However, 

there are no records that indicate that any such vehicles 

were actually built or supplied at that time. 

The first reports of the actual use of a medical 

evacuation system occurred during the American Civil 

War,4 which resulted in many battle-injured patients 

who challenged the military medical community.5 As a 

result, significant changes were made in how soldiers 

were evacuated. During this time, at least 10 different 

designs were proposed for ambulance wagons that 

were to transport sick and wounded military personnel. Dr Jonathan Letterman was the first to create an 

organized system of medical evacuation during the 

Civil War. His pioneering work formed the basis for the 

present military medical evacuation system. President 

Lincoln commissioned railroads and riverboats during 

the Civil War for the medical transport of patients.6

The invention of automobiles was followed shortly 

thereafter by the invention of motorized ambulances 

to transport emergency medical patients.7,8 More 

than 2 years prior to the United States’ formal entry 

into World War I, teams of US military surgeons and 

their support personnel had already been deployed 

to France.9

 The collaboration of military and civilian 

surgeons at the Ambulance Americaine in Paris led 

to the use of ambulances to evacuate injured military 

personnel throughout Europe during World War I.

The invention of aircraft led to evolutionary changes 

in the medical evacuation of military patients throughout the 20th century.10 The potential use of aircraft for 

the medical evacuation of injured military personnel 

was conceptualized in the early 1900s.11,12 Marie Marvingt, a French nurse, was one of the most influential 

and effective proponents for the use of aircraft to 

evacuate the wounded in combat settings.13 In 1913, 

Colonel Samuel F Cody demonstrated the potential 

use of a biplane as an air ambulance at Farnborough, 

England.14 The initial conversion of military aircraft 

into air ambulances by the US Army occurred during 

the period from 1918 to 1924.15 However, the concept 

of aeromedical evacuation of military medical patients 

did not gain widespread acceptance until World War 

II.16 At that time, naval vessels were the most common 

form of transport for movement of military personnel 

to and from the war zone. Ships were also the most 

common means of transporting casualties to the United States for more definitive medical care. However, 

transport by ship could take weeks; there was a need 

to provide faster medical evacuation for more seriously 

injured military personnel. Subsequently, extensive 

use of military aircraft for patient evacuation began 

during 1945 when approximately 625,000 casualties 

(25% of all patients) were aeromedically evacuated to 

the United States.16

The first widespread use of helicopters for aeromedical evacuation occurred during the Korean War.17

Use of helicopters was instituted because of the necessity to move patients rapidly from the battle area over 

rugged and inhospitable terrain. Helicopter evacuation 
193

The Aeromedical Evacuation

led to the successful transport of nearly 22,000 patients 

and is attributed to a reduction in the casualty mortality rate.17 The combat experiences of the United States 

in Korea, the British in Malaya, and the French in Indochina proved that rotary-wing aircraft were invaluFigure 13-1. The UH-60 Black Hawk. The UH-60 Black 

Hawk can hold up to six litters for patient transport and is 

the Army’s front-line helicopter for aeromedical evacuation 

in Iraq and Afghanistan. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/030822-F7709W-005.jpg.

Figure 13-2. The CH-46 Sea Knight. The CH-46 can accommodate up to 15 patients and was used extensively by the 

Marines during the battle of Fallujah in November 2004. 

Here, Marine Reserves—the “Moonlighters” from Marine 

Medium Lift Helicopter Squadron 764, based at Edwards 

Air Force Base, Calif—pause for refueling and servicing by 

the US Navy flight deck crew aboard the USS New Orleans, 

participating in a nine-country training excercise called 

Partnership of the Americas, July 3, 2010. Photographer: 

MSgt Peter C Walz.

Reproduced from: US Marines Web site. www.marines.mil/unit/marforsouth/PublishingImages/

NewsStoryImages/2010/100703-M-3168W-008.jpg.

Figure 13-3. The C-9 Nightingale. The C-9 is the only military 

aircraft that was specifically designed for the aeromedical 

evacuation. Nicknamed the “Cadillac of Medevac,” the C-9 

was the workhorse of medical evacuation. It was phased 

out in 2003. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/021202-O9999G-007.jpg.

Figure 13-4. The KC-135 Stratotanker. The KC-135 is used primarily for air refueling, but it can be configured with patientsupport pallets and used for aeromedical evacuation. 

Reproduced from: US Air Force Link photo library. www.

af.mil/shared/media/photodb/photos/ 060613-F4192W-808.jpg.

able in reducing battlefield death rates.18 During the 

Vietnam conflict helicopters were firmly established 

as an essential component of aeromedical evacuation 

on the modern battlefield.18 Operations Desert Shield 

and Desert Storm involved the deployment of 1,950 

aeromedical evacuation personnel to support medical 

airlift.19 Aircrews were deployed to 17 locations in the 

region and more than 12,500 patients were successfully 

airlifted using converted cargo aircraft.19 The majority 

of these patients were general medical patients and not 

battle-related injuries.
194

Combat and Operational Behavioral Health

Currently, the military uses a variety of vehicles 

for transport of patients to include medical ground 

vehicles, nonmedical ground vehicles, watercraft, rail 

transport, and sometimes whatever vehicle of convenience is available.20 However, today virtually 100% 

of casualties requiring transport away from areas of 

insurgent activities or out of the war zone are moved 

by aircraft. 

Aircraft Used for Aeromedical Evacuation

Rotary wing aircraft are the primary vehciles used 

for casualty evacuation from the battlefield. These 

aircraft, in addition to improved body armor and advancements in casualty care, are thought to contribute 

to the increased survival rate that has occurred during 

the military actions in Iraq and Afghanistan.2

The Army and Marines operate most of the rotary 

wing aeromedical evacuation aircraft. The UH-60 Black 

Figure 13-5. The C-17 Globemaster III. The C-17 is the most 

commonly used fixed-wing aircraft for aeromedical evacuation out of the combat theater to military medical centers. 

Reproduced from: US Air Force Link photo library.

www.af.mil/shared/media/photodb/photos/091118-F3431H-513.jpg.

Figure 13-6. KC-10A Extender. The KC-10A is another air 

refueler that can be configured for aeromedical evacuation 

when loaded with patient-support pallets. 

Reproduced from: US Air Force Link photo library. 

www.af.mil/shared/media/photodb/photos/091013-F3140L-112.jpg.

Hawk (Figure 13-1), the Army’s front-line utility helicopter, is used for air assault, air cavalry, and aeromedical evacuation. The UH-60 can hold up to six litters for 

patient transport. UH-60s can travel at high speeds, 

land on rough terrain in remote locations, and evacuate 

most injured patients for emergency department care 

within one hour—“the golden hour”21 of critical importance to casualty survival. The CH-46 Sea Knight (Figure 13-2) is a larger twin-engine heavy-lift helicopter 

similar to the CH-47 Chinook and can accommodate up 

to 15 litters. CH-46s and CH-47s are vital aircraft durFigure 13-7. The C-130 Hercules. The C-130 is the most 

versatile fixed-wing aircraft used for aeromedical evacuation. It can carry up to 70 litters and can operate in austere 

locations.

Reproduced from: US Air Force Link photo library. www.

af.mil/shared/media/photodb/photos/031030-F-9629J-005.

jpg.
195

The Aeromedical Evacuation

ing intense offensive military assaults when potentially 

large numbers of casualties need aeromedical transport 

during a short period of time. The AH-1W Cobra is an 

attack helicopter that often provides in-flight protection 

for rotary wing evacuations.

Fixed-wing aircraft are the primary means of aeromedical evacuation out of theater and from outside the 

continental United States (OCONUS) to the continental 

United States (CONUS) medical facilities. These are 

controlled by the Air Force. The C-9 Nightingale was 

introduced in 1968 and is the only military aircraft that 

was specifically designed for the aeromedical evacuation (Figure 13-3). However, the C-9 was phased out in 

2003 and all medical evacuations now utilize “aircraft 

of opportunity.” The development of patient-support 

pallets has increased the ability of alternative aircraft 

to be used for aeromedical evacuation. PSPs are built 

on a standard cargo pallet that can be loaded onto a 

variety of mobility aircraft. They provide support for 

six litters or a combination of three airline seats and 

three litters. The KC-135 Stratotanker (Figure 13-4) and 

KC-10A Extender (Figure 13-6) are aircraft used for air 

refueling that can be configured for aeromedical evacuation when loaded with patient-support pallets.

The C-17 Globemaster III (Figure 13-5) is the newest and most flexible long-range mobility aircraft. It 

was designed to support aeromedical evacuation as 

a secondary mission. The operational and tactical capabilities of the C-17 aircraft have led it to become the 

primary aircraft for airlift out of Iraq and Afghanistan. 

The design of the C-17 allows it to land on austere airfields. It can take off and land on runways as narrow as 

90 feet and as short as 3,000 feet. It can be configured 

to carry 48 litters and 40 ambulatory patients. The 

C-17s are used to transport patients from theater to 

Landstuhl Army Regional Medical Center in Germany 

to Andrews Air Force Base in Washington, DC. 

The C-130 Hercules (Figure 13-7) is a four-turboprop 

aircraft. First used by the Air Force in the 1950s, it is 

the oldest aeromedical evacuation aircraft. Its versatility, reliability, and capability of operating from rough, 

dirt strips make it an invaluable resource in deployed 

settings. Within theater, the C-130 Hercules can carry 

70 all-litter loads, or a combination of 50 litters and 27 

ambulatory patients. In Iraq, C-130s are often used for 

intratheater missions to Qatar and Kuwait.

The mission of the Department of Defense Patient 

Movement System is to transport US military casualties and other medical patients from combat zones to 

field hospitals or other fixed medical treatment facilities located in or out of the combat theater.22 Medical 

evacuation of military personnel injured in combat 

begins on the battlefield. Patients are assessed and 

treated across echelons of care. After combat life-saving 

care or forward surgical team intervention is provided 

at the initial injury site, the next echelon of care is often 

at an Army combat support hospital or an Air Force 

theater hospital. Navy medical hospital ships, such as 

the USNS Comfort (T-AH 20) or USNS Mercy (T-AH 

19), are also sometimes available as a first echelon of 

care in deployed locations. Patients not expected to be 

able to return to duty within 7 days (or the established 

combat theater evacuation policy standard) will normally be evacuated to the next level of care once they 

are approved for aeromedical evacuation. 

If patients require further evacuation, they are transported by fixed wing aircraft, rotary wing aircraft, or 

ground vehicle to a CASF, where they are prepared for 

aeromedical evacuation out of theater. Table 13-1 includes a summary of primary aeromedical evacuation 

instructions, regulations, and reference guidelines. 

Patient movement is tracked through a computerized system at entry and during transit, and completed 

at exit from the aeromedical evacuation system. Patient 

movement requirements (PMRs; also called “patient 

movement requests” and “patient movement records”) 

are medical requests to transport a patient to a higher 

echelon of care. The US Transportation Command is 

responsible for intertheater patient movement. Patients 

who require intertheater aeromedical evacuation 

are entered into the US Transportation Command 

Regulating and Command and Control Evacuation 

System (TRAC2ES), which allows their movement to 

be tracked by various facilities and the Joint Patient 

Movement Requirement Centers. The Global Patient 

Movement Requirements Center (GPMRC) is an 

organizational element of US Transportation Command that manages patient movement. The GPMRC 

integrates intertheater and CONUS medical regulation 

services, mission requirements, clinical validation, 

and related activities that support patient movement 

requests. Using TRAC2ES, the GPMRC and the Theater Patient Movement Requirements Center receives, 

consolidates, and processes PMRs to coordinate aeromedical evacuation requirements with available airlift 

operations, health service support capabilities, and 

available bed space. 

Aeromedical Evacuation Movement Precedence

When a patient requires aeromedical evacuation, the 

attending physician is responsible for determining the 

THE DEPARTMENT OF DEFENSE PATIENT MOVEMENT SYSTEM
196

Combat and Operational Behavioral Health

Title Publication Date Brief Description

Air Force Policy Directive 41-3 

Worldwide Aeromedical Evacuation

July 29, 1994 Establishes responsibilities and authorities for aeromedical 

evacuation with the Air Force Surgeon General, Air Mobility Command, Air Combat Command, and the surgeon generals of the US Air Force Reserves and National Guard.

Air Force Instruction 41-301 

The Worldwide Air Medical Evacuation 

System

August 1, 1996 Provides an overview of the entire aeromedical evacuation 

process. 

Air Force Instruction 41-303 

Aeromedical Evacuation Dietetic Support

March 27, 1995 Provides guidance and procedures for dietetics departments 

in medical treatment facilities that feed patients in the aeromedical evacuation system during peacetime and contingency operations. 

Air Force Instruction 41-305 

Administering Aeromedical Staging 

Facilities

December 1, 1997 Delineates requirements to set up and operate a contingency 

aeromedical staging facility including staffing and equipment lists. 

Air Force Instruction 41-307, Attachment 6 

Aeromedical Evacuation Patient Considerations and Standards of Care

August 20, 2003 Provides information on nursing care requirements and 

general guidelines for aeromedical evacuation of psychiatric 

patients. Includes descriptions of flight-specific medical 

issues, such as Boyle’s Law. Outlines the special considerations for psychiatric patients. 

Air Force Instruction 41-309 

Aeromedical Evacuation Equipment 

Standards

November 1, 

2001

Provides a listing of approved Air Force Research Laboratory 

and US Army Aeromedical Research Laboratory medical 

equipment, which can be used on fixed and rotary wing 

aircraft. 

Air Force Joint Instruction 41-315

Patient’s Regulated to and Within the 

Continental United States

March 30, 1990 Prescribes uniform procedures and establishes responsibilities during peacetime and contingencies for regulating the 

transfer of patients from overseas to the CONUS, the transfer of patients between uniformed services, VA, or civilian 

medical treatment facilities within the CONUS, and the assignment of beds in VA Medical Centers for members of the 

uniformed services who will require further hospitalization 

or nursing home care after separation or retirement from all 

military services.

DoD Directive 4500.9E 

Transportation and Traffic Management

February 12, 2005 Establishes DoD policy for transportation and traffic management. States that DoD transportation resources should be 

used for official purposes only. DoD transportation resources may be used to move non-DoD traffic only when the 

DoD mission will not be impaired and movement of such 

traffic is of an emergency or life-saving nature, specifically 

authorized by statute, in direct support of the DoD mission, 

or requested by the head of an agency of the government. 

DoD Directive 6000.12 

Health Services Operations and Readiness

January 20, 1998 Establishes patient movement policy and assigns the Commander, US TRANSCOM responsibilities as the DoD single 

manager for patient movement, other than intratheater 

patient movement. The Commander, US TRANSCOM is 

responsible for establishing and maintaining a system for 

medical regulating and movement.

DoD Regulation 4515.13-R 

Air Transportation Eligibility

April 9, 1998 Implements DoD policies governing the use of DoD-owned 

or DoD-regulated aircraft and establishes criteria for passenger and cargo movement. Chapter 5, “Aeromedical 

Evacuation” of DoD Regulation 4515.13-R is used to determine eligibility for patient movement. 

TABLE 13-1 

AEROMEDICAL EVACUATION PUBLICATIONS

(Table 13-1 continues)
197

The Aeromedical Evacuation

DoD Instruction 6000.11 

Patient Movement

September 9, 

1998

Establishes procedures for the movement of patients, medical attendants, and related patient movement items on 

DoD-provided transportation. Addresses the evacuation 

of patients through the Air Force fixed-wing aeromedical 

evacuation system and the medical regulating of patients 

to appropriate locations of care. Establishes aeromedical 

evacuation patient priorities that are used by competent 

medical authorities to classify a patient as a candidate for 

patient movement. 

Joint Pub 4-02.2 

Joint Tactics, Techniques and Procedures 

for Patient Movement in Joint Operations

December 30, 

1996

Delineates requirements and considerations for joint patient 

movement planning. Includes special aspects of special operations and military operations other than war. Describes 

doctrine of the exercise of command and control by joint 

force commanders engaged in all types of operations and 

exercises.

Army Technical Manual MED 289 

Aeromedical Evacuation: A Guide for 

Health Providers (also known as 

Armed Forces Pamphlet 164-4)

November 1, 

1991

Provides guidance to physicians and other healthcare providers who select and prepare patients for transport on all 

types of aeromedical evacuation aircraft. It applies to all 

DoD facilities using the aeromedical evacuation system, 

including Air National Guard and Air Force Reserve units 

and members.

United States Naval Flight Surgeon 

Handbook

1998 (2nd ed) Provides a brief summary of aeromedical evacuation as 

it applies to Navy medical personnel. It includes details 

on patient movement, patient classification, movement 

precedence, and special in-flight considerations regarding 

physicians and patients.

Table 13-1 continued

movement precedence, in accordance with the urgency 

for transport, to the destination medical facility. 

Urgent. The urgent precedence applies when immediate aeromedical evacuation is required to save life, 

limb, or eyesight or prevent complications of serious 

illness. The attending physician is required to coordinate with an accepting physician at the destination 

facility for urgent patients. 

Priority. A priority precedence is used when there 

is the need for prompt medical care not available locally. Similar to urgent cases, the attending physician 

must coordinate directly with the accepting physician 

for priority patients and the goal is to transport the 

patient within 24 hours. 

Routine. The routine precedence applies to all other 

patients. 

Patient Classification Codes for Aeromedical 

Evacuation

A patient classification code is used as a management tool to track types of aeromedical evacuation 

patients. Table 13-2 includes the patient classification 

codes for aeromedical evacuation. Mental health patients are classified in several different categories based 

on their diagnosis and risk prior to being manifested 

on an aeromedical evacuation flight. Attachment 6 of 

Air Force Instruction 41-307, Aeromedical Evacuation 

Patient Considerations and Standards of Care,

23 outlines 

the aeromedical evacuation psychiatric categories. The 

psychiatric patient categories include:

	 •	 Category 1A. This category is for the severely ill 

psychiatric patient who requires close supervision during the entire aeromedical evacuation process. Category 1A patients should 

be transported wearing hospital clothing or 

physical training gear. They should be chemically sedated and restrained on a dressed litter 

during the flight. These patients are required 

to have a medical attendant with a minimum 

rank of E-5 (sergeant). To help ensure patient 

safety, medical attendants for category 1A 

patients must be trained in neurological and 

circulatory checks and the proper use of restraints.

CONUS: continental United States

DoD: Department of Defense

MED: medical

Pub: publication

TRANSCOM: US Transportation Command

VA: Veterans Affairs
198

Combat and Operational Behavioral Health

TABLE 13-2 

AEROMEDICAL EVACUATION PATIENT 

CLASSIFICATION CODES

Code Classification

1 (Psychiatric)

1A Severe psychiatric patient

1B Intermediate psychiatric patient

1C Moderate psychiatric patient

2 (Litter)

2A Immobile patient

2B Mobile patient

3 (Ambulatory)

3A Nonpsychiatric, non–substance-abuse 

patient going for treatment

3B Recovered patient returning home

3C Drug or substance abuse patient going 

for treatment

4 (Infant)

4A Infant or child under 3 years old in bassinette or car seat

4B Recovered infant or child requiring seat

4C Infant in incubator

4D Child under 3 years old on a litter

4E Outpatient under 3 years old

5 (Outpatient)

5A Ambulatory, nonpsychiatric, or substance abuse outpatient going for 

treatment

5B Ambulatory, psychiatric, or substance 

abuse outpatient going for treatment

5C Psychiatric outpatient going for treatment and/or evaluation

5D Outpatient on litter for comfort and/or 

safety going for treatment

5E Outpatient returning on litter for comfort and/or safety

5F All other returning outpatients

6 (Attendant)

6A Medical attendant

6B Nonmedical attendant

	 •	 Category 1B. Category 1B is for moderately to 

severely ill psychiatric patients. These patients 

also should be chemically sedated, wear hospital clothing or physical training gear, and be 

transported on a litter. However, restraints are 

not routinely applied for Category 1B patients. 

A set of restraints must be readily available 

during the aeromedical evacuation flight and 

should be secured to the litter or maintained 

by the patient’s attendant.

	 •	 Category 1C. Cooperative, reliable, and moderately severe psychiatric inpatients traveling in 

ambulatory status are placed in Category 1C. 

These patients may wear their military uniforms and may have a medical or nonmedical 

attendant. They may administer their own 

medication based on the evaluation by the 

mental health provider and flight surgeon.

	 •	 Category 3C. This category is for ambulatory 

patients who are being evacuated for inpatient 

treatment for substance use disorders. These 

patients wear their military uniforms during 

aeromedical evacuation. A nonmedical attendant usually accompanies them.

	 •	 Category 5B. Ambulatory patients evacuated 

for outpatient treatment for substance use disorders are placed in Category 5B. A nonmedical attendant usually accompanies them.

	 •	 Category 5C. This category is for outpatient 

mental health patients evacuated for evaluation or treatment of psychiatric disorders. This 

category is rarely used when transporting a 

patient from the area of responsibility. It is 

more common when patients are transferred 

from Germany (OCONUS) to CONUS locations.

Completion of Patient Movement Records

The Aeromedical Evacuation Patient Record (Air Force 

Form 3899) is used for the initiation of an aeromedical 

evacuation. In most deployed locations, the PMR is 

completed in a handwritten format. A sample PMR is 

included in Exhibit 13-1. The Air Force Form 3899 includes information pertaining to treatment, diagnosis, 

medication, status as an inpatient or an outpatient, and 

the attending physician. Although PMRs are required 

to be signed by an attending physician, in many deployed locations where a psychiatric patient requires 

aeromedical evacuation, a mental health provider will 

complete a draft of the PMR and have it cosigned by 

the attending physician. 

An electronic version of the PMR has recently been 

developed. This form was previously only available on 
199

The Aeromedical Evacuation

exhibit 13-1

sample patient movement request
200

Combat and Operational Behavioral Health

paper, which sometimes resulted in clerical errors or 

loss of information. The electronic version of the PMR 

developed at Landstuhl is automatically populated 

with data from the European Composite Health Care 

System on a daily basis. All aeromedical evacuation 

personnel working at the first geographic CONUS 

sites encountered in patient transport (eg, Andrews 

Air Force Base, Landover, Maryland; the National 

Naval Medical Center [known locally as “Bethesda”], 

Bethesda, Maryland; and Walter Reed Army Medical 

Center, Washington, DC) can access a real-time version 

of the electronic PMR. 

AEROMEDICAL STAGING FACILITIES

Aeromedical staging facilities (ASFs) are medical 

facilities similar to a medical passenger terminal that 

are used to stage patients prior to aeromedical evacuation. Some ASFs are permanent facilities that operate in 

peacetime as well as times of military conflict (eg, ASF 

at Andrews Air Force Base). Contingency aeromedical staging facilities (CASFs) are temporary facilities 

placed at strategic locations to facilitate the aeromedical evacuation of patients. The mission of a CASF is the 

safe medical airlift of combat- and noncombat-related 

casualties from deployed locations to a higher echelon 

of medical care. CASFs operate around the clock to reassess, stabilize, stage, and transport US military medical patients. Other patients are sometimes transported 

through CASFs, including coalition military personnel, 

Department of Defense civilians, and patients engaged 

in humanitarian missions. 

The typical staffing composition of a CASF includes 

60 military medical personnel: 45 nurses, 2 flight surgeons, 6 administrative personnel, 3 mental health 

staff, and 1 individual from each of the logistics, bioenvironmental engineering, pharmacy, and nutritional 

medicine specialty areas. The CASF mental health team 

includes one officer and two enlisted mental health 

technicians. The officer position is usually filled by 

a psychiatric nurse or advanced practice psychiatric 

nurse. However, the specific staffing composition and 

requirements may be modified depending on the location and mission of the CASF. 

Aeromedical evacuation personnel provide medical care and treatment to patients during aeromedical 

evacuation flights according to published guidelines. 

Prior to cosigning the PMR and writing medication 

orders, a flight surgeon must ensure the patient is 

physically stable for flight. The aeromedical evacuation of psychiatric patients includes additional medical 

and logistical issues that must be considered for the 

safety of patients and aircrew members.24 Psychiatric 

patients should be given special consideration and 

attention during all phases of the aeromedical evacuation to safeguard their personal dignity and to help 

ensure respect for cultural, psychological, and spiritual 

values. The overall goal is to use the safest and least 

restrictive measures to control behavior of psychiatric 

patients during aeromedical evacuation. However, 

some psychiatric patients may place the aircraft, crew, 

and other patients at risk. The use of in-flight restraints 

is sometimes necessary for patients who present a clear 

risk to flight safety.23 A physician’s order is required for 

restraints and their use should be limited to cases in 

which there is a clear indication of a flight safety risk. 

Restraints should not be used merely for the convenience of the aeromedical evacuation crew. 

Mental health staff members play an important role 

in advising the flight surgeon regarding the patient’s 

mental health diagnosis, prognosis, and the need for 

aeromedical evacuation for psychiatric reasons. When 

a patient is manifested for aeromedical evacuation, a 

psychiatric category is determined depending on the 

severity of the illness, diagnosis, and mental status. 

It is the responsibility of the CASF mental health 

team to regularly reassess the patient to ensure that 

the assigned psychiatric category is appropriate. The 

CASF staff should alert the flight surgeon if a category 

requires changing or if other modifications are needed 

regarding medications, need for restraints, appropriateness for flight, and need for a medical or nonmedical 

attendant. Almost all mental health patients require 

either a medical or nonmedical attendant prior to entering the aeromedical evacuation system. Nonmedical attendants are usually a member of the patient’s 

military unit and are required to be the same gender 

and of higher military rank. Nonmedical attendants are 

assigned to accompany stable and cooperative mental 

health patients during the aeromedical evacuation. 

Medical attendants can include mental health technicians, mental health nurses, or other medical personnel 

who accompany more severe mental health patients 

during aeromedical evacuation. CASF mental health 

personnel ensure the patient’s attendant is briefed and 

educated on the responsibilities prior to the aeromedical evacuation flight. Furthermore, psychiatric patients 

are often asked to complete a behavioral contract form 

agreeing to comply with aeromedical evacuation system standards.

Contingency Aeromedical Staging Facilities

To provide medical support for operational missions, CASFs are positioned in key locations to facili-
201

The Aeromedical Evacuation

tate the aeromedical evacuation of patients. For OIF, 

a CASF was initially established in Baghdad adjacent 

to the Baghdad International Airport. The CASF was 

moved from this location because Baghdad International Airport was converted back to commercial use. 

The 332nd CASF was established at Joint Base Balad, 

which became the primary air hub in the region for 

all US operations. At Balad, about 25% of patients 

are direct transfers from one of several CSHs located 

throughout the area of responsibility. The largest 

proportion of the patients at the Balad CASF is first 

transferred to the Air Force Theater Hospital at Balad, 

where the patients are screened and treated prior to 

transfer to the CASF. A small number of stable patients not requiring medical screening are transferred 

directly to the CASF. Aeromedical evacuations from 

Balad depart for Germany several times per week. 

The frequency of flights depends on the number of 

medical patients requiring transport; more frequent 

flights are arranged when necessary. Critical care air 

transport flights are mobilized for the most seriously 

injured or ill patients who require urgent aeromedical evacuation after initial patient stabilization. The 

critical care air transport team consists of a physician, 

a nurse, and a cardiopulmonary technician, which 

allows ventilated patients to be evacuated. Burn 

patients are often evacuated on these critical care 

transport missions. 

The CASF at Kuwait has a significantly smaller 

mission than the Balad CASF. Patients with less severe injuries or ones who can be adequately treated in 

Kuwaiti hospitals are evacuated to the Kuwait CASF. 

Many of these patients are ones who are expected to 

be able to return to duty in the deployed setting after 

their medical care.

Currently, there is no CASF to support the transport 

of medical patients at Bagram Air Base in Afghanistan. Patients requiring aeromedical evacuation from 

Afghanistan are transferred to Bagram using rotary 

or fixed-wing aircraft. Patients are then transported 

to the CASF at Ramstein Air Base, Germany, on C-17 

aircraft. 

Patients evacuated from the combat zone in Iraq 

and Afghanistan are received at Landstuhl. Once there, 

patients are reassessed and may undergo additional 

surgery or medical treatments prior to aeromedical 

evacuation to CONUS. 

The Ramstein Air Base Contingency Aeromedical 

Staging Facility

The 435th CASF at Ramstein Air Base, Germany, is 

staffed by a contingency of 96 medical personnel. This 

includes two flight surgeons, 18 registered nurses, and 

76 medical technicians and administrative support 

staff. The medical staff is responsible for receiving 

patients aeromedically evacuated from all OIF and 

OEF locations. The ambulatory patients are housed 

in the CASF, which has a 60-bed capacity. Ambulatory patients are transported to CONUS on the next 

available flight. The more critically injured patients 

are transferred via ambulance bus from Ramstein Air 

Base to Landstuhl Army Regional Medical Center. 

Once patients are treated and stabilized at Landstuhl, 

a small proportion of them are returned to duty at 

their deployed location. Most patients, however, are 

medically evacuated to CONUS after treatment at 

Landstuhl. 

Those patients who require CONUS evacuation are 

transported to the Ramstein CASF. Patients are then 

sent to receiving hospitals within CONUS for further 

treatment and disposition. In most cases, patients from 

Landstuhl are first transported to the Andrews Air 

Force Base ASF and then to Walter Reed Army Medical Center. However, patients are also sent to a variety 

of military hospitals around CONUS, depending on 

the medical needs of the patient and the availability 

of medical care resources.

Between March 2003 and March 2007 approximately 

62,000 patients were seen at the Ramstein CASF as 

part of OIF and OEF. About 40,000 of these patients 

arrived at Landstuhl from OIF/OIF, and about 22,000 

of them were transported to CONUS. Differences in 

the inbound and outbound patient numbers reflect 

that slightly less than half of the patients who arrived 

were transported back to theater or to other locations 

through nonmedical transportation methods. Overall, 

battle-injured patients have accounted for about 21% 

of the total number of patients transported. 

The Andrews Air Force Base Aeromedical Staging 

Flight

The ASF at Andrews Air Force Base plays a critical 

role in the aeromedical evacuation process of patients 

during both war and peace. Andrews’ ASF is the first 

stop into the United States for all patients from the 

European theater, OIF, and OEF. The Andrews ASF 

is operated by 31 permanent party members and 33 

augmentees. In addition, the ASF has one marine and 

three soldiers permanently assigned to the unit to assist with the transition of marines and soldiers. The Air 

Force Family Liaison Officer program is also used to 

meet patient needs. To perform their mission, the ASF 

is equipped with six “ambuses” (medium-size buses 

equipped to carry litters), three ambulances, one box 

truck, one step van, and two patient-loading systems. 

On average, each month the ASF assists about 800 
202

Combat and Operational Behavioral Health

inbound and outbound patients. 

In Germany, the Joint Patient Movement Requirement Center coordinates with the GPMRC to establish 

CONUS destinations for patients who are grouped 

into mission loads based upon the bed availability at 

Landstuhl and patient care movement requirements. 

Aeromedical evacuation missions are launched three 

times per week from Germany, with other missions 

added as needed depending upon Landstuhl’s capacity or patient acuity. 

The mission operations component of the Andrews 

ASF receives information regarding the mission and 

its patient load. The PMR information obtained via 

TRAC2ES’ Web-based electronic record describes 

clinical information, equipment, staffing, and other 

operational information on every patient. This information is available to Walter Reed, Bethesda, and the 

Andrews ASF at the same time through TRAC2ES. 

The TRAC2ES system is also used in the area of 

responsibility and is the key communication link to 

the Theater Patient Movement Requirements Center 

in Qatar.

A typical mission load is 25 to 30 patients with a 

variety of diagnoses, medical conditions, and levels of 

acuity. These may include critical care, amputations, 

head injuries, psychiatric conditions, cardiac complications, diabetes, and eye injuries. An example of a 

mission package is as follows: “Mission K-6 includes 

12 litters, 17 ambulatory, 4 medical/nonmedical personnel arriving at 1600 hours at Andrews AFB [Air 

Force Base] on Julian date 214.” The mission load is 

further broken down to reveal which patients will be 

transported to Walter Reed or Bethesda, and which 

will need to remain overnight at Andrews prior to 

transport to another medical facility.

During the 24-hour period prior to a plane’s arrival 

at Andrews, much preparatory work is accomplished. 

Rooms are readied, meals are ordered, clinical information is reviewed, the flight line crews are alerted, 

and leaders are notified of mission and other pertinent 

clinical and administrative information.

Three hours before the plane’s arrival, the ASF 

flight line nurse arrives to review the latest information received from Germany on the patients’ conditions after the plane departed. A typical report might 

contain information such as the number of patients 

added or cancelled and reason for cancellation; number of critical care air transport (CCAT) cases; if blood 

was transfused en route; the need for an ambulance 

on arrival; patients with conditions requiring special 

room accommodations or care; family member traveling with a patient; amputee needs for wound wash 

or operating room visit for dressing change; and if a 

psychiatric patient is to be admitted at Walter Reed. In 

summary, to be properly prepared for the arrival of a 

mission, all staff members involved in each aspect of 

Andrews ASF review the latest available information 

regarding vital clinical and administrative information 

before the aeromedical evacuation mission arrives.

Prior to the plane’s landing, transport vehicles from 

Walter Reed Army Medical Center and the National 

Naval Medcial Center (Bethesda, Md) are positioned to 

move designated patients to their respective facilities 

based upon TRAC2ES information and any updates 

and changes from GPMRC. Sometimes patient destinations are changed while the plane is in the air due 

to changes in patient condition, medical capability 

changes, and other administrative reasons. All of this 

is done in the best interest of patient care.

Two hours before the plane’s arrival, all flight line 

personnel report to duty. This usually includes about 

10 personnel from the ASF, Walter Reed, and Bethesda; 

the Army and Marine liaisons; and volunteers. During the first hour, refresher training is conducted on 

the litter carry, and mission planning is performed to 

identify vehicles, drivers, spotters, and other necessary 

personnel. During the second hour, a mission brief is 

given on the latest clinical picture and an ASF flight 

surgeon is present to clarify any clinical questions. 

At the flight line landing zone, the ground crew 

coordinator interacts with the medical crew director 

and loadmasters to arrange the vehicles in the best 

manner to expedite the offload and transport of patients from the plane to the waiting motor vehicles. 

Priority is given to the CCAT patients. Usually, the 

Walter Reed and Bethesda buses are loaded prior to 

the Andrews bus, because they have a 40- to 50-minute 

travel time to their respective hospitals. During this 

transition period, a flight surgeon or other physician 

completes an assessment of every patient onboard. 

The flight surgeon can evaluate, stabilize, and arrange 

transportation for the patient to the emergency room 

at Andrews if needed. 

Once the patients arrive at their designated medical facilities, additional personnel process them based 

on their ward destinations. After treatment at Walter 

Reed or Bethesda, many patients are transferred to 

other hospitals depending on the specific needs of the 

patient. Patients are often transferred to hospitals or 

clinics near their home military station or near their 

hometown once they have become medically stable. 

The time frame for these transfers varies widely. The 

aeromedical evacuation process varies somewhat for 

special patient categories such as burn patients. Brooke 

Army Medical Center at Fort Sam Houston in San Antonio, Texas, is the Department of Defense Burn Center. 

Burn patients are transferred to Brooke as soon as they 

are stable enough for aeromedical evacuation. Some 
203

The Aeromedical Evacuation

patients are flown directly to the burn unit from the 

area of responsibility or from Landstuhl.

Patients remaining at Andrews Air Force Base are 

housed in the ASF, which has 32 beds and an expansion capability to 45. The next morning, missions are 

launched to transport patients to their various CONUS 

destinations. Ultimate destinations are determined by 

clinical needs and facilities’ capabilities.

AEROMEDICAL EVACUATION OF PATIENTS IN SUPPORT OF OPERATION ENDURING FREEDOM 

AND OPERATION IRAQI FREEDOM

As of January 2009, there had been over 65,000 

hostile and nonhostile US military casualities in Iraq, 

including over 4,000 fatalities and almost 30,000 

wounded in action.25 About 70% of the wounded 

were treated in theater and returned to duty without 

the need for evacuation for additional medical care. 

However, about 45,000 US military personnel required 

aeromedical evacuation out of Iraq, including about 

9,000 wounded, 9,000 with nonhostile injuries, and 

26,000 with other medical conditions. 

Significantly fewer aeromedical evacuations have 

been required for patients deployed to Afghanistan 

in support of OEF.26 As of January 2009, over 9,000 

US military personnel were evacuated, including 

about 1,400 wounded, 2,000 with nonhostile injuries, 

and 5,500 with other medical conditions requiring 

care outside the area of responsibility. There were 

over 600 US fatalities in OEF during this same time 

period.

Recent publications have underscored the potential mental health impact of the military operations 

in Iraq and Afghanistan on personnel.27–29 Since 2003, 

all personnel returning from deployment complete a 

Post-Deployment Health Assessment.30 A review of 

303,905 of these health assessments showed that over 

19% of soldiers and marines who returned from OIF 

met risk criteria for a mental health concern. However, 

only 18.4% of these “at risk” soldiers were referred for 

mental health treatment. In addition, posttraumatic 

stress disorder symptoms are associated with lower 

general health ratings, more primary care visits, and 

missed workdays among military personnel during 

the year following deployment.31

Several recent journal articles have evaluated the 

aeromedical evacuation of psychiatric patients from 

OIF/OEF.32–35 Turner and colleagues35 evaluated 116 

British military personnel who were evacuated between January 2003 and October 2003 to the United 

Kingdom for admission at a military inpatient psychiatric facility. The majority of the psychiatric patients 

(69%) were noncombatants, and 21% were Reserve 

personnel. A large percentage (37%) had a previous 

mental health history. 

Harman and colleagues32 completed a descriptive 

analysis of 11,183 US military patients who were aeromedically evacuated from Iraq between January 2003 

and December 2003. Of those patients evacuated, the 

most common patient categories were orthopaedic surgery (21.5%) and general surgery (13.3%). Psychiatric 

patients were the third most common patient category, 

comprising 6.9% of all evacuees. 

Two articles reviewed US military patients evacuated from both OIF and OEF. Stetz and associates34

evaluated 5,671 OEF/OIF patients evacuated from 

March 2003 to September 2003. Out of all patients 

aeromedically evacuated, 386 (6.8%) were psychiatric 

patients. Seventy-three patients (19%) were diagnosed 

with psychotic disorders, 242 (63%) were nonpsychotic 

disorders, and 60 (15%) had either DSM-IV (Diagnostic 

and Statistical Manual, 4th revision) V-codes or a deferred diagnosis. About l3% of patients had suicidal 

ideations or self-injurious behaviors. 

Rundell33 conducted the most comprehensive review of psychiatric patients evacuated from OIF/OEF. 

He included data from 1,264 US military psychiatric 

patients who were evacuated to Landstuhl Army 

Medical Center in Germany between November 4, 

2001 and July 30, 2004. The psychiatric patients were 

about 10% of the total population of 12,480 patients 

evacuated to Landstuhl. A retrospective review of the 

psychiatric clinical records was conducted to characterize the demographic composition, clinical diagnoses, 

and clinical dispositions given to the patients. A psychiatrist or clinical psychologist evaluated all patients 

according to a single, standardized clinical process. 

The results indicated that women were twice as 

likely to be psychiatric patients compared to the 

percentage of female medical patients (19% vs 10%). 

Psychiatric patients were more likely to be younger, 

enlisted, Reserve or National Guard members, and 

African-American or Hispanic. The majority of psychiatric patients were Army personnel (86%), which 

most likely reflects the higher proportion of deployed 

Army personnel during that time. About half of the 

psychiatric patients (49%) were evacuated during the 

first 3 months of their deployment. Another third of 

the patients (33%) were evacuated during the second 

3 months of deployment. 

The most frequent psychiatric diagnostic categories 

were adjustment disorders (34%), mood disorders 

(22%), personality disorders (16%), and anxiety disorders (15%). Of the patients diagnosed with anxiety 
204

Combat and Operational Behavioral Health

disorders, 36% were diagnosed with acute stress 

disorder and 29% with posttraumatic stress disorder. 

About 6% were diagnosed with a psychotic disorder, 

4% with bipolar disorder, and 5% with a substance 

abuse disorder.

After psychiatric hospitalization at Landstuhl, most 

patients (81%) were sent back to their home stations 

for outpatient mental health treatment, and 14% were 

transferred to other inpatient psychiatric settings. 

Only about 5% of these patients were returned to 

duty in a deployed location after successful treatment at Landstuhl. The long-term disposition of the 

psychiatric patients evacuated from OEF/OIF is not 

known. However, previous research has shown that 

about two thirds of active duty military members who 

are hospitalized for a mental health condition are discharged from active duty within 2 years of the initial 

hospitalization.30,36

BEHAVIORAL HEALTH CONSULTATION FOR MEDICAL PATIENTS

The primary mission of mental health staff members 

involved in the aeromedical evacuation process is the 

screening and preparation for evacuation of psychiatric 

patients. However, psychiatric patients are usually less 

than 10% of all patients evacuated, and it is known that 

a much larger percentage of patients have had some 

type of combat or other trauma exposure.34

Military personnel who sustain combat-related 

physical injuries are at increased risk for developing combat-related stress disorders. A recent study37

evaluated the relationship between combat-related 

physical injuries and posttraumatic stress disorder 

in 60 combat-injured soldiers. A matched group of 

40 soldiers who took part in the same combat situations but were not injured was used as a comparison 

group. The study found that 16.7% of the combatinjured soldiers met diagnostic criteria for posttraumatic stress disorder as compared to 2.5% in the 

noninjured comparison group. Another recent study 

found that a large percentage of combat-injured 

personnel have a delayed onset of combat stress 

symptoms.38 Almost 80% of combat-injured patients 

who initially screened negative for posttraumatic 

stress disorder or depression at the 1-month point 

after the injury were later found to screen positive 

at the 7-month point. These results suggest that brief 

contact of combat-injured personnel by mental health 

staff during the aeromedical evacuation process may 

be warranted. This may be important even if combat 

stress symptoms are not present at the time of the 

aeromedical evacuation. 

Many locations across the aeromedical evacuation continuum have implemented programs using 

a behavioral health consultation model to provide 

for brief contact and screening of all medical patients 

by mental health staff members. Various versions of 

behavioral health consultation programs are currently 

being used at the Air Force theater hospital and CASF 

at Balad,39 at Landstuhl, and at Walter Reed Army 

Medical Center.40

Brief contact with at-risk medical patients has 

allowed mental health providers to expand their 

role and be actively involved with all patients being 

evacuated for medical or nonpsychiatric reasons. This 

approach has been used successfully in primary care 

settings where many patients have significant behavioral health risk factors or are at risk for comorbid 

psychiatric conditions.41–45 A similar model was used 

with approximately 700 military personnel who were 

deployed to work at the Armed Forces Mortuary at 

Dover Air Force Base, Delaware, to process the human 

remains from the 189 individuals killed in the terrorist 

attacks at the Pentagon.46

The behavioral health consultation model involves 

brief individual consultation with all medical patients. 

The goals are to assess for trauma or combat stress 

exposure, normalize combat stress symptoms, initiate 

positive contact with mental health staff, and describe 

symptoms that might emerge in the future that would 

indicate that follow-up with a mental health provider 

might be helpful.39 It is helpful to provide patients 

with a description of the normal course of traumarelated symptoms and how some symptoms can have 

a delayed onset. 

SUMMARY

The US military aeromedical evacuation system is 

one of the primary contributors to the significantly 

improved survival rate in patients injured in support 

of OIF/OEF. Its ability to transport a patient from point 

of injury to specialized hospital trauma care is currently unsurpassed. The professionals who maintain 

this system continue to make strides to improve safety, 

comfort, and speed. Military mental health professionals play an important role in the aeromedical evacuation of medical and mental health patients from a war 

zone. Mental health professionals are actively involved 

in all aspects of the aeromedical evacuation system, 

including screening of psychiatric patients, making 

recommendations of psychiatric patient category, 
205

The Aeromedical Evacuation

preparing patients and attendants for the aeromedical evacuation flight, and providing organizational 

consultation to aeromedical evacuation medical staff. 

Nonpsychiatric medical personnel often have little or 

no experience in working with severe psychiatric cases. 

The placement of mental health professionals as part 

of the aeromedical evacuation system is a significant 

relief to medical staff. 

The Department of Defense patient movement and 

aeromedical evacuation system involves a complex 

interaction between patients, healthcare providers, patient movement administrators, aircraft, and computer 

tracking systems. In this chapter, an overview of the 

entire aeromedical evacuation process was provided 

with as much accuracy as possible. However, as with 

many complex systems, changes in the aeromedical 

evacuation process occur on a regular basis depending on local conditions, operational requirements, and 

changing priorities. Therefore, it is likely that some of 

the specific details contained in this chapter may have 

changed since the time that the chapter was written. 

Nevertheless, it is hoped that this chapter will serve 

as a general guide for the military aeromedical evacuation system and a helpful tool for military personnel 

involved in the aeromedical evacuation of patients in 

both deployed and nondeployed locations.

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36. Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among US military personnel in the 1990s: association with 

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Conn: Psychosocial Press; 1997.

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Psychol Res Pr. 1995;26:117–122.

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209

Behavioral Healthcare at Landstuhl Regional Medical Center

Chapter 14

behavioral healthcare at landstuhl regional medical center

JEFFREY V. HILL, MD*; DAVID REYNOLDS, PhD†; and RONALD CAMPBELL, MD‡

INTRODUCTION

ROLE OF LANDSTUHL REGIONAL MEDICAL CENTER IN WARTIME

Initial Assessments

Medical and Surgical Evacuees

Psychiatric Evacuees

CHALLENGES TO PROVIDING PSYCHIATRIC CARE TO EVACUEES

Patient Actions and Behaviors

Staff Characteristics and Actions

Development of an Emergency Mental Health Model

Local Area Support

INPATIENT PSYCHIATRY AT LANDSTUHL REGIONAL MEDICAL CENTER, 

2003–2007

Increasing Patient Load

Psychological Stressors and Staff Resilience

DEVELOPMENT OF LANDSTUHL’S staff RESILIENCY PROGRAM

Precipitating Event and Command Response

Structure and Focus of Program

DAily OPERATIONS

Member Dispersal

Committee Meetings

Surveys

CHALLENGES AND FUTURE DIRECTIONS

Program Director

Personnel

Central Point of Contact

Stigma

Data Collection

Types of Stressors

SUMMARY

*Lieutenant Colonel, Medical Corps, US Army; Chief, Child and Adolescent Psychiatry, Landstuhl Regional Medical Center, CMR 402 Box 1356, APO 

AE 09180; formerly, Chief, Outpatient Psychiatry, Landstuhl Regional Medical Center 

†

Major, Biomedical Sciences Corps, US Air Force; Mental Health Element Leader, Department of Psychology, Malcolm Grow Medical Center, 1050 

West Perimeter Road, 779 MDOS/SGOH, Andrews Air Force Base, Maryland 20762; formerly, Chief, Department of Health Psychology, Landstuhl 

Regional Medical Center, Landstuhl, Germany

‡

Chief, Inpatient Psychiatry Service, Department of Behavioral Health, Landstuhl Regional Medical Center, CMR 462, APO AE 09180
210

Combat and Operational Behavioral Health

The mission of Landstuhl Regional Medical Center 

(LRMC) is to provide world-class comprehensive and 

compassionate care to the nation’s warriors, their families, retirees, and all other patients as directed, while 

maintaining unit and personal readiness to meet the 

demands of the United States. This is accomplished by 

maintaining a trained and ready healthcare force that 

seeks, thrives on, and embraces change while accomplishing the healthcare mission, utilizing outcomes to 

drive medical decisions. 

LRMC sits on a hill overlooking the German city of 

Landstuhl. The garrison belongs to the Kaiserslautern 

military community, which consists of several military 

bases scattered in the Kaiserslautern area. Landstuhl is 

a city of 20,000 located in the Rheinland-Pfalz province 

of Germany, about 30 miles east of the French border, 

near the town of Kaiserslautern and Ramstein Air 

Force Base. US Army outpatient psychiatric care in 

Germany catchment areas consists of the Wurzburg 

area in the southeast, the Heidelberg area in the southcentral region, and LRMC, covering outpatient psychiatric care in southwest Germany (Figure 14-1).1

This US Army facility is the largest American hospital outside the United States and the only American 

tertiary (specialty) care hospital in Europe, serving 

245,000 beneficiaries within the European command, of 

which 100,000 are primary care beneficiaries. Landstuhl 

also supports active duty service members, their family 

members, and other beneficiaries in Africa and Asia. 

About half of the LRMC permanent staff is civilian, with 

Army personnel making up the next largest group, and 

the remainder being US Air Force and small percentages of Navy personnel. Some personnel are borrowed 

from local units. There are also global war on terror 

augmentees (including civilians). In total, about 2,800 

personnel are assigned to work at LRMC, with about 

ROLE OF LANDSTUHL REGIONAL MEDICAL CENTER IN WARTIME

LRMC serves as the primary evacuation center for 

Central Command, thus the majority of Operation 

Iraqi Freedom (OIF) and Operation Enduring Freedom 

(OEF) evacuees pass through LRMC. (Table 14-1 details 

the impact of OIF/OEF on the patient load at LRMC.1

) 

Nearly every day a transport aircraft lands at Ramstein 

Air Force Base near the city of Frankfurt and unloads 

medical evacuees who are then transported to LRMC. 

As they arrive, medics, nurses, physicians, and other 

clinicians gather in front of the emergency room. The 

patients are unloaded from the back of the bus, some 

walking, others on stretchers. As of November 24, 

2008, over 51,750 OIF and OEF service members have 

Figure 14-1. Landstuhl Regional Medical Center and outlying clinics as of 2007.

NATO: North Atlantic Treaty Organization

SHAPE: Supreme Headquarters Allied Powers Europe

Wiesbaden

Dexheim

Kleber

Vicenza

NATO

SHAPE

Baumholder

Landstuhl

Livorno

100,000 Primary

Care Beneficiaries

245,000 Total

Beneficiaries in

the European Command

2,200 permanent party. A typical day at LRMC in Fiscal 

Year 2008–2009 will see 20 admissions, 14 operating 

room cases, an intensive care unit (ICU) census of 6.4, 

2.5 births, and an average length of stay of 3.2 days.1

been treated at LRMC (10,575 battle injuries, 41,178 

nonbattle injuries). Of these, 35,939 were outpatients; 

the remaining 15,814 were inpatients.1

 Over 9,000 were 

returned to duty in Central Command.1

Initial Assessments

Staff members triage the patients, taking the most 

seriously injured to the ICU or surgery. The less seriously wounded and injured are taken to the medical 

and surgical wards, where they share rooms with 

other, similarly injured patients. The psychiatric 

patients are quickly evaluated and either sent to the 

INTRODUCTION
211

Behavioral Healthcare at Landstuhl Regional Medical Center

on the local economy. Patients treated at LRMC are 

usually discharged or complete their course of treatment within a week, thereafter returning to theater, 

the United States, or their home station. Many leave 

within 72 hours of arrival. 

Medical and Surgical Evacuees 

All patients evacuated to LRMC for medical and 

surgical reasons are screened for mental health issues 

by their primary physicians both downrange and 

upon arrival at LRMC. Most inpatients are briefly 

screened by members of the outreach team, which is 

separate from the consultation team and consists of 

multidisciplinary healthcare professionals, chaplains, 

and technicians trained to provide proactive mental 

health outreach to wounded warriors. Chaplains 

brief all arriving soldiers on combat operational stress 

awareness. Many primary care providers also include 

brief education and screening for combat-related emotional problems. Medical staff members are constantly 

trained to recognize and provide basic levels of care 

for combat stress and other combat-related symptoms. 

Few of these patients evacuated for medical or surgical 

reasons demonstrate significant psychiatric symptoms. 

Those demonstrating significant psychiatric symptoms 

are referred to behavioral health providers after ruling 

out medical etiologies. Inpatients in emotional distress 

or with symptoms secondary to emotional distress are 

referred to the behavioral health inpatient consultation 

team. Outpatients are referred to the outpatient behavioral health team. The inpatient consultation team 

consists of multidisciplinary behavioral healthcare 

workers (social workers, psychiatric nurses, psychologists, psychiatrists, counselors, and mental health technicians) who provide consultation and management 

suggestions to primary medical staff. 

Psychiatric Evacuees

Most arriving psychiatric casualties are triaged 

through either the outpatient behavioral health clinic, 

consisting of a multidisciplinary team of technicians, 

psychiatrists, psychologists, and social workers, or the 

after-hours on-call emergency clinicians. After-hours 

services are provided through the combined efforts of 

the LRMC and Ramstein Air Force Base psychiatrists, 

social workers, psychologists, nurses, and mental 

health technicians. 

Characteristics of Psychiatric Evacuees

Landstuhl supports various coalition countries. 

Foreign service members are rare in the outpatient 

TABLE 14-1

IMPACT OF OPERATIONS IRAQI FREEDOM

and ENDURING FREEDOM ON PATIENT

LOAD: A TYPICAL DAY AT LANDSTUHL. 

COMPARISON BETWEEN 2001 AND 2006

2001 2006 Change

Admissions 16 23 + 43%

Operating Room Cases 9 16 + 73%

Intensive Care Unit

Census 3 9 + 300%

Overall Acuity 2.7 5.01 + 85%

Meals 800 1,178 + 47%

Births 3 2.3 - 23%

Average Length of Stay 

(days)

4.6 3.4 - 27%

Pharmacy Products 1,026 1,589 + 54%

outpatient clinic or seen in the emergency room by the 

mental health team after hours. All psychiatric evacuations are seen, evaluated, and have their dispositions 

determined the day of their arrival. Many are on medications; most have been traveling for hours, some for 

days, and may be tired and hungry. 

While psychiatric patients are at LRMC, the Deployed Warrior Medical Management Center (DWMMC) tracks their progress and provides logistical 

support, including briefings, housing, food, finance, 

and other needed support. Each soldier is assigned 

a DWMMC case manager, a liaison from the service 

member’s unit or service, and given access to primary 

care physicians. DWMMC has other staff members, 

nurses, and medics or corpsmen, to assist as needed. 

The case managers and liaisons manage service members with the full spectrum of illness, from the severely 

injured to stable routine patients. 

Until 2007, outpatient evacuees from OIF/OEF 

usually stayed at another military base within the 

Kaiserslautern military community. Due to concerns 

about supervision and access to the hospital, a new 

facility known as the Medical Transient Detachment 

was opened in 2007, allowing many outpatients (especially psychiatric) to stay next to the hospital on the 

Landstuhl base. These patients fall under a military 

command organization with regular formations and 

accountability. During their free time they may engage in on- and off-post activities such as visiting the 

gym and the post exchange, or engaging in activities 
212

Combat and Operational Behavioral Health

Numbers of service

members with the diagnosis

160

140

120

100

80

60

40

20

0

Adjustment Disorder

Depression

Posttraumatic Stress Disorder

Anxiety Disorder

Bipolar Disorder

Figure 14-3. Top five Landstuhl Regional Medical Center outpatient psychiatry diagnoses for Operation Iraqi Freedom/

Operation Enduring Freedom evacuations during 2005 (563 

patients, diagnosis known on 507). Anxiety includes acute 

stress disorder/acute stress reaction. 

mental health setting but are often seen in medical 

and surgical wards. The number of OIF/OEF patients 

evacuated to LRMC has steadily increased since the 

war began (Figure 14-2). This influx of battle-zone patients significantly affects the daily mission at LRMC. 

Figure 14-3 demonstrates the top five diagnoses given 

to OIF/OEF evacuees by outpatient psychiatry during 

a 1-year period: (1) adjustment disorder, (2) depression, 

(3) posttraumatic stress disorder (PTSD), (4) anxiety 

disorder, and (5) bipolar disorder. 

Dangerous Patients

One notable characteristic of a majority of patients 

evacuated for psychiatric reasons is concern for 

dangerousness to self or others. Patient Movement 

Requests are the documents the evacuating physician 

completes in the combat theater when evacuating a 

service member from the combat environment. Each 

request contains a brief paragraph about the concerns 

leading to the evacuation. In a 3.5-month review of all 

available Patient Movement Requests of psychiatric 

patients evacuated to LRMC, the evacuating physician 

had concerns about suicidality or homicidality in nearly 60%. By the time of arrival at LRMC, however, active 

suicidal or homicidal thoughts diminish considerably. 

Less than 3% of OEF/OIF service members reported 

active suicidal or homicidal thoughts on presentation 

at LRMC in the psychiatric intake paperwork. Nevertheless, patient safety cannot be assumed; each evacuee 

receives a clinical assessment for dangerousness to 

self or others. When the evaluating provider deems a 

patient at-risk for harm to self or others, the patient is 

admitted to the inpatient psychiatry service. 

Patient Actions and Behaviors 

Patients who are evacuated for psychiatric reasons 

often have behavioral components to their illness. 

As described above, a high proportion are evacuated 

because of potential for harming themselves or others. They may be in the midst of an emotional crisis 

when they arrive at LRMC. Sometimes their efforts 

are manipulative attempts to avoid combat or simply 

to go home.2

 They often do the unexpected. By policy, 

if the assessing clinician has doubt about the patient’s 

ability to function in the outpatient setting, the pateint 

is admitted to LRMC Inpatient Psychiatry. 

Minimally Supervised

Until the establishment of the Medical Transient Detachment , evacuees were minimally supervised. Now 

there is a chain of command that increases supervision 

substantially. However, determined service members 

have accessed alcohol and weapons. Case Study 14-1 

describes the potential problem of an unsupervised 

patient stay at LRMC. 

Case Study 14-1: Two service members in their early 

twenties were evacuated from theater with adjustment 

disorder symptoms and triaged to outpatient evacuation to 

700

600

500

400

300

200

100

0

2003 2004 2005 2006

Year

Number of Patients

Figure 14-2. Operation Iraqi Freedom/Operation Enduring 

Freedom evacuations by year. Those seen in the Landstuhl 

Regional Medical Center outpatient clinics represent the 

majority, but do not include those admitted to the psychiatric 

ward in the evening or on the weekend.

CHALLENGES TO PROVIDING PSYCHIATRIC CARE TO EVACUEES
213

Behavioral Healthcare at Landstuhl Regional Medical Center

the United States. The evening after their evacuation they 

returned to the barracks and immediately booked a hotel in 

downtown Kaiserslautern, where they spent the next 2 days 

drinking local beer and missing medical and accountability 

formations. This resulted in delays in the soldier’s treatment. 

The soldiers’ down-range rear detachment commands were 

notified. 

Potential Harm to Self or Others 

Frequently by the time service members arrive 

at LRMC they expect to be sent home to the United 

States. They no longer consider returning to duty an 

option. When clinicians attempt to send such service 

members back to combat duty, it almost always leads 

to a worsening of symptoms with frequent acting out. 

Case Study 14-2 describes such a case. 

Case Study 14-2: A 25-year-old active-duty male soldier became involved in a love triangle with his girlfriend 

and her other boyfriend in the deployment environment. 

An altercation ensued in which the patient was attacked. 

Shortly afterwards he described symptoms of acute stress 

disorder relating to the attack. He was evacuated to LRMC 

after mentioning suicidal thoughts. On arrival at LRMC he 

related that the treating clinicians in theater had told him 

he would be going home. By the time he arrived at LRMC 

he demonstrated no symptoms. When told he would be 

returning to duty he became extremely anxious and all his 

symptoms of flashbacks, reported dissociation, dreams, and 

jumpiness returned. The following morning he presented 

to the emergency room after superficially cutting both his 

wrists. The treating clinician continued the air evacuation to 

the continental United States (CONUS) for treatment and 

disposition there. 

Case Study 14-3 describes the interaction of two 

soldiers who arrived at LRMC for different reasons 

requiring psychiatric evaluation and shared quarters 

while awaiting their evaluations. 

Case Study 14-3: Soldier #1 is a 30-year-old seasoned 

veteran, family man with several young children, on his third 

deployment. In prior deployments he had been personally 

involved in some of the most notable battles with intense 

urban warfare, including hand-to-hand fighting. He witnessed 

multiple deaths and maimings of both friendly and enemy 

forces. He presented to Landstuhl cardiology for onset of 

chest pains. There were no medical findings and he was 

referred to psychiatry for evaluation. 

His roommate, Soldier #2, a 24-year-old junior noncommissioned officer (NCO) on his first combat tour, had flown to 

the forward operating base on a helicopter, had never been 

outside the perimeter, never seen any combat action, nor 

witnessed trauma of any sort. He was anxious and reported 

vague suicidal ideation contingent on his return to theater. 

The two soldiers arrived together at the psychiatry clinic. 

Soldier #2 was evaluated first. The clinician felt that he presented too much risk for acting out if returned to duty and 

decided to return him as an outpatient to the United States. 

On his way out he met Soldier #1, the veteran war fighter, and 

gloated over the psychiatrist’s decision to send him home. 

He was happy and felt he got what he desired. 

After Soldier #1’s evaluation the clinician informed him he 

would be returned to duty. The chest pain was likely related 

to stress. Though he had some combat-related symptoms, 

the clinician felt he could be returned to duty with continued 

mental healthcare in theater. The veteran NCO pleaded with 

the evaluator not to send him back to combat. He cited past 

experiences, heroic actions, and circumstances contrasting with those of his “suicidal” roommate. He related how 

he knew his roommate was just lying to get out of duty. He 

stated he could never harm himself or lie about suicidality 

to get out of duty, but cited the unfairness of the situation 

where someone who had truly sacrificed and experienced 

much was returned to harm’s way, while someone who had 

never faced any danger would be spared threat. He further 

stated that after doing more than his share of combat he had 

been having premonitions that he would be killed in action, 

leaving his family alone and his wife widowed. The provider 

empathized with the soldier, but could not justify removing 

him from combat. In the end, the heroic NCO, Soldier #1, 

was returned to duty while Soldier #2 (most likely malingering) was taken out of theater. 

Similar situations repeat themselves nearly every 

day at LRMC and most likely throughout the military. 

Soldiers and other service members who have already 

sacrificed much are required to give more. Many other 

soldiers are returned to CONUS for suicidal ideation 

based solely on anxiety about returning to combat. Often the providers suspect malingering as a cause but are 

unable to act on mere suspicions and are unwilling to 

risk repercussions of a bad outcome due to the provider 

taking a risk returning such a patient to combat. 

Because of such incidents and the lack of supervision and control of return-to-duty patients while they 

await return to their units, most clinicians are not willing to send such patients back to the combat environment. In many cases such service members are using 

statements of self-harm to manipulate the system or go 

home early.3 An unfortunate aspect of their evacuation 

is that other soldiers, who will not go to the extremes of 

manipulation and may have some symptoms, will return to duty while those manipulating the system will 

achieve their exit from the situation. In this embroiled 

climate, clinicians are likely to continue exercising 

conservative judgment such that many patients will 

be sent to CONUS instead of returning to duty in Iraq 

or Afghanistan. The return-to-duty rate for OIF/OEF 

mental health evacuees at LRMC varies between 3% 

and 6%. Even when it is clear that a service member 

is malingering, the risks of that soldier acting out if 

forced to return to duty may necessitate continued air 

evacuation to the home station (Figure 14-4). 
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Combat and Operational Behavioral Health

Circumvention of Evacuation Channels 

Many service members are evacuated to LRMC 

for routine medical evaluation. Often they present to 

LRMC’s behavioral health division as a self- or clinician referral. For the most part they have not yet been 

treated by behavioral health personnel in theater.3

Clinicians noted that this population’s return-to-duty 

rates were especially low. Often the mental symptoms 

increased after arrival at LRMC and even further after 

presenting to behavioral health. They are especially 

challenging to treat, given their isolation from sources 

of support and unit supervision.4

 Some were expecting 

to be sent to CONUS for treatment of their medical 

symptoms, but instead were found medically able 

to return to the combat zone. In essence, they skip 

in-theater mental health resources and become a rearechelon psychiatric evacuation upon presentation at 

LRMC. 

Clinicians observe that with this rear-echelon 

presentation, service members’ chances of return to 

duty are considerably less than if they first presented 

in theater (95%–99% vs 3%).5

 It seems that with each 

passing moment at LRMC, it becomes more difficult 

to return such a soldier to the combat zone. Living 

in a safe environment, along with a lowered expectancy of returning to combat duty, decreases levels 

of vigilance and combat mind frame, and alters one’s 

view of oneself. Often such service members develop 

ever-increasing psychiatric symptoms as their returnto-duty day draws near (see Case Study 14-2 and Case 

Study 14-3). One potential factor contributing to these 

mental symptoms is the loss of expectancy that they 

will return to duty. Such loss of expectancy has been 

found to be related to worse outcomes.6

One controversial approach, based on the assumption that these service members’ units and 

social supports are better in theater, is to return such 

soldiers to their combat duty stations to receive 

their care. They are triaged for dangerousness, and 

evaluation and treatment at LRMC are minimized. 

They are expected to return to duty and get further 

care in theater. Appropriate mental health resources 

are usually available through combat stress control 

or other behavioral health personnel in theater. This 

approach not only maintains the fighting force but 

potentially improves the long-term prognosis for 

those treated in theater. In a sense, without the presence of fellow soldiers to provide social support and 

a leadership role in a service member’s care, they will 

actually receive a lower level of care at LRMC than 

they would in theater with such peer support.3,4,6–8 It 

is assumed that many service members with similar 

emotional symptoms are functioning in the combat 

zone. Their presentation at Landstuhl behavioral 

health, rather than at their in-theater mental health 

service, is determined solely by their need for a medical evaluation, which should not determine the level 

of mental healthcare required. 

This approach, however, is not entirely without risk. 

Some of the potential hazards are that the service members may act out at LRMC, there may not be adequate 

care available for them in their combat duty stations, 

and they may perceive that they are being denied care 

at LRMC. The alternate approach of thoroughly evaluating and treating each such soldier is risky and may 

cause unnecessary delays in return to duty and thus 

lessen overall return-to-duty rates (Figure 14-5). 

Staff Characteristics and Actions

Rotating Staff

To meet the additional duty of immediately evaluating all OIF/OEF mental health evacuees, LRMC is 

augmented with clinicians who have been rotating 

to LRMC for the majority of the wars. Though the 

augmentees are vital to performing the LRMC OEF/

OIF mission, the rotations are not always predictable. 

Year

2003 2004 2005 2006 2007

Evacuations Return to Duty

700

600

500

400

300

200

100

0

Figure 14-4. Operation Iraqi Freedom/Operation Enduring 

Freedom total evacuations compared to return to duty by 

year until February 2007. Those seen in Landstuhl Regional 

Medical Center outpatient clinic represent the majority, but 

do not include those admitted to the psychiatric ward in the 

evening or on weekends.
215

Behavioral Healthcare at Landstuhl Regional Medical Center

Sometimes the clinicians scheduled to arrive never 

show up. Usually this is due to an administrative or 

mobilization problem. Sometimes the rotation schedule is manipulated, bringing a clinician to LRMC either 

later or earlier than expected, thereby creating overlap 

or underlap and resulting in too many clinicians at 

some times and too few at others. 

Augmentees are generally Army, Navy, or Air Force 

reservists. Usually they are clinically adept. They 

share the latest skills and knowledge from the civilian world, keeping the staff current. Some understand 

principles of combat operational stress control while 

others do not. They often need extensive training and 

supervision as they take on the relatively unique role 

of OIF/OEF evaluation and disposition. Figure 14-6 

demonstrates a 5-month period in which the numbers 

of OIF/OEF patients are graphed compared with the 

number of available providers in the clinic. The number of clinicians available does not always correlate 

with the number of OIF/OEF evacuations. In some 

instances it is almost an inverse relationship. The 

unpredictable OIF/OEF load and the unpredictable 

augmentee support challenge the ability of the clinic 

to provide cohesive, continuous mental healthcare to 

those living in the local area. 

The primary difficulty lies in maintaining adequate 

clinician availability to meet the surges of OEF/OIF 

patients without wasting clinician time or tying them 

down with excessive case loads. The need to maintain 

this reserve challenges measures of provider performance and productivity with the ever-looming threat 

that future personnel allocations will be based on that 

productivity. 

Outreach to Wounded Warriors 

As already mentioned, the majority of OIF/OEF 

evacuees sent to LRMC will stay only a couple of days. 

Concerned clinicians have consistently pondered the 

question, “What can we do to help the mental health 

of these patients?”9 Concerns expressed by clinicians 

interacting with the wounded warriors include concern about harming the soldiers’ mental recovery 

(perhaps by making them talk about their experience 

before they are ready, or by creating or worsening 

symptoms through conscious or unconscious suggestion during interactions) and concern about loss of 

follow-up care. 

More than one soldier has stated that discussing 

the problem once was hard enough. There was no 

desire or intent to discuss it with another professional 

later. The relationship that is formed when a soldier 

discusses trauma is often intense and trusting, and 

may be ill-timed given that the soldier will leave 

within the next couple of days. Thus the mental health 

professional may have concerns about consciously or 

unconsciously pathologizing or labeling the patient’s 

symptoms, or concerns about stigmatizing service 

members as either “crazy” or weak.10

Development of an Emergency Mental Health 

Model

The majority of clinicians serving in this capacity 

Mental Health

Channels in Theater

Buddy

Medic

Chaplain

Unit Leadership

CSC or BDE

Mental Health Team

Division Mental

Health Team

Restoration/Fitness

CSH

LRMC

Battle Lines

Combat

Support Hospital

Landstuhl Regional Medical Center

Brigade

Support

Area

Brigade

Support

Area

Division

Support 

Area

Brigade

Reserve

Area

Figure 14-5. Circumventing mental healthcare in theater. 

Soldiers evacuated for medical reasons who then present at 

Landstuhl for mental health reasons may have skipped all 

mental health resources in theater and, in essence, become 

rear-echelon psychiatric casualties (with rear-echelon returnto-duty rates). 

BDE: brigade; CSC: combat stress control; CSH: combat support hospital; LRMC: Landstuhl Regional Medical Center.

120

110

100

90

80

70

60

50

40

30

Number of OIF/OEF Patients

Number of Available Providers

10

9

8

7

6

5

4

OIF/OEF patients Providers available

Aug 06 Sep 06 Oct 06 Nov 06 Dec 06 Jan 07 Feb 07

[Note: Delete text at the bottom that begins with “LRMC Outpatient...” and 

bump up the font size of the text to the left and right sides of the graphic, 

as well as that on the bottom that indicates dates (“Aug06,” etc.).]

Figure 14-6. Comparison between Operation Iraqi Freedom/

Operation Enduring Freedom evacuations and available clinicians at Landstuhl Outpatient Behavioral Health Clinic.
216

Combat and Operational Behavioral Health

at LRMC have supported an emergency mental health 

model with the following key components: 

	 •	 Avoid stigmatizing service members. Avoid 

diagnostic labeling,11 and do not single out 

any one soldier. For example, clinicians could 

say: “Hello, I’m a psychiatrist working with 

your medical team. Every patient gets ‘topto-bottom’ care.”

	 •	 Look after basic needs. Many patients are less 

than 2 days out from a major traumatic event, 

though many of them have been having traumatic events for months in the deployment 

setting. Ensure that their physical needs (rest, 

food, medical care) are being met.

	 •	 Help them learn to ask for help and to communicate their needs. Let them know that the 

more comfortable they are, the sooner they 

will heal. Observe comfort measures—pain 

control, room temperature, hydration, nutrition, sunlight, and privacy.

	 •	 Ask about their pain and comfort. Using a 

0-to-10 pain scale (with 10 being the most pain 

possible and 0 being no pain), ask soldiers 

how they would rate the pain and at what 

level they would call the nurses. Catching 

the pain early may reduce the total amount 

of pain medication required.

	 •	 Help them answer questions about what 

happened. The most common questions 

asked by wounded service members at Landstuhl concern the status of their buddies, what 

happened, what weapons were involved, and 

whether they were personally responsible for 

what happened.

	 •	 Connect them with their unit if indicated. 

The unit may provide information to clarify 

the event and prevent solidification of false 

impressions or memories.

	 •	 Normalize reactions. Educate patients on 

symptoms they may experience.

	 •	 Refrain from making statements indicating 

that they are ill, or even that they scored higher than others on various screening tools.

	 •	 Talk about normal things—sports, football, 

or their hometown.

	 •	 Assess them for posttraumatic stress symptoms.

	 •	 Help service members take charge of their 

medical care. Ensure that they know what 

they need to about their condition and options, give them a sense of control, explore 

their knowledge of their injury, and help them 

understand the injury.

	 •	 Help them know when they can expect to fly 

and where they will be transferred. Many are 

anxious about the next step in their evacuation.

	 •	 Follow up on their care. Communicate to 

receiving physicians about service members 

demonstrating psychological symptoms.

	 •	 Instill hope by discussing others who have 

recovered from similar events.

	 •	 Sincerely express appreciation for what they 

have gone through. Add value and meaning 

to their experience.

Case Study 14-4: A 22-year-old soldier lost his vision 

in an explosion and was evacuated to LRMC. One of the 

outreach team members entered his room and noticed 

that the soldier’s lips were parched and dry. The team 

member asked him if he was thirsty. The soldier replied 

“Yeah, I guess I could use a drink.” There was a glass 

of ice water sitting a few inches away from where the 

soldier was resting his hand. The team member gave 

him the water then took his hand and showed him where 

the water was placed. During the ensuing conversation 

the team member mentioned that all the soldier needed 

to do is ring for a nurse to help him with his needs. The 

soldier replied, “I know that, but they are busy and there 

are a lot of us here.”

Case Study 14-5: A 23-year-old soldier lost his leg in 

an explosion in Iraq. When he arrived at LRMC he was 

agitated and anxious to know if his gunner had survived 

the explosion. His primary physicians were unsure whether 

25

20

15

10

5

0 Sept 06 Oct 06 Nov 06 Dec 06 Jan 07

Consults

ETOh

PTSD/ASD

Nighmares

TBI

Physical Trauma Other

Figure 14-7. Landstuhl Regional Medical Center psychiatric 

consultation to medical and surgical wards, September 1, 

2006, to February 1, 2007. By November 2006, the multidisciplinary Combat and Operational Stress/Staff Resiliency 

team and patient outreach teams were effectively established 

throughout the hospital. There was a significant drop in official consultations as informal, nonstigmatizing outreach efforts proceeded. Data are from 236 inpatient consultations.

ETOh: ethanol (alcohol abuse); PTSD/ASD: posttraumatic 

stress disorder/acute stress disorder; TBI: traumatic brain 

injury. 
217

Behavioral Healthcare at Landstuhl Regional Medical Center

they should tell him that the gunner, a close friend of his, 

had died. They contacted the behavioral health consultation team. In discussing his desire to know about his friend 

with the treating physicians, chaplains, and members of 

the soldier’s unit (by telephone), the team decided on an 

appropriate time and place to let him know the bad news. 

The team arranged for the service member to speak to 

his unit members by telephone during the meeting. The 

soldier was notably saddened by the news but stated that 

the additional support of his unit by telephone helped him 

“drive on.”

Case Study 14-6: A 25-year-old squad leader lost several 

squad members during a firefight and blamed himself for not 

reacting appropriately during the action. Regardless of what 

the physician and nursing staff told him, he continued to hold 

himself responsible for actions over which he had no real 

control. The outreach team arranged a telephone consultation with the soldier’s command and fellow unit members. 

During the conversation, the events of the firefight were 

related and the squad leader realized that he did not cause 

the deaths of his subordinates, but rather that he acted as 

any other NCO would have done. 

Local Area Support

One of the greatest challenges of the LRMC behavioral health division is to maintain consistent, continuous, mental health support to its catchment area 

despite unpredictable surges in staffing and patient 

load (Figure 14-7). Eight outlying clinics—(1) North 

Atlantic Treaty Organization, Holland; (2) Supreme 

Headquarters Allied Powers Europe, Belgium; (3) 

Vicenza, Italy; (4) Livorno, Italy; (5) Kleber, Germany; 

(6) Dexheim, Germany; (7) Wiesbaden, Germany; 

and (8) Baumholder, Germany—fall under the LRMC 

support area, which covers approximately 100,000 

primary care beneficiaries (see Figure 14-1). In addition 

to the primary care mission, the tertiary care mission 

includes approximately 245,000 total beneficiaries in 

the European command. Many service members in 

the LRMC support area have served in OIF/OEF and 

experience ongoing sequelae of their time there,1,12

resulting in additional combat-related patients for the 

psychiatry service.

INPATIENT PSYCHIATRY AT LANDSTUHL REGIONAL MEDICAL CENTER, 2003–2007

Increasing Patient Load

The inpatient psychiatry service maintains an 18-

bed service for all active duty service members and 

beneficiaries throughout Europe, Asia, Africa, and 

the Middle East. Criteria for admission are similar to 

those in the civilian world. However, given the limited 

supervision of patients treated and evacuated in the 

outpatient setting, if an evaluating provider has concerns about safety, including the patient’s potential to 

abuse substances, then the patient is admitted, usually 

for continued evacuation in the inpatient setting. In 

2003 there were 382 OIF/OEF service members admitted; in 2004 there were 269; in 2005 there were 346; in 

2006 there were 408; in 2007 there were 563; and as of 

October 2008 there were 481 OIF/OEF admissions. As 

for total admission numbers, which include OIF/OEF 

as well as other patient populations (family members, 

local military), there were 902 total in 2006, 990 total 

in 2007, and 822 (as of Oct 2008) in 2008. 

The majority of OIF/OEF patients admitted remain in the inpatient setting for evacuation to the 

United States. Most OIF/OEF admissions continue 

their evacuation within a couple of days, leading to 

extremely rapid turnover on the ward. Contacting 

an accepting physician in the United States can be 

challenging, especially given the 6- to 9-hour time 

difference and sheer volume of turnaround. This is 

partially resolved by the ability to send patients on to 

Army hospitals with an “open OIF/OEF” status that 

does not require physician-to-physician discussion to 

establish an accepting physician. However, such is not 

the case with accepting hospitals from sister services, 

which often require physician-to-physician establishment of acceptance. 

Prior to 2003, the 18-bed inpatient psychiatry service 

had averaged about 675 admissions per year. By June 

2003, it was admitting 100 patients per month (1,200 

annualized rate). As many of the admissions seemed 

inappropriate, a 100% screening was implemented for 

patients arriving from OIF. This helped, but in 2005, for 

example, 902 patients were still admitted (Figure 14-8 

and Figure 14-9). The 100% screening, in turn, caused 

its own problems. It became necessary to change the 

psychiatry call schedule to accommodate the numbers 

of OIF patients who were arriving and needed screening. The inpatient psychiatrists were augmented by 

outpatient psychiatrists and further augmented by the 

local Air Force providers. 

The ward itself was augmented by a succession of 

reservists. The nursing personnel came for a year at 

a time. Their “train up” required an intensive schedule of activities before they could begin to “orient.” 

Even after the formal train-up activities, the nursing 

personnel required considerable time to make them 

comfortable in handling all the nuances of the inpatient ward. 

The psychiatrists who came to augment LRMC were 

there for only 90 days. They varied greatly in experience levels, ranging from current active duty to reserv-
218

Combat and Operational Behavioral Health

ists who had never been activated. Some were quickly 

able to absorb the complexities of the rapid turnover of 

patients, while others could master only a portion of 

the tasks at hand. The Composite Health Care System 

electronic medical record used throughout the military 

proved to be a record-keeping system that many inexperienced physicians could not master. 

The effect of the patient volume can be understood 

by dividing 902 admissions in 2006 by the number 

of inpatient beds available: 18. The result, 50.1, is the 

number of times that a bed was turned over during 

the year. Dividing that 50 into 365 yields a theoretical 

length of stay of slightly over 7 days. 

Receiving patients, screening them, stabilizing them 

on the ward, and placing them on an aeromedical evacuation became the routine. With increased OIF/OEF 

workload, the ward was frequently too full to accept 

nonactive duty patients. The “available to nonactive 

duty” measure (over 90% on an annual basis during 

the pre-OIF period) decreased to approximately 60% 

once casualties from OIF began arriving (meaning that 

there were spaces available to nonactive duty personnel only 60% of the time.) 

With the slowly increasing census of inpatients 

since 2003, air evacuation flights from Landstuhl to 

CONUS became more and more crowded. Beginning 

in November 2006 and continuing regularly over the 

next several months, the inpatient team encountered 

difficulties getting patients out on air evacuation 

flights fast enough to have beds available for incoming service members. Service members coming 

from garrisons in Europe were diverted to German 

hospitals. Such diversions of active-duty soldiers to 

German hospitals usually lasted only a few hours 

to a couple of days, but demonstrate that the 18-bed 

inpatient psychiatry ward is insufficient to handle 

both local support and air evacuation missions during wartime. 

Psychological Stressors and Staff Resilience 

The daily psychological stressors for LRMC team 

members are significant. A recent article in a German 

newspaper described LRMC’s role as being at the outer 

perimeter of the Iraq battlefield.13 Indeed, in previous 

wars many of the casualties arriving at LRMC would 

not have made it out of theater. Now, however, modern 

transportation and stabilization capabilities bring the 

battle to LRMC’s front door,13 exposing many LRMC 

staff to trauma of combat casualties on a daily basis. 

In previous wars the patients seen at LRMC would 

probably have been seen in a hospital much closer to 

Number of Patients

Year

Operation Enduring Freedom

Operation Iraqi Freedom

2002 2003 2004 2005 2006 2007

1000

900

800

700

600

500

400

300

200

100

0

Figure 14-8. Landstuhl Regional Medical Center inpatient 

admissions, 2002 through July 2007.

Suicidal

Year

Suicide Attempt

Homicidal

PTSD

2003 2004 2005 2006 2007

400

350

300

250

200

150

100

50

0

Figure 14-9. Landstuhl Regional Medical Center (LRMC) 

inpatient admissions, 2003 through July 2007. LRMC began 

tracking homicidal ideations and posttraumatic stress disorder (PTSD) in 2004.
219

Behavioral Healthcare at Landstuhl Regional Medical Center

the battlefield. The Combat and Operational Stress 

Response/Staff Resilience Program at LRMC was 

developed to address the short- and long-term consequences of this experience with casualties. 

Compassion Fatigue

In its present-day connotation, compassion fatigue 

refers to the deleterious effect on caregivers of repeated 

exposure to physically or psychologically traumatized 

patients. Compassion fatigue was initially construed 

as a secondary trauma experienced by those treating 

PTSD patients, who have experienced primary trauma.14 The symptoms are similar. And although it has 

been called various things (secondary traumatic stress 

disorder or compassion stress), the main point is that 

anyone in a care-giving or helping profession—from 

psychotherapists to nurses to police—can experience 

acute and chronic stress reactions in the course of their 

duties. So, too, may they experience symptoms as a 

result of their own primary trauma or occupational 

burnout. 

Specific to LRMC, compassion fatigue results from 

caregivers’ repeated exposure to soldiers with severe 

burns, amputated limbs, or traumatic brain injury. 

With the exception of those staff who have worked 

in major metropolitan trauma centers, most have 

not been exposed to this frequency and severity of 

wounds. Because LRMC is the deployed location for 

many of its personnel (ie, the Navy and Army reservists who deploy to Landstuhl to help with the wartime 

mission), many staff who are actually deployed personnel will face deployment-related stressors such as 

being away from home and loved ones. 

Combat and Operational Stress Reaction

Army Field Manual 4-02.51, Combat and Operational 

Stress Control,15 redefines soldiers’ negative reactions 

to combat and support operations (previously known 

as “battle fatigue”) as combat and operational stress 

reactions (COSR). This new term considers soldiers 

who are not directly involved in battle but nonetheless develop stress-related symptoms (loss of appetite, 

increased irritability, or a desire to smoke), as having 

a normal reaction to a potentially hostile environment 

and the related demands that this entails (high operations tempo, living in austere conditions, and extensive 

separations from family). 

Resiliency

Just as two soldiers can be involved in the same 

firefight and one develop COSR while the other 

does not, so, too, can two providers treat a similar 

number and type of patients and one develop compassion fatigue while the other remains intact. The 

mechanism that allows this has come to be called 

“resilience.” Combat and Operational Stress Control15

mentions resilience as something that is desirable 

and can be increased, but does not describe how this 

can be accomplished. 

Resilience as a phenomenon has been studied in 

the civilian population, including in children who 

suffer physical and emotional abuse or neglect,16 adult 

victims of crime,17 and people exposed to natural 

disasters.18 Proposed factors leading to individual 

resilience are physical (exercise, nutrition), emotional 

(social support, optimism), psychological (attributional 

style), and spiritual (a life meaning or purpose). Unit 

morale and cohesion are additional factors within 

the military social context that may lead to resiliency 

among troops. 

DEVELOPMENT OF LANDSTUHL’S STAFF RESILIENCY PROGRAM

Precipitating Event and Command Response

Following a series of patient fatalities in LRMC’s 

ICU in July 2005, the hospital commander contacted 

the on-call chaplain to discuss what could be done to 

alleviate some of the providers’ stress. After that discussion (and the resulting actions taken to help reduce 

the effect of these ICU deaths on the staff), a team was 

formed to address this overlooked need among physicians, nurses, and their technical staff. 

A consultative team approach was deemed the best 

way to deal with these operational stressors. Although 

various agencies (chaplaincy, employee assistance 

program, behavioral health) already existed to help 

LRMC staff cope with stress or PTSD symptoms, these 

services were not accessed by those in need for various reasons (eg, stigma, availability). The plan was to 

provide outreach by chaplains and behavioral health 

staff who typically worked in close proximity with 

LRMC staff to address their concerns and direct them 

toward the best resources. 

Structure and Focus of Program

In November 2006, the compassion fatigue team 

changed its name to “Combat and Operational Stress/

Staff Resiliency” (COSR/SR). This is not merely semantics. Rather, the scope of concern has been widened beyond compassion fatigue (trauma secondary 

to care giving) to include COSR, acute or chronic 
220

Combat and Operational Behavioral Health

reactions to primary trauma (ie, PTSD), burnout, and 

efforts to restore or improve resiliency. In addition to 

physicians and nurses in the ICU, COSR/SR consultation now includes all LRMC staff, from those who 

carry litters and help move patients, to the finance 

staff who hear soldier’s stories as they help with pay 

and benefits. 

Program Director

Prior to August 2006, LRMC’s COSR/SR team 

utilized an informal committee led by a behavioral 

health provider. Funding was secured to hire a clinical 

psychologist to fill the position of program director. 

This individual leads the team and, more importantly, serves as the main point of contact for COSR/

SR-related questions. This program director is tasked 

to conduct a majority of the brief consultations and 

office visits. 

Team Membership

The COSR/SR team is composed of chaplains, 

nurses, and behavioral health providers in officer 

ranks or their civilian equivalent. Team members 

voluntarily take on—as an additional duty—reaching 

out to LRMC personnel who might not otherwise access services for symptoms that develop as a result of 

treating severely wounded soldiers and operations in 

support of this mission. They also make short presentations at various venues—newcomers’ orientation, 

professional and clinic staff meetings, and for new 

leadership. Additional ways of “getting the word out” 

about the program include a trifold brochure that outlines the program. A business card listing online and 

local resources is also used. Finally, e-mail messages 

distributed to LRMC staff describe sponsored events 

(sleep hygiene or stress-management classes) and 

highlight the COSR/SR program. 

Confidential Visits

In an attempt to circumvent the often-noted stigma 

associated with seeking help, LRMC’s COSR/SR team 

allows for two consultation meetings that are highly 

confidential. If there is no diagnosis, there is no documentation. As always, domestic violence, child abuse, 

and intent to harm oneself or others must be reported. 

Although previously one “free” visit had been advertised, the hope was that a second such visit would 

allow for additional assessment of any advice or suggestions given. If the problems were continuing, this 

second visit would give the COSR/SR team member 

a better opportunity (because of increased rapport) to 

encourage entry into some form of treatment or referral 

to an appropriate resource.

The goal is for LRMC staff to feel comfortable in 

reaching out to COSR/SR team members, knowing 

they can get some advice on psychological or emotional symptoms they may experience as a result of 

their work at LRMC or from other situations. Some 

of the symptoms LRMC staff may experience include 

poor sleep, increased irritability, and hypervigilance. 

The key is that LRMC staff must have confidence that 

their personal affairs will remain private and their 

careers will not be put in jeopardy. In those cases 

where minor support and guidance is not enough, 

COSR/SR team members will point the LRMC staff 

member in the right direction and, perhaps, answer 

some questions of concern such that, in most cases, 

their anonymity is protected. 

Hallway Consultation Versus Office Visit

In an attempt to track the utility of LRMC’s COSR/

SR program, short, informal consultations were differentiated from longer, sit-down sessions. This differentiation is useful to characterize support and minimal 

advice-giving from processing and intervention. For 

example, during October through December 2006, 65 

LRMC staff were provided hallway consultation and 

four were seen in an office visit. Of these, 20% were 

later seen in formal treatment. Due to a multitude 

of changes from one month to the next, these visits 

fluctuate. In March and April 2007, for example, the 

COSR/SR team had 38 hallway consultations and 46 

office visits. In part due to the increase in office visits, 

the follow-on to treatment rate dropped to 10%. 

In addition to tracking hallway consultation versus 

office visits, COSR/SR team members collect information on the staff member’s ward or clinic. By learning 

about the events and environment of wards and clinics 

throughout the hospital, the COSR/SR team is able to 

understand the experiences and conditions of most 

of the hospital workers. The COSR/SR team can then 

reallocate resources to those areas most needing them. 

When the mental health needs, working environment, 

or experience of the staff dictates, consultation with the 

clinic or service chief may prove beneficial. 

Debriefs

Critical incident stress management defusings and 

debriefings appear to have fallen out of favor. However, hospital staff can still benefit from a chance to 

process their experiences in a safe, nonjudgmental 

setting. LRMC’s COSR/SR team attempts to provide 

this environment. A prime example of where this ap-
221

Behavioral Healthcare at Landstuhl Regional Medical Center

pears to be helpful is with the personnel team, which 

provides litter bearers and evacuation personnel for 

the incoming and outgoing flights. Many of these 

team members are exposed to physically traumatized, 

wounded, maimed, and dying service members. 

These LRMC staff are at substantial risk for mental 

and emotional problems. At the end of each team’s 

1-month rotation, a debrief is held during which 

a chaplain, supported by another COSR/SR team 

member (typically a behavioral health staff member), 

leads the members through mental processing. Most 

of the manpower team members feel the experience 

is meaningful and generally positive. Often they develop a greater appreciation for the positive factors 

in their lives, such as health, well-being, and a supportive family. Occasionally problems with the system 

are discussed in the debriefings. Problems (with the 

personnel system or other units debriefed) that can 

be remedied by command action are anonymously 

conveyed to command staff who may act to correct 

the situation. 

In the months of March and April 2007, 134 LRMC 

staff were debriefed in some capacity, either because 

of a critical event (death of a patient who was on the 

ward for an unusually long time) or a chronic stressor (higher than average number of amputees). One 

example of the latter is a young troop member who, 

while replacing equipment in a wounded soldier’s 

room, was affected by the smell of the patient’s burn 

wound. He said that on and off for several nights afterward he dreamt of the event. By addressing how the 

human brain processes trauma to self or others, and 

normalizing his reaction, he was able to quickly return 

to his previously high-functioning status. 

DAILY OPERATIONS

Member Dispersal

Team members are dispersed throughout the 

hospital to consult on COSR/SR as needed. Additionally, members take part in hospital committees 

and functions to ensure that system-wide efforts are 

made to reduce stress or provide input to command 

staff on actionable items. The main point is that the 

COSR/SR team attempts to address issues not only 

on a one-on-one basis, but also at higher levels within 

the organization, by consulting with supervisors and 

commanders. In large part this is due to research suggesting that unit morale and cohesion are factors of 

resiliency, which should be addressed at all levels by 

everyone involved. 

Committee Meetings

The multidisciplinary COSR/SR team convenes 

weekly to discuss consultation trends and upcoming 

issues, either in terms of wards or units affected, or 

the types of stressors reported. The meeting is vital 

to disperse information and provide emotional and 

leadership support to team members. Based on the 

feedback from the team members, an accurate picture 

can be developed of the emotional status throughout the hospital and resources can then be allocated 

to those areas needing them. A forum is provided 

where advice dealing with particular situations can 

be asked for and shared. Additional planning is also 

coordinated at these meetings to ensure continued 

advertising and coverage for clinic debriefs or presentations. 

Surveys

In an attempt to keep pace with LRMC as a dynamic 

organization, the COSR/SR team periodically surveys 

various wards or sections on stress levels, morale, and 

general knowledge of the program.

CHALLENGES AND FUTURE DIRECTIONS

Program Director 

Presently [in 2007], the COSR/SR program has 

funds for a 1-year program manager position, someone solely dedicated to advancing the program and 

working with staff. Although additional funds will 

be requested, it is difficult to find potential candidates 

willing to relocate to Germany, knowing their position 

is time-limited. Other options, such as using interns 

or community volunteers, are being considered. Additionally, there is some debate whether the ideal candidate for the position of COSR/SR program director 

should be a psychiatrist, psychologist, or social worker, 

with or without experience in community or systemwide interventions. Ideally the candidate would be 

familiar with the military and its deployment process 

as well as the healthcare system in general and work 

at a major medical hospital, specifically. 

Personnel

The Mental Health Advisory Team II noted that 
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Combat and Operational Behavioral Health

20% to 30% of behavioral health personnel reported 

burnout, low motivation, or some form of impairment 

related to deployment.19 Thus, it will be important to 

assess COSR/SR team members and provide respite 

or resiliency support to avoid their becoming overwhelmed.19 Consideration is being given to the use 

of enlisted medical technicians to work with enlisted 

LRMC staff seeking access to the COSR/SR program. 

Additionally, peer support personnel may be culled 

from LRMC’s wards and clinics to help augment the 

COSR/SR team. Within the framework of focusing on 

building and supporting staff resiliency, clinic chiefs 

and NCOs may be encouraged to identify those subordinates they see as “resilient” and match them up 

with those deemed “at risk.” 

Central Point of Contact 

One difficulty noted is that hospital staff may not 

know who to contact, especially given the need for 

team members to rotate on-call availability. Asking 

around to find the appropriate person may feel uncomfortable. It also decreases the anonymity of the 

person seeking help. Efforts are being made to simplify 

the process by establishing a designated cell phone 

number to be carried by the COSR/SR team member 

on duty. That cell phone number could be published 

throughout the hospital, thus ensuring that hospital 

workers know how to access the team. 

Stigma

Recent surveys of LRMC staff show continued 

evidence of a stigma against seeking help from any 

official program. The COSR/SR team continues to 

advertise the difference between COSR help and being ”crazy” (ie, psychotic), as well as the likelihood 

of career impact from voluntarily seeking behavioral 

health counseling versus being command directed to 

seek such help. These data collection points will be 

included on future surveys. 

Data Collection

The aforementioned surveys used a modified form 

of the Secondary Trauma Cost-of-Caring scale20 with 

unknown validity and reliability. Future efforts will go 

toward securing or developing a sound psychometric 

tool with which to assess COSR/SR. Ideally such 

measures would include objective indicators of the 

organization’s health as a whole. For example, days 

missed from work or number of letters of counseling 

or reprimand might be useful signs of organizational 

distress, which could then be tracked. 

Types of Stressors

In an effort to obtain more data to form more 

precise interventions, LRMC’s COSR/SR team has 

begun to collect information about the types of 

stressors addressed—operational, organizational, 

occupational, home front, interpersonal, or other. 

The pace of one’s duty is an example of an operational stressor. An organizational stressor could be 

the impact of staff turnover during the permanentchange-of-station season. Occupational stressors 

include burnout and the effect of a specific duty 

(working with amputees or burn victims). Home 

front and interpersonal issues are self-explanatory 

and take the form of relationship problems or parenting issues, and communication or teamwork in the 

workplace, respectively. Considered in the “other” 

category are attempts by COSR/SR team members 

to reassure staff that psychotherapy works, addressing how confidential sessions really are, or defining 

various diagnostic categories (ie, “Am I dealing 

with acute stress disorder or PTSD and what does 

that mean?”). 

SUMMARY

The COSR/SR team at LRMC has grown from a 

“psych–spiritual” dyad, consisting of a behavioral 

health provider and chaplain supporting ICU staff, 

to a full compliment of providers from several 

disciplines and branches dispersed throughout the 

hospital, to include the much-appreciated ancillary 

and support services such as finance and personnel 

teams. The scope of concern has been widened from 

provider secondary trauma (ie, compassion fatigue) 

to all stress reactions produced by operating in a 

major medical facility that receives nearly every 

OEF/OIF casualty. This adaptive contingent of professionals will be bolstered by additional direction 

and support from higher command levels (in terms 

of funding and personnel), and will lean towards 

becoming a proactive (rather than a reactive) force, 

perhaps through a newcomer’s combat and operational stress assessment and resiliency development 

plan, yet to be created. Work remains to be done, 

but the underlying concept of the COSR/SR team 

approach is sound and of value to the LRMC staff 

and the patients they serve. 
223

Behavioral Healthcare at Landstuhl Regional Medical Center

REFERENCES

1. Lein B. Colonel, Medical Corps, US Army. Command brief, Landstuhl, Germany, November 24, 2008.

2. Ritchie EC, Keppler WC, Rothberg JM. Suicidal admissions in the United States military. Mil Med. 2003;168(3):177–

181. 

3. Forsten R, Schneider B. Treatment of the stress casualty during Operation Iraqi Freedom One. Psychiatr Q. 2005;76(4):343–

350.

4. Hill JV, Johnson RC, Barton RA. Suicidal and homicidal soldiers in deployment environments. Mil Med. 2006;171(3):228–

232.

5. Mental Health Advisory Team (MHAT). Operation Iraqi Freedom (OIF). Report. The US Army Surgeon General and 

Department of the Army G-1. December 16, 2003. Available at: www.armymedicine.army.mil/reports/mhat.html. 

Accessed September 4, 2008. 

6. Solomon Z, Benbenishty R. The role of proximity, immediacy, and expectancy in frontline treatment of combat stress 

reaction among Israelis in the Lebanon War. Am J Psychiatry. 1986;143(5):613–617.

7. Hassinger AD. Mentoring and monitoring: the use of unit watch in the 4th Infantry Division. Mil Med. 2003;168(3):234–

238.

8. Bacon BL, Staudenmeier JJ. A historical overview of combat stress control units of the US Army. Mil Med. 2003;168(9):689–

693. 

9. Ritchie EC, Owens M. Military issues. Psychiatr Clin North Am. 2004;27:459–471.

10. Greene-Shortridge TM, Britt TW, Castro CA. The stigma of mental health problems in the military. Mil Med. 

2007;172(2):157–161. 

11. McDuff DR, Johnson JL. Classification and characteristics of Army stress casualties during Operation Desert Storm. 

Hosp Community Psychiatry. 1992;43(8):812–815.

12. Blackwell J. Captain, US Army. Chief, Managed Care Division, Landstuhl Regional Medical Center. Personal communication, May 2007.

13. Fichtner U. The German front in the Iraq war: a visit to the US military hospital at Landstuhl. Spiegel Online International. March 14, 2007. Available at: http://www.spiegel.de/international/germany/0,1518,471654,00.html. Accessed 

September 3, 2008.

14. Figley CR, ed. Compassion Fatigue: Coping With Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. 

New York, NY: Brunner/Mazel; 1995.

15. US Department of the Army. Combat and Operational Stress Control. Washington, DC: DA; July 6, 2006. Army Field 

Manual 4-02.51.

16. Daigneault I, Hébert M, Tourigny M. Personal and interpersonal characteristics related to resilient developmental 

pathways of sexually abused adolescents. Child Adolesc Psychiatr Clin N Am. 2007;16(2):415–434.

Acknowledgment

Thanks to Major Michael McBride, MD, who made many contributions to the outreach team protocols 

and developed many of the interventions discussed in this chapter.
224

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17. Winkel FW, Blaauw E, Sheridan L, Baldry AC. Repeat criminal victimization and vulnerability for coping failure: a 

prospective examination of a potential risk factor. Psychol Crime Law. 2003;9(1):87–95.

18. Tang CS. Trajectory of traumatic stress symptoms in the aftermath of extreme natural disaster: a study of adult Thai 

survivors of the 2004 Southeast Asian earthquake and tsunami. J Nerv Ment Dis. 2007;195:54–59.

19. Mental Health Advisory Team (MHAT-II). Operation Iraqi Freedom (OIF-II). Report. The US Army Surgeon General. 

January 30, 2005. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 4, 2008.

20. Motta RW, Hafeez S, Sciancalepore R, Diaz AB. Discriminant validation of the Modified Secondary Trauma Questionnaire. J Psychothera Independent Pract. 2001;2(4):17–24. 
225

Traumatic Brain Injury in the Military Population

Chapter 15

TRAUMATIC BRAIN INJURY IN THE 

MILITARY POPULATION

LOUIS M. FRENCH, PsyD*; KATHERINE H. TABER, PhD†; KATHY HELMICK, MS, CNRN, CRNP‡; ROBIN 

A. HURLEY, MD§; and DEBORAH L. WARDEN, MD¥

INTRODUCTION

ETIOLOGY AND DIAGNOSIS OF TRAUMATIC BRAIN INJURY

Forces That Cause Traumatic Brain Injury

Vulnerable Areas and Injury Evolution

DETERMINING SEVERITY OF TRAUMATIC BRAIN INJURY

Structural Neuroimaging

Combat-Related Traumatic Brain Injury

COMMON COGNITIVE SEQUELAE

Postconcussive Disorder

The Relationship Between Posttraumatic Stress Disorder and Traumatic Brain 

Injury

In-Theater Management

The Relationship Between Substance Abuse and Traumatic Brain Injury

SYMPTOM TREATMENT 

Educational Interventions

Rest and Return-to-Duty Issues

SUMMARY

*Director, Traumatic Brain Injury Service, Defense and Veterans Brain Injury Center and Department of Orthopaedics and Rehabilitation, Walter Reed 

Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307; Department of Neurology, Uniformed Services University of the Health 

Sciences, Bethesda, Maryland 20814

†

Research Health Scientist, Department of Research and Education, WG Hefner Veterans Affairs Medical Center, Mailstation 11M, 1601 Brenner Avenue, 

Salisbury, North Carolina 28144; formerly, Research Fellow, School of Health Information Sciences, University of Texas at Houston 

‡

Senior Executive Director, Traumatic Brain Injury, Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, 1335 East-West 

Highway, 9th Floor, Suite 700, Silver Spring, Maryland 20910; formerly, Deputy Director, Defense and Veterans Brain Injury Center, Walter Reed 

Army Medical Center, Washington, DC 

§

Associate Director, Education, WG Hefner Veterans Affairs Medical Center (Mailcode 11F), 1601 Brenner Avenue, Salisbury, North Carolina 28144; 

formerly, Associate Director, Mental Health, WG Hefner Veterans Affairs Medical Center, Salisbury, North Carolina 

¥

Formerly, National Director, Defense and Veterans Brain Injury Center Headquarters; Departments of Neurology and Psychiatry, Walter Reed Army 

Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307; Departments of Neurology and Psychiatry, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307-5001
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Combat and Operational Behavioral Health

INTRODUCTION

Traumatic brain injury (TBI) is a very significant 

public health issue and the leading cause of death and 

disability in young people. The Centers for Disease 

Control and Prevention (CDC)1

 estimates that 1.4 

million individuals sustain a TBI in the United States 

annually, with 50,000 deaths. About 80,000 to 90,000 

individuals suffer permanent disability. The monetary 

cost to society is almost $50 billion annually when 

treatment costs, lost wages, disability, and death are 

considered.2,3 Even more significant, at its most severe, 

TBI robs individuals of important aspects of their relationships, well-being, and happiness. 

Service in the military, which includes both rigorous and often dangerous training, and exposure to 

the combat environment, places individuals at greater 

risk than the general population. Surprisingly, young 

adult men (the group with the highest rate of TBI in 

the civilian population), have about the same rate of 

TBI as young women in the military, a figure that underscores the inherent risk in service.4

 However, Ivins 

and colleagues,5 in a recent paper examining trends 

in TBI-related hospitalizations in the active duty US 

Army during the 1990s, reported that the Army’s TBIrelated hospitalization rates decreased for all severity 

levels, both sexes, and all age categories during that 

decade. The paper also indicated that in the first half 

of the 1990s, many of the Army’s adjusted TBI-related 

hospitalization rates, including the overall rate, were 

higher than the rates for US civilians 17 to 49 years of 

age. In the second half of the 1990s, most of the Army’s 

adjusted TBI-related hospitalization rates, including 

the overall rate, were lower than civilian rates, with a 

75% reduction overall. These decreases resulted in a 

relative improvement in the Army’s TBI-related hospitalization rates over civilian rates by the late 1990s. 

This may be related to successful educational efforts 

or other factors.

Somewhat more difficult to quantify is the effect 

of TBI on military readiness. Because some potential 

consequences of TBI include slowed reaction, reduced 

speed of cognitive processing, and mood changes, 

the effects of even transitory symptoms could have 

implications for the deployability or fighting effectiveness of the service member. Additionally, there is 

the risk that the TBI, especially at the milder end of 

the spectrum, will be unrecognized. This chapter will 

describe (a) what TBI is, (b) how severity is determined, 

(c) common consequences of the injury, and (d) some 

treatment strategies. Furthermore, the identification 

and management of TBI in a military operational setting will be discussed. Although the entire spectrum of 

brain injury severity will be discussed, the focus of the 

chapter is on those with mild TBI (mTBI), as that is the 

population that is most likely to come to the attention 

of the military behavioral health provider. Additionally, the overlap of typical postconcussive symptoms 

with symptoms of mood, anxiety, or other disorders 

may make referral to such providers probable when 

an individual with such symptoms of unclear etiology 

is recognized. 

The current conflicts in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) 

are different than past wars in terms of the survival 

rates of those injured. The current wounded-to-killed 

ratio in Iraq is more than 9:1,6

 compared to less than 

3:1 in Vietnam and Korea, and approximately 2:1 in 

World War II.7 This increased survival of wounded 

personnel is related to numerous factors including 

advanced in-theater medical care and superb protective equipment. With these new survival rates come increased numbers of those who may have experienced 

a TBI. Because the most common injury mechanism in 

the current conflict is blast, there are possibilities for 

TBI either through direct blast effect or secondary or 

tertiary blast effects. It is essential for the healthcare 

provider to be aware of the possibility that an injured 

service member may also have sustained a TBI. In 

many cases, this identification is early after the injury. 

There is greater potential, however, for more delayed 

recognition of such an injury, especially if the TBI is at 

the milder end of the severity spectrum. These “silent 

injuries” may have implications for functioning over 

the short or long term, and may affect recovery and 

rehabilitation of other more visible injuries.

ETIOLOGY AND DIAGNOSIS OF TRAUMATIC BRAIN INJURY

TBI is described as either penetrating or closed. A 

penetrating brain injury occurs when a foreign object 

or bone penetrates the dura surrounding the brain. 

(In the military setting, the object is most commonly a 

bullet or fragment.) In a closed TBI, penetration does 

not occur, but forces acting on the head cause damage 

to the brain. Although there is some variability in the 

definition of TBI, especially at the milder end of the 

spectrum, most accepted definitions (CDC,8

 American 

Congress of Rehabilitative Medicine [ACRM],9

 American Psychiatric Association [APA],10 and World Health 

Organization [WHO]11) have common elements. The 

Defense and Veterans Brain Injury Center (DVBIC) 

defines mTBI in a military operational setting as an 
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Traumatic Brain Injury in the Military Population

injury to the brain caused by an external force, with 

either an acceleration or deceleration mechanism 

(or both in some instances), from an event such as a 

blast, fall, direct impact, or motor vehicle accident. 

This trauma causes an alteration in mental status, 

typically resulting in the temporally related onset of 

symptoms such as headache, nausea, vomiting, dizziness or balance problems, fatigue, insomnia or other 

sleep disturbances, drowsiness, sensitivity to light or 

noise, blurred vision, and difficulty remembering or 

concentrating. 

This operational definition of mTBI was established 

in 2006 by a workgroup of experts in the field of military operational medicine and TBI.12 They drew from 

widely accepted definitions, such as those already 

mentioned (CDC, ACRM, APA, and WHO), as well 

as the National Athletic Trainers’ Association position 

statement on management of sport-related concussion,13 and the Prague sports concussion guidelines,14

incorporating common criteria. These established 

definitions endorse biomechanical forces as the cause 

of concussion that results in an alteration of consciousness (AOC), including loss of consciousness (LOC), 

posttraumatic amnesia (PTA) or retrograde amnesia, 

or being dazed or confused at the time of the injury. 

An important aspect of this new operational definition of TBI is that LOC is not a required characteristic 

of concussion. That is, a service member does not 

have to have an LOC to have sustained a concussion 

or mTBI (these terms are used interchangeably). The 

group acknowledged the continued usefulness of these 

parameters and adopted them with a few changes. 

Variations from the established definitions included 

adding common combat-related mechanisms such as 

exposure to blast as a possible mechanism of injury, 

as well as adding a comprehensive list of TBI-related 

symptoms.

The majority of TBI experts in this workgroup 

agreed that symptoms are common following mTBI, 

but the presence of these symptoms is not mandatory 

to establish the diagnosis of mTBI. That is, although 

concussion to the brain may have occurred, it does 

not always result in self-reported symptoms. In some 

circumstances there may be measurable changes in 

functioning or performance, such as increased latency 

of response on measures of reaction time, even in the 

absence of changes noticeable to the injured individual.15 It should be noted that wide consensus among the 

members of the workgroup supported the inclusion of 

an AOC in the definition of mTBI, including reports of 

feeling “dazed and confused” after a traumatic event. 

There are instances, both in the sports literature and 

military arena, of individuals who were involved in 

a traumatic event but did not report any AOC, yet 

these patients subsequently developed symptoms 

consistent with concussion, with onset temporally 

related to the event. Given these cases, a conservative 

approach might be that those individuals involved 

in events with an associated high risk for TBI, who 

report subsequent symptoms, be evaluated further. 

However, without supporting diagnostic evidence, 

these individuals do not meet the criteria for having 

sustained an mTBI. More research is needed to better 

characterize this group.13

Closed-TBI severity is characterized by duration of 

length of LOC and PTA, and initial, postresuscitation 

Glasgow Coma Scale (GCS) score (Table 15-1). Those 

individuals who meet these criteria as having sustained an mTBI, but have positive findings on imaging 

of the brain, are classified as having suffered a TBI of 

moderate severity, as these individuals are known to 

have outcomes similar to those who meet criteria for 

moderate TBI on the basis of length of coma or duration 

of LOC.16,17 It is important to note that these designations describe the severity of the brain injury itself, and 

do not necessarily describe clinical outcomes or functionality in the future. Although there is greater chance 

for persisting problems as injury severity increases, 

many patients at the more severe end of the spectrum 

can have good outcomes, while some patients who 

were initially diagnosed as having a “mild” TBI go on 

TABLE 15-1

TRAUMATIC BRAIN INJURY DESCRIPTION

Severity GCS* LOC PTA

Mild 13–15 < 20 min–1 h < 24 h

Moderate 9–12 1–24 h 24 h– < 7 days

Severe 3–8 > 24 h > 7 days

GCS: Glasgow Coma Scale

LOC: loss of consciousness

PTA: posttraumatic amnesia

*The Glasgow Coma Scale (GCS) is the most commonly used scale to 

determine the severity of a brain injury. It must be noted, however, 

that a GCS score signifies the patient’s “best” response. A patient 

could have a serious deficit that is not indicated by the GCS. Also, the 

score does not indicate the amount of stimulation required to get the 

patient to score at that level. A severe brain-injured patient usually 

has a GCS score of 3–8 and presents with a significant neurological 

deficit. The lowest GCS score is 3 (no neurological functioning). A 

patient with a severe brain injury also will experience loss of consciousness for more than 1 hour. Posttraumatic amnesia (PTA) refers 

to the loss of memory of events immediately following the injury. A 

typical question to ask to assess for PTA is, “What is the first thing 

you remember after your injury?” If the first memory occurred more 

than 24 hours after the injury, then, by definition, the patient has 

suffered a moderate-to-severe traumatic brain injury. 
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Combat and Operational Behavioral Health

to have seemingly catastrophic changes in personal, 

social, and occupational functioning. Persistent postconcussional syndromes are discussed more fully later 

in this chapter.

Forces That Cause Traumatic Brain Injury

Traumatic brain injury may arise from many causes, 

including accidents, assaults, falls, and exposure to 

explosions. The physical forces exerted on the brain 

during most of the events that can cause TBI are 

reasonably well understood (Figure 15-1). The brain 

can be physically displaced within the skull by linear 

forces. It can also be rotated or twisted by angular or 

rotational forces. These forces make the lower-density 

tissues, particularly the outer layer of the brain (the 

cerebral hemispheres), move more quickly than the 

higher-density tissues that make up the core of the 

brain. They can also twist the brain around its central 

axis. Both types of movement result in stretching and 

shearing forces within the brain. Explosion-related 

brain injury is a new area of investigation. Although 

it is not yet proven that the changes in pressure that 

characterize the blast wave directly injure the brain as 

they do other parts of the body (eg, air-filled organs 

such as the lungs, tympanic membrane, and abdominal viscera), preliminary evidence suggests that this 

can occur.18 It is clear that both the blast wave and 

the blast wind propel objects, including people, with 

sufficient power to cause TBI due to both linear and 

angular forces. 

Vulnerable Areas and Injury Evolution 

The most common primary injuries in TBI are traumatic axonal injury (TAI), contusion (bruising), and 

subdural hemorrhage. Movement of the brain within 

the skull can tear the surface veins that bridge from the 

brain to the dural venous sinus, resulting in a traumatic 

subdural hemorrhage (Figure 15-2).19 The most common locations are the frontal and parietal convexities 

on the same side as the injury.20 Subdural hemorrhage 

is crescent shaped on neuroimaging and conforms to 

the cerebral surface.19,20 Its spread is limited by the dural 

reflections, and it rarely crosses the midline. When the 

brain moves within the skull enough to impact bone, 

Figure 15-1. The physical forces exerted on the brain during 

most of the events that can cause traumatic brain injury are 

reasonably well understood. Both linear (green) and rotational (blue) forces can arise. The brain can be physically 

displaced within the skull. It can also be rotated or twisted. 

Rotational forces make the lower-density tissues (eg, cerebral 

cortex) move more quickly than the higher-density tissues 

(eg, subcortical white matter), resulting in stretching and 

shearing forces.

Figure 15-2. Traumatic subdural hemorrhage occurs when the brain moves within the skull enough to tear the vessels that 

bridge from the brain surface to the dural venous sinus (a). The most common locations are the frontal and parietal convexities on the same side as the injury (b).
229

Traumatic Brain Injury in the Military Population

it can cause contusion of the brain parenchyma (Figure 

15-3). The most common locations are the superficial 

gray matter of the inferior, lateral, and anterior aspects 

of the frontal and temporal lobes; the occipital poles or 

cerebellum are less often involved.20

The most likely injury to occur in mTBI is TAI, also 

called diffuse axonal injury. Certain areas of the brain 

are particularly vulnerable to TAI (Figure 15-4). One 

is the corticomedullary (gray matter–white matter) 

junction, particularly in the frontal and temporal lobes. 

Areas of very concentrated white matter, such as the 

corpus callosum and internal capsule, are also quite 

vulnerable. Finally, the deep gray matter and upper 

brainstem are also frequent sites of TAI.20 TAI is the 

result of shearing, stretching, or angular forces pulling 

on axons and small vessels.21

The old view of TAI was that these forces produced 

mechanical tearing of axons. Although this can occur, it is now considered to be unusual. The present 

understanding is that TAI is a progressive injury.22,23

Stretching of the axon and its enclosing myelin sheath 

results in increased permeability, allowing an influx 

of calcium. This, in turn, triggers events that loosen 

the normally tight myelin sheath in the vicinity of the 

injury and also cause damage to the axon’s cytoskeleton (a complex network of microtubules and neurofilaments that form the internal supporting structure 

for neurons). 

The integrity of the cytoskeleton is essential for 

many vital functions, including transport of substances from the cell body out to the axon and dendrites 

Figure 15-3. Contusions occur when the brain moves within the skull enough to impact bone, causing bruising. The most 

common locations are the superficial gray matter of the inferior, lateral, and anterior aspects of the frontal and temporal 

lobes, with the occipital poles or cerebellum less often involved.

Figure 15-4. Traumatic axonal injury (TAI) results when 

shearing, stretching, or angular forces pull on axons and 

small vessels. Impaired axonal transport leads to focal 

axonal swelling and (after several hours) may result in 

axonal disconnection. The most common locations are the 

corticomedullary junctions (particularly frontotemporal), 

internal capsule, deep gray matter, upper brainstem, and 

corpus callosum.
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Combat and Operational Behavioral Health

(axoplasmic transport). Breakdown of the cytoskeleton 

disrupts transport of materials within the axon. Material collects proximal to the injury, leading to focal 

axonal swelling. If the swelling continues to progress, 

the axon eventually detaches. The proximal end seals 

and continues to swell, leading to the formation of 

the classic axonal retraction ball. The distal portion 

of the axon undergoes Wallerian degeneration, a process that can take several months in humans.24 (This 

account is based primarily on the study of heavily 

myelinated, large-diameter axons, such as those that 

make up the majority of the corpus callosum and 

internal capsule.) 

Growing evidence suggests that the injury cascade may be quite different in other populations of 

axons (eg, small-diameter, unmyelinated axons) and 

vulnerable areas (eg, injuries close to cell bodies, as 

occurs at the corticomedullary junction and in deep 

gray matter).24 This has important implications both 

for neuropathological identification of TAI and for 

potential therapeutic targets.24 Secondary processes 

can cause further brain injury.24–27 For example, there 

may be a widespread release of glutamate (an excitatory neurotransmitter), with the potential for lethal 

overstimulation of neurons (excitotoxicity). Release of 

blood into brain tissue has toxic effects, including the 

possibility of triggering cerebral vasospasm, which 

increases the risk for ischemia. 

DETERMINING SEVERITY OF TRAUMATIC BRAIN INJURY

Structural Neuroimaging 

TAI is characterized by multiple small injuries, often 

widely dispersed in the brain rather than clustered. As 

a result, its identification on structural neuroimaging 

can be quite challenging. Although magnetic resonance 

imaging (MRI) is more sensitive than computed tomography in detecting this type of brain injury, even 

MRI is often negative.20,22,28–31 Gradient-echo MRI is 

especially useful because it can visualize even very 

small areas of hemorrhage, as often occur in conjunction with axonal injury.32–36 This type of MRI is sensitive to alterations in magnetic susceptibility. Presence 

of blood within tissue creates a local magnetic field 

disturbance, causing a decrease in signal intensity in 

the area containing blood. Areas of TAI not containing 

hemorrhage are better seen on T2*-weighted spin-echo 

MRI, where they will appear bright. Particularly useful is the FLAIR (fluid attenuated inversion recovery) 

sequence, in which the normally high signal intensity 

of cerebrospinal fluid is suppressed, making lesions 

near the ventricles much easier to identify.37 A newer 

method of MRI that shows great promise for improved 

imaging of TAI is diffusion tensor imaging, in which 

the image is made sensitive to the speed and direction 

of water diffusion.38,39 In gray matter and fluid, water 

diffuses at the same speed in all directions (isotropic 

diffusion). In white matter, water diffuses much more 

quickly along the length of axons (fibers, tracts) than 

across them (anisotropic diffusion). Thus, diffusion 

tensor imaging provides a way to examine the structural integrity of the white matter. 

Combat-Related Traumatic Brain Injury

There is increasing evidence that combat-related 

TBIs are a frequent occurrence. Approximately one 

half of combat-related injuries, many a result of explosions, involve the head or neck.40,41 Several studies 

from the DVBIC document the presence of TBI in soldiers returned from Afghanistan or Iraq.42–45 Common 

postconcussive symptoms included headache (47%), 

irritability or aggression (45%), difficulty with memory 

(46%), and difficulty with concentration (41%).43 Studies of active duty soldiers suggest that the majority of 

brain injuries would be classified as mild, as indicated 

by either no or only brief LOC.44,46 In most cases these 

less severe injuries would not have required medical 

evacuation.45

It is well known that mTBI in civilians is underrecognized by both medical personnel and patients, 

resulting in significant underreporting.47,48 A similar 

situation exists in the military in that combat-related 

mTBI may often be unrecognized by both medical 

personnel and service members.44,46,49 DVBIC has recently released a new assessment tool—the Military 

Acute Concussion Evaluation (MACE)—to facilitate 

identification and evaluation of postconcussive symptoms following combat-related brain injuries. The 

literature on concussion strongly supports the need 

to fully evaluate anyone experiencing alteration in 

mental status (eg, dazed, confused, “saw stars,” LOC) 

as a result of exposure to conditions that can injure 

the brain.26 Of particular importance is evaluation of 

memory, as presence of PTA appears to be associated 

with higher rates of cognitive difficulties during the 

first few weeks after injury.49

Postconcussive symptoms may include altered 

consciousness (drowsiness, confusion, lethargy), headache, amnesia, nausea or vomiting, fatigue, irritability, 

restlessness, auditory or vestibular disturbances (balance problems, ringing in the ears, dizziness, hearing 

changes, sensitivity to noise), visual disturbances 

(blurred vision, sensitivity to light, double vision), gait 
231

Traumatic Brain Injury in the Military Population

abnormalities, and problems sleeping.50,51 Although 

most patients recover well from mTBI, the rate of recovery is highly variable. During this period of healing 

individuals are likely to perform below their normal 

level on both physical and cognitive tasks. Evidence 

also suggests that the brain is more vulnerable to reinjury during this period. Therefore, in the context of 

active combat, premature return to duty increases risks 

for both the individual and the team.26

Many mild brain injuries will not become evident 

until after the service member returns home. Although 

the majority of people recover well following mTBI, a 

significant minority do not.25 Common problems in the 

chronic phase following TBI include headaches, dizziness, fatigue, sleep disturbances, spasticity, vestibular 

impairments, visual difficulties, personality changes, 

and cognitive or emotional deficits. Some studies 

indicate that as many as one third of these patients 

may have psychiatric symptoms within the first year 

postinjury.52–54

COMMON COGNITIVE SEQUELAE

An examination of cognitive dysfunction following 

TBI must take into account myriad factors, including 

severity and nature of the injury (focal vs diffuse), 

time since injury, motivation of the subject, and other 

injuries. In the case of mTBI, there is agreement that 

there are short-term cognitive consequences of the 

injury, affecting various aspects of attention, speed of 

processing, and other cognitive domains. Even in the 

absence of self-reported cognitive dysfunction or other 

symptoms, decrements in reaction time have been 

reported.14 The longer-term cognitive consequences 

from mTBI are less clear.

Iverson and colleagues55 report data on a group of 

young adult patients seen in the trauma service of a 

Pennsylvania general hospital (1991–1994) with mTBIs 

(based on postinjury GCS scores) who completed neuropsychological testing within the first week postinjury. Those who met severity inclusion criteria and 

were under age 40 accounted for 484 of the 1,695 total 

patients. Most were men, with motor vehicle accidents 

being the most common cause of injury. Most patients 

(82%) had GCS scores of 15, with the remaining ones 

having GCS scores of 14. About 56% had known LOC, 

with about 18% negative, and the rest unclear or unknown. The prevalence of intracranial abnormalities 

on day-of-injury computed tomography was 11.8%. 

The rest of these patients had negative (68.6%) or missing (19.6%) results. The patients were split into two 

groups on the basis of differences on the Galveston 

Orientation and Amnesia Test (GOAT). The groups 

were relatively evenly split by scores above 90 and 

those below (range 0–100). Scores between 90 and 75 

are not low enough to indicate frank PTA, but do suggest some ongoing confusion. All those patients were 

administered a brief (30–45 minutes) but wide-ranging 

neuropsychological test battery. Overall, the results 

suggested that when trauma patients are evaluated 

shortly after an mTBI, the presence of posttraumatic 

confusion is related to worse short-term neuropsychological outcome in that subjects with lower GOAT 

scores had significantly worse scores on measures of 

simple attention, verbal learning, verbal and visual 

memory, and some aspects of executive functioning 

than did subjects in the above-90 range on GOAT. Furthermore, brief traumatic LOC (less than 5 minutes) is 

not related to short-term neuropsychological outcome 

(there were no significant differences in scores based 

solely on whether or not there was brief LOC).

Belanger and colleagues56 conducted a metaanalysis 

of the relevant literature based on 39 studies involving 1,463 cases of mTBI and 1,191 control cases to 

determine the impact of mTBI across nine cognitive 

domains—(1) global cognitive ability, (2) attention, (3) 

executive functions, (4) fluency, (5) memory acquisition, (6) delayed memory, (7) language, (8) visuospatial 

skill, and (9) motor functions. The overall effect of 

mTBI on neuropsychological functioning was moderate (d = .54). However, findings were influenced by 

cognitive domain, time since injury, patient characteristics, and sampling methods. Acute effects (less than 3 

months postinjury) of mTBI were greatest for delayed 

memory and fluency. In unselected or prospective 

samples, the overall analysis revealed no residual neuropsychological impairment by 3 months postinjury. In 

contrast, clinic-based samples and samples including 

participants in litigation were associated with greater 

cognitive sequelae of mTBI.

In another metaanalysis focused on the sports concussion literature, the authors reviewed studies from 

1970 to 2004 from which 21 studies met inclusion criteria, with 790 cases of mTBI and 2,016 control cases.57

The overall effect for size of concussion on cognition 

was 0.49, with delayed memory, memory acquisition, 

and global cognitive functioning showing the greatest 

effects acutely. No residual effects were found from the 

group tested over 1 week postinjury.

Postconcussive Disorder

A WHO analysis of outcome in mTBI concludes 

that although acute symptoms are common, the vast 

majority of individuals have good resolution of their 
232

Combat and Operational Behavioral Health

mTBI symptoms by 3 months postinjury and many 

quite sooner.58 The authors acknowledge (and this is 

consistent with clinical practice in both military and 

civilian settings) that there are individuals who show 

persistent symptoms. The fourth edition of the Diagnostic and Statistical Manual for Mental Disorders proposed 

diagnostic criteria for a postconcussional disorder in 

its appendix of provisional diagnostic criteria sets.10

Diagnosis of a postconcussional disorder required 

a “significant cerebral concussion” with measured 

cognitive deficit and the presence of at least three of 

eight symptoms—(1) fatigue, (2) sleep disturbance, 

(3) headache, (4) dizziness, (5) irritability, (6) anxiety/

depression, (7) personality change, and (8) apathy—

with onset after injury and persistence past 3 months. 

(See Exhibit 15-1 for full criteria for postconcussional 

disorder.) Criteria have also been included in the International Classification of Diseases, 10th Revision (ICD10).59 These criteria require a history of TBI and the 

presence of three of eight symptoms—(1) headache, (2) 

dizziness, (3) fatigue, (4) irritability, (5) insomnia, (6) 

concentration problems, (7) memory difficulty, and (8) 

reduced tolerance of stress, emotion, or alcohol. 

Boake et al60 compared these two diagnostic sets and 

concluded that there was a large difference between the 

prevalence of postconcussive syndrome using these 

two criteria sets, with the ICD-10 criteria being more 

inclusive. The differences suggest that there could 

be disagreement in diagnosis depending on which 

criteria set is used. Furthermore, they concluded that 

both criteria sets had limited specificity to TBI (if the 

history of TBI itself was removed as a criteria), as 

the other criteria could be met after general trauma, 

whether or not the brain was injured. The authors 

point out that this finding is supportive of previous 

CDC recommendations—namely that postconcussional symptoms in themselves are not sufficient to 

make a diagnosis of mTBI. Iverson and colleagues,61

in a review article on outcome from mTBI, also report 

that postconcussion symptoms are common in healthy 

subjects, those without a history of TBI, and in various 

patient groups.

The existence of a group of patients with persistent 

symptoms has been controversial. The scope of the 

problem itself is difficult to determine (clinical lore has 

set the figure at 10%–20% although it is likely less than 

5% of the total number of individuals who suffer mTBI; 

see Iverson55 for a complete discussion). There is also 

disagreement concerning the cause of these persistent 

symptoms. Various authors have attributed them to different causes, some believing them to reflect the injury 

itself, and others attributing these symptoms to a multicausal etiology, with premorbid personality characteristics, social-psychological factors, and exaggeration 

EXHIBIT 15-1

RESEARCH CRITERIA FOR POSTCONCUSSIONAL DISORDER

A. History of closed head injury:

	 •	 Causing cerebral concussion

	 •	 Symptoms include:

 ° loss of consciousness

 ° posttraumatic amnesia

 ° posttraumatic onset of seizuers (less common)

B. Difficulty (based on cognitive evaluation) in: 

	 •	 attention, such as:

 ° concentration

 ° shifting focus of attention

 ° performing simultaneous cognitive tasks

 or

	 •	 memory, such as:

 ° learning

 ° recalling information

C. Three or more of the following occuring posttrauma (and lasting 3 or more months):

	 •	 easy fatigue

	 •	 disordered sleep

	 •	 headache

	 •	 vertigo/dizziness

	 •	 irritability/aggression on little or no provocation

	 •	 anxiety/depression/affective lability

	 •	 changes in personality

	 •	 apathy/lack of spontaneity

D. “B” and “C” symptoms:

	 •	 have onset following head trauma

 or

	 •	 represent a substantial worsening of preexisting symptoms

E. Disturbance causes significant impairment/significant worsening in:

	 •	 social/occupational functioning (adults)

	 •	 school/academic performance (school-age

children)

F. Symptoms do not meet criteria for/not better accounted for by:

•	 dementia due to head trauma

	 •	 another mental disorder such as:

 ° amnestic disorder due to head trauma

 ° personality change due to head trauma

Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual. 4th ed. Washington, DC: 

APA; 2000: 761–762.
233

Traumatic Brain Injury in the Military Population

(either conscious or unconscious) playing a role.

The Relationship Between Posttraumatic Stress 

Disorder and Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) can result from 

highly stressful experiences, such as being in combat 

or being injured in combat. Hoge and colleagues62 reported that for all groups surveyed after their deployment, there was a strong relationship between intensity 

of combat experiences (killing the enemy, being shot 

at) and exposure to traumatic combat-related events 

(handling dead bodies, knowing someone who was 

killed), and the prevalence of PTSD. Among service 

members in OIF, the prevalence of PTSD increased 

with the number of firefights during deployment (with 

increases to 19.3% for those involved in more than five 

firefights). The rates of PTSD were significantly associated with having been wounded or injured (odds 

ratio for those deployed to Iraq, 3.27; odds ratio for 

those deployed to Afghanistan, 2.49). This is consistent 

with the findings of Koren et al63 in a small but welldesigned study looking at rates of PTSD in injured 

Israeli war veterans. That study clearly indicated that 

bodily injury is a risk factor for PTSD, with odds of 

developing PTSD following traumatic injury approximately eight times higher than following injury-free 

emotional trauma. The authors suggest that even this 

rather high figure might be an underestimate of the 

rate because 35% of these injured combat veterans had 

refused to participate in the study. 

Controversy exists, however, regarding the rate 

and risk factors for PTSD following TBI. Bombardier 

and colleagues64 report a cumulative rate of 11.3% in 

a mixed sample of those with TBI ranging from mild 

to severe over a 6-month period. Furthermore, their 

findings were consistent with those of previous studies suggesting that more severe TBI may be protective with regard to the development of PTSD, that is, 

the AOC or LOC associated with TBI may lessen the 

individual’s ability to reexperience the trauma.65 Risk 

factors for developing PTSD following TBI include 

having less education, feeling terrified or helpless, and 

having major depression.64

In-Theater Management

The in-theater management of TBI depends on its 

severity. (There are guidelines recently released on 

the management of more severe combat TBI,66 but 

in-depth discussion of these guidelines is beyond the 

scope of this chapter.) The clinical management of the 

mTBI patient in a military occupational setting was 

addressed in the 2006 DVBIC workgroup. A graphical 

representation of the level-I practice guideline is shown 

in Figure 15-5. This guideline relies on the use of the 

MACE (see Exhibit 15-2 for full instrument), a tool developed by the DVBIC. The MACE has both a history 

and evaluation component. The history component 

can confirm the diagnosis of mTBI after establishing 

that a trauma has occurred and during the course of 

this traumatic event, the service member experienced 

an AOC. An AOC can be defined on a continuum from 

“dazed and confused,” to not remembering the injury, 

to an LOC. The evaluation component, designed to be 

easily used by medics and corpsmen, can be administered within 5 minutes. It utilizes the Standardized 

Assessment of Concussion67 to preliminarily document 

neurocognitive deficits in four cognitive domains: (1) 

orientation, (2) immediate memory, (3) concentration, 

and (4) delayed recall.

The Relationship Between Substance Abuse and 

Traumatic Brain Injury

The relationship between TBI and substance use 

and abuse is an important one that presents a number 

of complexities for understanding their interrelatedness. Intoxication is in itself a risk factor for TBI. That 

is, TBI can result from unintentional alcohol-related 

causes such as motor vehicle accidents or falls while 

intoxicated. More intentional alcohol-related TBI 

can result from other causes such as assault while 

intoxicated (both on the part of the victim and perpetrator), mate-related abuse, and direct self-harm such 

as suicide attempts.1

 Savola, Niemelä, and Hillbom68

investigated the relationship of different patterns 

of alcohol intake to various types of trauma. They 

examined the alcohol consumption in a series of 385 

consecutive trauma admissions. On admission, 51% of 

the patients had alcohol in their blood. Binge drinking was the predominant (78%) drinking pattern of 

alcohol intake, and assaults, falls, and biking accidents 

were the most frequent causes of trauma. Dependent 

alcohol drinking and binge drinking were found to be 

significantly more common among patients with head 

trauma than in those with other types of trauma. The 

relative risk for head injury markedly increased with 

increasing blood alcohol levels. 

A TBI can also exacerbate previous substance 

abuse or lead to behavioral and personality changes 

that could lead to alcohol or drug misuse. Prior history of a substance abuse disorder is a risk factor for 

greater morbidity69 and excessive use following TBI.70

Substance-use disorders following TBI adversely affect 

neuropsychological functioning, subjective well-being, 

employment, and involvement with the criminal justice system.71–74
234

Combat and Operational Behavioral Health

Traumatic Event Occurs: Possible Concussion

(blast exposure, fall, motor vehicle collision, etc)

Assess for loss of consciousness (LOC)/alteration 

of consciousness (AOC): dazed, “bell rung,” “seeing stars,” memory loss, etc

• If positive AOC/LOC after trauma, diagnose con-

 cussion and 

 (1) Administer MACE

 (2) Assess for red flagsa

 and symptomsb

Red flagsa present?

Symptomsb present or MACE < 25?

Perform exertional testing,e

 followed by alternate version of MACE cognitive examination

Refer to level 3

Primary care management

Reevaluate q1 3 days up to 7 days

Symptoms resolved?

Positive symptoms or MACE < 25

Provide education

Return to duty

Continue PCM

Screen for depression & acute stress reaction

Consider combat stress referral

Consider referral 

to level 3

Continue concussion 

& combat stress manage- ment up to 14 days (consider longer if rapidly improving)

a

Red Flags

1. Progressively declining LOC

2. Progressively declining neurological exam

3. Pupillary asymmetry

4. Seizures

5. Repeated vomiting

6. Clinical verified GCS < 15

7. Neurological deficit: motor or sensory

8. LOC greater than 5 minutes

9. Double vision

10. Worsening headache

11. Cannot recognize people or disoriented to place

12. Slurred speech

13. Weakness

bSymptoms

1. Confusion (< 24 h)

2. Unusual behavior

3. Irritability

4. Unsteady on feet

5. Vertigo/dizziness

6. Headache

7. Photophobia

8. Phonophobia

c

Primary Care Management (PCM)

 1. Give educational sheet to all mTBI 

 patients

 2. Reduce environmental stimuli

 3. Ensure adequate rest

 4. Be aggressive in headache manage-

 ment: use acetaminophen q 6 h × 48 h. After 48 h, may use naproxen 

 pm

 5. Avoid tramadol, narcotics

 6. Consider nortriptyline or amiltriptyline, 

 25 mg po q h for persistent head-

 aches (> 7 days); prescribe 10 days 

 maximum

 7. Implement duty restrictions

 8. Send consult to 

 triconsult@us.army.mil for further 

 guidance if needed

 9. Consider for evacuation to higher 

 level care if clinically indicated

10. Document concussion diagnosis in 

 electronic medical recordd

dICD-9 Codes

850.0 Concussion w/o LOC

850.11 Concussion w/ LOC < 30 min

E979.2 Injury from terrorist ex-

 plosion/blast

e

Exertional Testing Protocol

1. Achieve 65%–85% THR 

 (THR = 220 – age), using 

 pushups, step-aerobic 

 treadmill, hand crank

2. Assess for symptoms 

 (headache, vertigo, pho-

 tophobia, balance, dizzi-

 ness, nausea, tinnitus, 

 visual changes, others) or 

 MACE < 25.

†

Return-to-Duty Evaluation

1. Neurocognitive testing if 

 available and expertise for 

 interpretation available

Yes

No

Yes

No

Yes

Yes

No

No

No Neg Pos
235

Traumatic Brain Injury in the Military Population

Figure 15-5 (left page). Initial management of concussion in a deployed seting. Defense and Veterans Brain Injury Center 

decision algorithm for battlefield mild traumatic brain injury at a Level I setting. Definitive assessment and care is given 

by providers to include a more detailed assessment, management recommendations, and consideration for evacuation to a 

higher level of care. 

AOC: alteration of consciousness

GCS: Glascow Coma Scale

HS: at bedtime

ICD-9: International Statistical Classification of Diseases, 

9th edition

LOC: loss of consciousness

MACE: Military Acute Concussion Evaluation

mTBI: mild traumatic brain injury

po: by mouth 

q: every

THR: target heart rate

w/: with

w/o: without

Reproduced from: US Army Institute of Surgical Research. Joint Theater Trauma System Web site. Available at: http://www.

usaisr.amedd.army.mil/cpgs/mTBIDplydSet0811.pdf. Accessed December 15, 2009.

SYMPTOM TREATMENT

Symptom treatment for mTBI can be discussed from 

four areas: (1) pharmacologic management, (2) educational interventions, (3) rest/return-to-duty decisions, 

and (4) targeted therapies. An extensive discussion of 

the pharmacologic interventions in TBI is beyond the 

scope of this chapter. The reader is referred to reviews 

of the evidence for various pharmacologic interventions.45,73–76 In general, however, symptomatic treatment strategies can be the most effective, including 

regulation of sleep through pharmacologic and nonpharmacologic strategies,77 headache management,78

pain management,79 and treatment of depression.80

Treatment of all of these has been associated with 

improved quality of life or outcomes. 

Educational Interventions

Educational and psychological therapies have also 

proven effective in mTBI. Mittenberg et al81 compared 

two mTBI groups: a treatment group (n = 29) and a 

control group (n = 29). The treatment group received a 

printed manual and met with a therapist prior to hospital discharge to review (a) the nature and incidence 

of expected symptoms, (b) the cognitive-behavioral 

model of symptom maintenance and treatment, (c) 

techniques for reducing symptoms, and (d) instructions for gradual resumption of premorbid activities. 

The control group received routine hospital treatment 

and discharge instructions. After 6 months, the treated 

patients reported significantly shorter average symptom duration (33 days vs 51 days) and significantly 

fewer symptoms at follow-up. The conclusion was that 

brief, early psychological interventions are effective in 

reducing the incidence of postconcussive symptoms. 

Ponsford and colleagues82 have shown similar results 

in a group of individuals with mTBI. Those who were 

seen at 1 week postinjury and given informational 

material reported fewer symptoms overall and were 

significantly less stressed at 3 months after the injury 

than a group that did not receive the same education. A number of educational materials effective for 

individuals with brain injuries and their families are 

available at a number of sources including the Defense 

and Veterans Brain Injury center Web site (www.dvbic.

org/cms.php?p=Education).

Rest and Return-to-Duty Issues

Other palliative interventions such as bed rest have 

been shown to have some efficacy in treating postconcussive symptoms over the short term (eg, decreased 

dizziness), but have not proven to have long-term 

outcomes better than individuals who did not get 

such rest.83 Return-to-duty issues in the military operational setting are addressed in the algorithm above 

(see Figure 15-5). Most of the decisions are based on 

the resolution of self-reported TBI symptoms as well 

as the integration of clinical data based on testing a 

service member to see if symptoms may return when 

physically stressed. 

SUMMARY

In modern warfare, TBI is a common occurrence that 

has significant implications for the health and welfare 

of the troops, as well as overall fighting effectiveness. 

Early identification of less obvious (usually milder) 

TBI is important, as is a basic understanding of when 

individuals may be treated in situ and ways to maximize recovery. Even in peacetime, there are concerns 

about TBI because it occurs at high rates in the military. 

It is essential, therefore, that healthcare providers and 

the fighting force both have a basic understanding of 

the need for prevention of these injuries, and early 

identification when they do occur.
236

Combat and Operational Behavioral Health

Exhibit 15-2 

military acute concussion evaluation form

 (Exhibit 15-2 continues)
237

Traumatic Brain Injury in the Military Population

Reproduced from: Defense and Veterans Brain Injury Center, Walter Reed Army Medical Center. Military Acute Concussion Evaluaton 

(MACE) form.

Exhibit 15-2 continued
238

Combat and Operational Behavioral Health

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37. Paterakis K, Karantanas AH, Komnos A, Volikas Z. Outcome of patients with diffuse axonal injury: the significance 

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echelon II Medical Unit during Operation Iraqi Freedom. Mil Med. 2005;170:516–520.

41. Gondusky JS, Reiter MP. Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II. Mil Med. 2005;170:546–549.

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experience at Walter Reed Army Medical Center (WRAMC). J Neurotrauma 2005;22:1178.

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

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75. Neurobehavioral Guidelines Working Group. Warden DL, Gordon B, McAllister TW, et al. Guidelines for the pharmacologic treatment of neurobehavioral sequelae of traumatic brain injury. J Neurotrauma. 2006;23(10):1468–1501. 

76. Lee HB, Lyketsos CG, Rao V. Pharmacological management of the psychiatric aspects of traumatic brain injury. Int 

Rev Psychiatry. 2003;15(4):359–370.

77. Thaxton L, Myers MA. Sleep disturbances and their management in patients with brain injury. J Head Trauma Rehabil. 

2002;17(4):335–348.

78. Walker WC, Seel RT, Curtiss G, Warden DL. Headache after moderate and severe traumatic brain injury: a longitudinal 

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79. Young JA. Pain and traumatic brain injury. Phys Med Rehabil Clin N Am. 2007;18(1):145–163, vii–viii.

80. Alderfer BS, Arciniegas DB, Silver JM. Treatment of depression following traumatic brain injury. J Head Trauma Rehabil. 

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81. Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR. Cognitive-behavioral prevention of postconcussion 

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83. de Kruijk JR, Leffers P, Meerhoff S, Rutten J, Twijnstra A. Effectiveness of bed rest after mild traumatic brain injury: a 

randomised trial of no versus six days of bed rest. J Neurol Neurosurg Psychiatry. 2002;73:167–172.
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

Chapter 16

PSYCHIATRIC INTERVENTION FOR THE 

BATTLE-INJURED MEDICAL and 

SURGICAL PATIENT FOLLOWING 

TRAUMATIC INJURIES

HAROLD J. WAIN, PhD*; SCOTT C. MORAN, MD†; MARVIN OLESHANSKY, MD‡; ANDREE BOUTERIE, 

MD§

; and CHRISTOPHER L. LANGE, MD¥

INTRODUCTION

INJURIES AND THE STRESS OF TRAUMA

THERAPEUTIC INTERVENTION FOR THE PREVENTION OF PSYCHIATRIC 

STRESS DISORDERS

INDIVIDUAL THERAPEUTIC COMPONENTS

TREATMENT

SUPPORTING MEDICAL STAFF WHO CARE FOR MEDICALLY INJURED 

TRAUMA VICTIMS

SUMMARY

*Chief, Psychiatry Consultation Liaison Service, Building 2, Room 6238, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, 

DC 20307-5100

†

Major (P), Medical Corps, US Army; Psychiatry Residency Training Program Director, Psychiatry Consultation Liaison Service, Building 6, Room 

2060, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5100

‡

Colonel, US Army (Retired); Staff Psychiatrist, Psychiatric Outpatient Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White 

Road, Honolulu, Hawaii 96822; formerly, Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, Washington, DC 

20307-5100

§

Staff Psychiatrist, Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307-5100

¥

Lieutenant Colonel, Medical Corps, US Army; Program Director, National Capital Consortium Forsenic Psychiatry Fellowship Program, Department of 

Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 6, Room 3038, Washington, DC 20307; formerly, Staff Psychiatrist, 

Psychiatry Consultation Liaison Service, Walter Reed Army Medical Center, Washington, DC
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Combat and Operational Behavioral Health

INTRODUCTION

Trauma, whether resulting from the actions of humans or nature, as a precipitant of medical and surgical 

injuries can be emotionally overwhelming, not only for 

the patient dealing with the medical issues, but for the 

family and caregivers as well. Each will have to cope 

with the trauma of the event leading to the injury as 

well as the subsequent psychological sequelae. In the 

hierarchy of needs regarding patient care, stabilization of the medical physical injury of the patient takes 

precedence. However, often ignored are the psychiatric 

after-effects that traumatic injury may elicit. 

For years the Psychiatry Consultation Liaison 

Service (PCLS) at Walter Reed Army Medical Center (WRAMC) has been helping patients deal with 

the psychiatric and psychological consequences of 

medical and surgical disease. Since the beginning of 

the global war on terror in 2001, the goal for the psychiatry consultation liaison service at Walter Reed has 

been two-fold: (1) decrease the psychiatric manifestations of trauma that may disrupt medical treatment, 

and (2) decrease the chronic and disabling psychiatric 

disorders that may occur as a result of trauma. Several 

chapters and articles describing in detail the PCLS 

approach to meet these goals have been published, 

including discussions of Gulf War I,1

 the Pentagon 

attacks,2 the bombings of the US embassy in Nairobi,3

and the current wars in Afghanistan and Iraq.4 Since 

2003, PCLS has seen over 3,000 battle-injured patients 

using the methods described in these chapters.

One of the main features of effective mental health 

intervention in polytrauma (or any consultationliaison psychiatry setting for that matter) is for mental 

healthcare providers to ally themselves with the patient, the patient’s family, and the patient’s treatment 

team. Since the start of the global war on terror, PCLS 

has been a routine part of trauma care at WRAMC. 

Immediately following the attack on the Pentagon 

on 9/11, casualties who required extended inpatient 

management of their injuries were admitted to civilian 

hospitals closer to the Pentagon than WRAMC. During 

that time, PCLS deployed teams to these facilities to 

assist in their clinical management. The PCLS teams 

were recognized consultants to the endogenous medical team of the local hospitals.

Trauma patients are routinely seen upon arrival at WRAMC and followed with the trauma 

team throughout the hospital stay as integral part 

of the medical care. Mental health interventions are 

provided to assist these patients in processing their 

trauma and its aftermath, support the family members who provide critical emotional support to these 

patients, and facilitate interactions with their treatment team for an optimal clinical outcome. All this 

happens as the patients undergo medical and surgical 

care and seek to adapt physically and mentally to the 

new realities imposed upon them by their traumatic 

injuries. Thus, a comprehensive program designed 

to help the medical institution as a whole respond 

to the psychological demands of a traumatic event 

must take into account the needs of not only the 

patients, but also the patients’ families and medical 

staff involved in their care. 

This chapter focuses on the psychological and psychiatric issues of medical and surgical patients suffering from traumatic injuries. This approach to care for 

these patients, their family members, and medical care 

providers, was developed by the PCLS, and is based on 

the experience of the authors and their colleagues in 

the care of these patients, family members, and treatment teams at WRAMC over the past 30 years. 

INJURIES AND THE STRESS OF TRAUMA

Soldiers wounded in combat in Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF) 

receive immediate lifesaving intervention on the battlefield or in the battalion aid station by a combat medic, 

further treatment at a combat surgical hospital, and 

then aeromedical evacuation to Landstuhl Regional 

Medical Center. The military air evacuation system 

facilitates transfer of the patient to WRAMC following injuries in theater and stabilization at Landstuhl. 

Because of advances in medical care on the battlefield 

and through far-forward surgical interventions and 

advances in critical care transport, casualties survive 

wounds that in previous wars would have lead to 

certain death. Casualty rates have dropped from 1 

in 2 in the American Civil War to 1 in 16 in OIF. This 

means many more patients survive to deal with the 

psychological after-effects of traumatic injury. 

The nature and severity of traumatic injuries vary 

depending on the inciting event. Terrorist attack 

victims suffer from injuries that include severe and 

extensive burns, blunt trauma, multiple wounds from 

fragments or broken glass, and smoke inhalation injuries. Combat trauma includes gunshot wounds, fragment wounds, abdominal wounds, brain and spinal 

cord injuries, and amputations. Many of the soldiers 

injured in OIF and OEF have multiple categories of 

wound and are referred to as polytrauma patients.

The resulting injuries from the traumatic event often 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

represent the end of life as the patient knew it, and the 

beginning of a painful and arduous ordeal with an 

uncertain outcome. The surviving patient is subject 

to a broad range of psychological stresses throughout 

the process of recovery. Pain is exacerbated by frequent 

wash-outs and debridement, dressing changes, skin 

grafts, plastic surgery, and the need to exercise damaged limbs to avoid contractures. Medical treatments, 

including the use of narcotics, can often interfere with 

patients’ motivation. The patient may need to be 

isolated until the danger of infection has passed, and 

extensive bandaging further reduces environmental 

contact, especially for facial or ocular wounds. A tracheotomy or traumatic brain injury (TBI) may interfere 

with communication.

Initial medical and surgical care is essential for the 

recovery of the trauma victim. The patient and the 

family report that this clinical care is often experienced as a significant ongoing stressor, and, in severe 

cases, as an extension of the trauma itself. The mental 

healthcare provider must take into account not only 

the effects of the traumatic event, but also the effect of 

the stressors arising from their medical and surgical 

management in the wake of trauma, in order to prevent 

or minimize psychological sequelae and to optimize 

clinical outcome.

Neurological and physiological disturbances and 

behavioral changes often follow traumatic injury that 

has resulted in amputations, brain injury, spinal cord 

injury, facial disfigurement, burns, blindness, and 

mutilating and castrating wounds of the external male 

genitalia.5

 Stressors including pain, complications 

arising in the course of the patient’s treatment and 

recovery, infection, the need for repeated incision and 

drainage or revision of surgical wounds, development 

of decubiti in the bedridden, side effects from medications, hospital-acquired infections, delays in recovery 

and prolonged hospital stays, and uncertainty in the 

outcome and time course are just a few of the emotional 

and psychological effects on the patient. 

The Effect of Trauma

Trauma results in the normal adaptive mechanisms 

being compromised when psychological defenses cannot be employed.6

 Self-integrity, self-confidence, and 

self-esteem may be undermined as a consequence of 

trauma. Trust of others is diminished, critical judgment 

is suspended, feelings of helplessness, dependency, 

and regression may occur. Feelings of rage, anger, and 

frustration may also result. Personality structures and 

defenses are pushed to their limits. Trauma may also 

recreate previous maladaptive patterns of behavior 

that had been dormant. 

To facilitate patient care it is critical to obtain a 

good biopsychosocial and developmental history. 

The patient or the patient’s family, or both, may have 

previous trauma or mental health issues that affect the 

response to trauma following injury. It is facilitative if 

the clinicians are aware of the underlying personality 

structures and defense mechanisms that the patient 

utilizes to personal advantage to help facilitate mental health interventions. The method of gaining this 

information needs to be different than traditional approaches with nontraumatized patients. A directive 

approach may cause a revivification of the trauma 

and contribute to regressive behavior that may disrupt 

medical care. A normal supportive conversational tone 

with humor (if possible, and if the provider is comfortable) is advocated.

Traumatic injuries may result in both short- and 

long-term emotional trauma, most of which are acute 

stress reactions and posttraumatic stress disorder 

(PTSD). Studies conducted at WRAMC have shown 

that the level of physical severity of injury may be correlated with the development of depression and PTSD 

following traumatic injury.7

 It has also been well documented that traumatic injury in the civilian healthcare 

setting often results in stress disorders.8,9 Rates of 

PTSD following traumatic injury vary from 12% to 

30%, but at WRAMC battle-injured service members 

had a 4% prevalence at 1 month, and 12% prevalence 

at 7 months following injury.7 Trauma victims may 

also experience a variety of psychological responses 

that occur independently or simultaneously with the 

above disorders. Other diagnoses, including affective, 

anxiety, and somatoform spectrum disorders as well 

as TBI, may also occur.10 Some of these responses that 

have been observed by the authors include separation anxiety, grief, anger, rage, fear, frustration, regret, 

shame, dissociation, regression, denial, and shattered 

ego integrity. 

Soldiers in combat have a battle mindset while in 

theater. This mindset includes many psychological 

symptoms that, although helpful in a war zone, are not 

helpful when returning home or following evacuation 

for injury, as many of these symptoms may mimic acute 

stress disorder. These may include difficulty sleeping, irritability, hypervigilance, exaggerated startle 

response, and motor restlessness. Other symptoms that 

may develop (and that can be detrimental) are poor 

concentration, fear, helplessness, horror, anxiety, detachment, absence of emotions, numbing, and anxiety. 

Cognitive symptoms may consist of recurrent dreams, 

thoughts, and flashbacks. Behavioral symptoms can 

include avoiding people, places, activities, thoughts, 

emotions, conversations, or television programs 

reminiscent of the event. Typically these resolve over a 
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period of time, but may persist after the initial trauma 

is over in a significant percentage of patients, and do 

not rise to the level of clinical diagnosis of acute stress 

disorder or PTSD. 

PCLS routinely assesses patients for these symptoms and provides psychoeducational interventions, 

normalization of the responses, and empathic exposure 

as a means to develop resiliency and return patients 

to mental health. The clinician’s awareness of the effect of these responses to the patient facilitates the 

development of therapeutic alliances with the patient 

that improve treatment outcomes and reduce stigma 

associated with mental health providers. 

The severity of the injury and body part affected 

may also help to determine the patient’s response 

to the traumatic injury. Injury to parts of the body 

with real or perceived significance may increase the 

patient’s stress.11 Therefore, PCLS routinely assesses 

patients for body image and physical integrity issues 

following trauma. Phantom limb pain is often treated 

with a combination of medications and hypnotherapy 

performed at the patient’s bedside. Patients are also 

taught self-hypnosis techniques to manage their pain. 

Patients with facial disfigurement and spinal cord 

injuries often have the most severe body image reactions to their injury. PCLS providers attempt to address 

these issues early in the course of treatment. In addition to the patient’s emotional reaction to these types 

of injuries, medical and surgical providers also have 

difficulty with these types of injuries.

 Trauma patients who experience severe pain 

are less likely to be amenable to psychotherapeutic 

interventions. Schreiber and Galai-Gat12 identify 

uncontrolled pain as a stressor that, if not treated 

effectively, may result in the development of PTSD. 

Uncontrolled pain may also lead to the development 

of anxiety, depression, loneliness, hostility, and sleep 

disturbances.13 Studies at WRAMC have also demonstrated that increased pain may be a predictor for the 

development of PTSD and depression in battle-injured 

soldiers.14 PCLS uses many interventions to reduce or 

eliminate pain. As mentioned above, hypnotherapy is 

often practiced at the bedside. Other therapies—such 

as cognitive reframing, antidepressant medications, 

and stimulants—are recommended to the treating 

trauma team as adjuncts to manage pain. 

Physical loss of a limb brings with it the added 

anxiety of potential social and interpersonal difficulty. 

Trauma patients are described by Blum15 as experiencing a loss of identity, self-confidence, self-esteem, 

self-reliance, and ideal self. Horowitz16 and Landsman and colleagues17 noted that patient’s reactions 

to traumatic injury can be similar to bereavement. In 

addition to concern regarding physical appearance, 

patients sustaining an amputation may be concerned 

with the reactions from peers, the ability to earn a 

living,11 socialization, dating, and sexual behavior.10

Trauma victims are at risk for developing psychiatric 

illnesses based on these factors: exposure to trauma, 

intensity of exposure, psychiatric history, gender, and 

level of education.18

The need for early psychiatric intervention was recognized following the attacks on 9/11.4,19,20 Hoge and 

colleagues21 demonstrated that the greatest deterrent to 

soldiers exposed to trauma who may need psychiatric 

intervention is their perception of psychiatry. To destigmatize mental health for the battle-injured soldier, 

the PCLS service was redesignated as Preventive Medical Psychiatry (PMP) to gain greater acceptance by 

patient, family, and staff alike. This change addressed 

the need for the mental health team to be seen as any 

other medical service,20 and ensured that every patient 

from OIF/OEF hospitalized on a medical surgical unit 

at WRAMC was evaluated and followed. Integrating 

psychiatry into the trauma team and providing routine preventive psychiatric interventions with trauma 

patients may prevent psychiatric symptoms from 

becoming disabling. The benefit of this program is 

demonstrated by the fact that the rate of PTSD development among medically injured patients treated at 

WRAMC is lower than noninjured soldiers exposed to 

trauma.7,21 Furthermore, early psychiatric intervention 

may also alleviate the stigma associated with being a 

psychiatry patient and allow appropriate psychiatric 

intervention to occur when necessary, often after the 

patient has left the hospital.

Hospitalization and the Meaning of Injury

 In the period immediately following injury, patients 

often report a sense of shock, denial, and disbelief. 

The feeling of being dependent on others can become 

intimidating and overwhelming. Fear over loss of life, 

limb, or capability, as well as a feeling of loss of control 

is a common occurrence. Apprehension of being abandoned prior to regaining control or receiving help can 

be very overpowering. Once help has arrived and the 

fear of being alone is relieved, a sense of initial comfort 

develops, along with potential dependency needs. 

Based on the severity of the injury, patients may not 

be aware of all that has transpired until they awake in 

the hospital. Some patients are initially elated at being 

alive. After a time, however, the elation may fade and 

anxiety and depressive symptoms may appear. Others 

who suffer brain injuries or loss of consciousness may 

never remember the event or the trauma and wait for 

others to fill in the gap. 

In general, a patient who is exposed to trauma can 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

experience a threat to both physical and emotional 

integrity. Loss of body parts and threat of death or annihilation are also significant fears for these patients. 

They become vulnerable and dependent, a state many 

patients have not experienced in many years. Fear or 

discomfort with strangers may also become prominent 

because of the unknown effect of the disfigurement on 

the new relationship. Fear of not having as many loved 

ones around and leaving a safe environment are also 

major concerns for patients being discharged from the 

hospital. Patients’ perceptions can result in childlike 

patterns of behavior, which lead to conflicts with the 

nursing and medical staff. Regression and dependency 

needs are frequently observed in traumatically injured 

patients, and an overwhelming sense of narcissistic 

injury is frequently present.

Complicating these factors are the anxieties of the 

patient’s loved ones. The family’s needs must be addressed so that their anxieties do not affect the patient 

and thus exacerbate an already emotionally complicated situation. For example, family members often 

choose to sleep in the patient’s room rather than leaving them alone at night. This, however, can result in 

the patient later having difficulty sleeping if someone 

isn’t in the room.

An individual’s adaptive functioning may be 

compromised by the traumatic event. Most patients 

eventually find ways to deal with the emotional effects of traumatic injury, and although personality 

features that have been effective as coping styles in 

the past may become overwhelmed initially, patients 

usually self-correct. Patients with poor or disordered 

personality structures may have conflicts with staff 

or families and are at risk for developing maladaptive behaviors or psychiatric illnesses. These patients 

may respond in a less-than-optimal manner because 

medical or traumatic injuries can be an overwhelming 

stressor. These patients and families are vulnerable and 

need support and guidance from caring individuals. 

Developing a therapeutic relationship with them is 

imperative. Utilizing warmth, caring, empathy, and 

support can go a long way when attempting to form 

an alliance with the family and the patient, and can 

facilitate healthy behaviors and responses.

The Role of Psychiatry Following Trauma

Nearly all survivors exposed to traumatic events 

briefly exhibit one or more stress-related symptoms.22

In many instances these symptoms dissipate within a 

reasonable amount of time. However, symptoms persisting for a prolonged period following a traumatic 

event increase the probability of developing PTSD or 

other stress-related psychiatric disorders. Koren8 found 

that injured soldiers were more than five times as likely 

to develop psychiatric symptoms than were those 

only exposed to trauma. Though the initial goal of the 

mental health team is to facilitate medical treatment, 

a secondary goal is to prevent or decrease the probability of chronic debilitating psychiatric symptoms. 

To meet these goals in treating the medical-surgical 

patient following a traumatic injury, new approaches 

were adapted at WRAMC.2,10

Rather than waiting for consultations to be received 

before intervention occurs, the PMP at WRAMC developed a therapeutic interaction to overcome the 

stigma of being seen by psychiatry. Overcoming this 

obstacle is important because many patients tend 

to downplay their distress and underreport their 

symptoms for fear of being labeled a psychiatric patient. (As discussed above, the PMP was developed 

to decrease the stigma associated with mental health 

and psychiatry). 

Case Study 16-1: A 36-year-old soldier with a soft-tissue 

injury to the right eye, fractures to the left femur and tibia, and 

a right-leg below-the-knee amputation (BKA) responded in a 

sullen manner to his orthopaedic and physical therapy teams. 

Upon the initial visit by a psychiatrist he denied any problems 

as a result of the improvised explosive device (IED) blast. 

He claimed he did not need psychiatric intervention and was 

upset that the team referred him. When he became aware 

that the psychiatry approach was routine and preventive in 

nature, he began describing his concerns about his decisionmaking process while in theater that may have led to his unit 

receiving the blast it sustained. He continued to describe his 

concerns, and the psychiatry team worked to reframe what 

had happened while maintaining an advocacy role. As he 

accepted the routine of the psychiatry approach, he began 

to respond more favorably, assimilated the intervention, and 

cooperated more fully with his rehabilitation.

THERAPEUTIC INTERVENTION FOR THE PREVENTION OF PSYCHIATRIC STRESS DISORDERS

The PMP service at WRAMC employs the Therapeutic Intervention for the Prevention of Psychiatric 

Stress (TIPPS) disorders model.10 The approach draws 

upon many tools used by the mental health provider 

in the consult–liaison setting. This intervention was 

developed to address the psychological needs of 

trauma victims, provide support to the individuals 

and their families, assess psychiatric status, provide 

early intervention when needed without stigmatization of the patient, and support the staff. To help with 

the clinical process, objective instruments are given 

to patients while they are in the hospital. The questionnaires are helpful in providing objective data and 

facilitating follow-up.
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The major components of the TIPPS approach are 

mental health becoming a routine part of trauma 

care, empathetic exposure therapy, developing a 

strong therapeutic alliance with the patient and family, normalizing the experience and the psychological 

response to the trauma, reinforcing resiliency, and 

promoting positive coping behaviors. TIPPS has been 

used successfully at WRAMC since the attacks on the 

Pentagon on September 11, 2001. Studies infer the effectiveness of this approach for reducing the prevalence 

of mental health disorders in battle-injured soldiers 

treated at WRAMC.7 Other significant components 

of the intervention include recognizing personality 

styles and psychological defenses, countertransference 

and transference issues, normalizing events, cognitive 

reframing, educating patients and families, prescribing 

appropriate psychopharmacology, and utilizing hypnotic and relaxation techniques. Reinforcing patients’ 

strengths regarding their survival was also a primary 

theme of this approach. A review of some of the principles of TIPPS follows.

Routine Consultation and Therapeutic Alliance

The patients are initially approached with an informal style and avoidance of traditional psychiatric 

jargon. A typical introduction may begin by saying, 

“Hello, I’m Dr ____ from Preventive Medical Psychiatry. Welcome back. We are sorry you had to experience 

your injury and we all thank you for what you did. 

You took care of us by being there. It is now our turn 

to take care of you.” Family members are also greeted 

in a similar manner if they are present. The provider 

is introduced to the family as staff of the PMP service. 

The provider also lets the soldier and the soldier’s 

family know that mental health assessment is part of 

the routine care for returning OIF/OEF patients. This 

approach frequently sets patients and families at ease. 

Providers are trained to be cognizant of the variety of 

reactions to mental healthcare that patients and families 

may have and adjust their approaches accordingly.

The therapeutic alliance is built with the patient and 

families over time, as patients are seen briefly several 

times per week. PMP involves the entire family unit in 

adjusting to, and recovering from, the traumatic event. 

The family may be seen separately from the patient 

as well as together. Understanding their position and 

problems is necessary. PMP social workers also follow 

patients and their family members twice a week. The 

child and adolescent psychiatry service joins the PMP 

for rounds and sees families with children of injured 

soldiers to assess the family support structure and to 

help the family deal with the effect of trauma. 

Patients are asked to rate how they are feeling, their 

pain, and their sleep, and if they are having any nightmares or feelings about the trauma. The development 

of the therapeutic alliance cannot be underestimated. 

It facilitates the assessment of psychological symptoms and treatment while in the hospital and allows 

for easier follow-up treatment if problems arise for 

patients or their families upon discharge. This helps 

ensure that patients feel comfortable approaching 

psychiatry for help, if needed.

Transference and Countertransference in the 

Therapeutic Relationship

Understanding the interpersonal interaction between clinician and patients facilitates evaluation and 

treatment.20 Patients’ responses to clinicians will often 

be expressed in various manifestations of transference. 

At times the transference can be modified by the actual 

behavior of the therapist. The need to elicit a therapeutic alliance and a positive transference from the 

trauma patient is crucial. This will likely occur when 

the clinician is perceived as both good and helpful in 

the here-and-now situation. Negative transferences 

are more likely to recreate spontaneous reenactments 

due to rapidly shifting mood, affect deregulation, and 

disconnection within self. The potential for revictimization may be enhanced or diminished by the negative 

transference experience of the patient. With a negative 

transference, the trauma patient may come to categorize the clinician as a past perpetrator. This occurrence 

may likely contribute to a regression or oppositional 

style to medical treatment. This is detrimental in 

particular for the wounded soldier because medical 

stabilization and recovery is of necessity. It is clearly 

essential for the clinician to recognize the significance 

of the transference responses and react in an appropriate therapeutic manner. During the early stages of 

therapy with trauma patients, the immediate goal is 

to establish the holding milieu for the emergence of 

positive transference. 

Clinicians can also develop countertransference issues that need monitoring. Clinician overindulgence 

of patients’ needs, silence, avoidance, and overidentification with the patient or family members can cause 

disruption in the recovery of the patient. The concept 

of neutrality can be lost and patients can feel revictimized. In general, being aware of patients’ transference 

or countertransference issues and the effect on the 

therapeutic process allows for greater clinical clarity 

and appropriate interventions. Awareness of countertransference issues also allows the PMP clinician to be 

a more effective clinician and consultant. Knowledge 

of these skills can help colleagues in other services in 

their interactions with their patients. 
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INDIVIDUAL THERAPEUTIC COMPONENTS

Empathic Exposure

Providers allow the patient to process the trauma 

through empathic supportive exposure therapy. In 

other words, in an empathic manner, patients are asked 

to reflect on their traumatic experiences, suggesting that 

description at present is helpful in the future. Empathic 

exposure may help them integrate the past trauma into 

their present stream of consciousness. Patients are usually seen three times per week for 15 to 20 minutes. The 

frequency of this empathic exposure appears to allow 

for the normalization of the event and consolidation of 

the experience in the patient’s memory.

Providers are trained to offer rapid empathic responses to patients’ recall of their trauma and injuries. 

As the patients continue to relate their trauma, empathic reinforcing statements are made about their psychological assets. These statements reinforce their positive 

behaviors during their descriptions. Nonthreatening 

techniques are employed and confrontational approaches are avoided. Comments that demonstrate 

patients’ positive assets are quickly reinforced, such 

as, “How did you know to do that?” or, “Where did 

you learn that?” Traditional psychotherapeutic interventions aid the provider in supporting the trauma 

patient. Acceptance, respect, empathy, warmth, advice, 

praise, affirmation, and a sense of hope are qualities 

and characteristics the clinician is encouraged to display while working with these patients. Providers need 

to be viewed as genuine in their concern and support 

of the patient, while offering empathic validation 

and encouraging patients to elaborate on reactions 

relevant to the trauma. These techniques reinforce the 

therapeutic alliance and treatment. In summary, while 

the patients are relating their traumas, clinicians find 

a way of reinforcing their assets. Providers continue 

this procedure each time they see these patients. Supportive reinforcing statements regarding their assets 

while they are describing their trauma may help them 

integrate the conflict in a more productive manner.

Hypnotherapy

Hypnotic techniques are taught while the patients 

are in their beds. Providers have them practice breathing and then utilize a rapid hypnotic induction that 

patients can repeat to themselves. This can, at times, 

allow for management and control over symptoms 

such as pain, hypervigilance, and anxiety. It may also 

allow for distancing from the trauma—giving patients 

some control in finding a safe mental place where they 

can begin processing thoughts and feelings about the 

trauma. The clinician can facilitate the patient’s going 

to the imaginary safe place to process and reframe 

traumatic events. Subsequently these patients can get 

to their safe place on their own. These techniques can 

also be an outstanding adjunct to help pateints integrate their conflicts with phantom-limb pain, sleep, 

and smoking cessation in a facilitative manner. Many 

of the trauma patients at WRAMC smoke even when 

they know smoking disrupts wound healing.

Group Therapy

As a supplement to individual therapy, groups 

can provide beneficial support and help many of the 

patients begin working through the process. Group 

therapy was demonstrated as an effective technique 

for treating Vietnam-era veterans with PTSD.23 At 

WRAMC, groups are held twice a week in the hospital 

ward and led by providers. The groups are open to the 

medical and surgical injured patients. Topics such as 

anger, expectations, recognition of limitations, sexual 

fears, separation anxieties, survivor guilt, losses, family concerns, and public responses are discussed after 

initiated by a patient. 

Pharmacological Interventions

Pharmacological approaches are often used to facilitate mental health recovery from traumatic injury. 

Physical trauma results in significant somatic pain and, 

according to Schreiber and Galai-Gat,12 uncontrolled 

pain may result in the development of PTSD. Some 

patients associate pain with the severity of their injury, 

which may also lead to the development of anxiety, 

depression, loneliness, hostility, and sleep disturbances.11,13 Studies at WRAMC have demonstrated that 

patients with increased levels of physical injury are 

more likely to develop PTSD and depression following 

injury.7

 Furthermore, patients experiencing pain are 

less likely to respond to traditional psychotherapeutic 

interventions.13 Thus, prompt pain control is critical in 

trauma patients and must be addressed early with judicious use of analgesics. PMP often recommends several 

adjunct treatments to the trauma team to manage pain, 

including tricyclics and other antidepressants, hypnotherapy, and relaxation therapy. Myriad pharmacological interventions are available to treat patients with 

psychiatric diagnoses or symptoms such as agitation, 

anxiety, or perceptual disturbances. Some of the agents 

utilized are antipsychotics, atypical antipsychotics, 

selective serotonin reuptake inhibitors (SSRIs), and 

serotonin-norepinephrine reuptake inhibitors. 
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Insomnia

Insomnia in the polytrauma patient is a near universal observation. Insomnia can be attributed to delirium, nursing care interventions, lab draws, pain, fever, 

and doctors’ rounds, among other things encountered 

in the hospital. Benzodiazepines, anticholinergic medications, and antidepressants can interfere with clarity 

of thought and prevent psychological integration of 

the traumatic event, as well as foster the development of a delirium. Insomnia in the trauma patient is 

treated with a variety of interventions. First, orders 

are reviewed to ensure that nursing care interventions 

(such as q4 hour vitals) are not still ordered when no 

longer necessary. Patients are given permission to close 

their doors and put signs up instructing that they not 

be disturbed. The nursing staff is encouraged to allow 

for uninterrupted sleep. Patients are also educated on 

sleep hygiene, and relaxation techniques are taught to 

help them rapidly induce sleep. 

Often, however, these measures are insufficient. 

Medications for insomnia can be extremely useful 

in the hospitalized setting. The choice of medication 

is often based on the patient’s symptoms, medical condition, and preference. For nightmares and 

sleep maintenance problems, Seroquel (quetiapine; 

AstraZeneca US, Wilmington, Del) is often used 

in low doses, 25–100 mg. There has only been one 

small open-label study published looking at Seroquel and sleep quality, which showed effects on 

nightmares and sleep maintenance. The experience 

at WRAMC shows this approach to be effective and 

well-tolerated by patients. However, there have been 

a few patients who experienced elevations in their 

liver-associated enzymes due to Seroquel. There are 

other drawbacks. Seroquel is expensive and is an 

atypical antipsychotic; there is debate about its cost 

effectiveness and the risks of dyslipidemia, bloodsugar abnormalities, and extrapyramidal symptom 

disruptions. In treating thousands of patients at 

WRAMC with this medication, there have not been 

observed instances of these problems. Other antipsychotics have been employed somewhat successfully for the treatment of sleep disturbances with 

nightmares. Other medications may be indicated 

in the presence of flashbacks or disorientation and 

emotional dysregulation from multiple or high-dose 

pain medications or other medical issues.

Ambien (zolpidem; Sanofi-Aventis, Bridgewater, 

NJ) has not been found to be as useful as Seroquel in 

patients at WRAMC. The half-life of Ambien is short 

and patients quickly develop a tachyphylaxis. Also, 

Ambien does not seem to work as well for stressinduced insomnia. When insomnia is associated with 

anxiety or depression, mirtazapine can offer relief. 

Nightmares, when overwhelming, have been reported 

to respond well to prazosin, though caution should be 

exercised due to its hypotensive properties. One small 

study of 10 patients showed some alleviation from 

nightmares in patients with PTSD using prazosin. A 

discussion on the use of pharmacotherapy is provided 

elsewhere in this volume. 

TREATMENT

As described earlier, a variety of psychotherapeutic 

and psychopharmacologic interventions, techniques, 

and styles are utilized. In the PMP service, the mechanism of normalization of feelings is a fundamental 

aspect of treatment. Soldiers in the initial phases of 

trauma recovery are not generally willing to discuss 

their feelings with the providers, but with the mandatory screening and monitoring that the service provides, patients become “used to” someone coming in 

and normalizing some of their “potential” emotional 

responses. After some time, they may often choose 

to speak more freely, knowing they are going to be 

listened to and understood.

The first step is to allow these patients to fully describe their losses. It is only through this step that the 

necessary information can be gathered to determine 

if their depression is from grieving, from a sense of 

helplessness in not knowing how they are going to 

handle a change of life as a result of their injury, or if 

there is a truly endogenous depression. In these initial 

few sessions, mental health professionals can learn 

a great deal about value systems, usual responses to 

adverse life events, and expectations and fantasies of 

what would happen in the next few months of these 

patients’ lives.

These soldiers, regardless of the etiology of their 

situations, must be given a chance to mourn their 

losses. An essential aspect of working through this 

is identifying the loss, the importance of that loss in 

their lives, and its effect. In each of these “grieving sessions,” the psychiatrist needs to focus on the recurrent 

themes and begin to lay foundations for growth and 

resiliency despite the loss. As these patients discover 

that life does not halt because of the loss, they realize that the traumatic incident is another chapter in 

the rest of their lives. They can then begin to recover 

their sense of purpose and well-being. Some soldiers, 

despite psychotherapeutic interventions, continue to 

have depressive or anxiety symptoms, and require 

pharmacological interventions. Fortunately, soldiers 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

in these situations typically respond well to the usual 

treatment course of antidepressants.

Depression and Mood Disturbances

Being a patient often precipitates a sense of loss that 

many cannot verbalize. Because soldiers are taught 

throughout their military training to “bottle up” their 

feelings, their sense of loss can manifest itself though 

behavioral problems. This section addresses the various ways that loss can be experienced by these patients, 

how the process of normalization of experiences can 

allow them to work through their sensations, and effective treatment strategies for the more recalcitrant 

cases.

From the very beginning, battle-injured soldiers will 

generally indicate that they are simply “happy to be 

alive.” However, this statement is often followed by a 

second statement: “I guess I was lucky.” The progression of this thought is stunning; soldiers will seem 

genuinely relieved at their fortune, but an overriding 

sense of guilt actually visibly appears to overtake them, 

and they must attribute this fortune to luck to again 

regain their emotional control over survivor guilt. 

The reality of survivor guilt has been well established 

in patients who are covictims in traumatic events. In 

soldiers, this guilt is intensified by the ubiquitous code 

of teamwork that military service requires of its members. This feeling is often stronger in those patients 

who have minimal injuries compared to the death or 

severe maiming of their peers.

Loss of functioning goes well beyond the mere 

physical loss of limbs. Many of these soldiers tend 

to be athletic and active in their preinjury lives. They 

perceive their lives as “forever changed” because of the 

amputations, and frequently believe they will have no 

ability to engage in their former activities. Although 

there is some basis in reality with this thought, unless 

they move through this phase, they will not be able to 

see the abilities they still have or may regain.

Case Study 16-2: AB was a 22-year-old Army sergeant. 

He was the team leader for four other infantry soldiers. The 

unit had been together in theater for 7 months when they 

were attacked by an IED on a routine patrol. AB was knocked 

unconscious by the blast, but awoke with a BKA of his left 

leg. He learned that two members of his team had perished 

in the blast, another had an amputation of his right arm and 

leg, and the fourth one had suffered a TBI and his status 

was unknown to the patient. AB spent 3 weeks in a facility 

before being transferred to WRAMC. In that time he had 

minimal exposure to mental healthcare, primarily because 

of his statements that he was “doing fine.” However, after 

his air evacuation to the United States, AB stated that he 

was “surrounded by the reminders of his loss,” and became 

tearful during his history and physical with his primary team. 

They requested a consultation. AB spoke of his loss of his 

own limbs, but realized that he was “lucky.” However, this 

conflicted with his sensation that he “should” feel more for 

his soldiers than for his own self. He stated that this was 

the reason that he spoke little of his feelings in his previous 

hospitalization, believing that if he focused on himself, he 

would be perceived as weak. AB was deeply troubled at 

his change of lifestyle, but extremely worried that he would 

need to “forever show his grief” when he was at his unit to 

pay homage to his team soldiers. Determining that he would 

“never be happy,” he fell into a state where he would not 

participate in activities, have outside visitors, or speak with 

his unit liaisons as they visited in the hospital.

Anxiety

During the acute period of hospitalization of battleinjured soldiers, the PMP service observes a range of 

symptoms in the anxiety spectrum of disorders. Most 

commonly seen are those symptoms that are consistent 

with acute stress reactions. In particular, the reexperiencing of traumatic events through nightmares, 

flashbacks, intrusive thoughts, and recurrent images 

are common. Equally common are symptoms related 

to hyperarousal, such as difficulty falling or staying 

asleep, hypervigilance, increased startle response, 

irritability, and poor concentration. Obsessive rumination themes in the injured soldiers include worries 

regarding the threat to physical integrity, the effect 

on current and future functioning, and the effect on 

family members and friends. Soldiers removed from 

theater often worry about unit members left behind 

and are distressed by their perceived inability to help 

their friends in the field. Many soldiers hear the sound 

of the blast or the gunshot that injured them replayed 

over and over either in their minds or in dreams. Others may ruminate over the death of friends and are 

overcome by survivor guilt. Very frequently battle 

scenarios are reviewed over and over and soldiers 

wonder what they might have done differently to 

have effected a different outcome. Some of the most 

distressing memories for patients include seeing fellow soldiers die, seeing dead children, and exposure 

to body parts. Finally, shame may lead to emotional 

conflicts that may ultimately feed anxiety. 

In the absence of traumatic or anoxic brain injuries, where patients have no recollection of traumatic 

events secondary to organic causes, few patients seem 

concerned about overt dissociative symptoms (such 

as not recalling important aspects of the trauma or a 

feeling of emotional numbing or detachment) in the 

acute period. Indeed, it appears that most patients, 

at least in the initial period of hospitalization, seek to 

reconnect with family members and loved ones and 
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are particularly comforted by contact with commanders and unit members still in the field. Although some 

hospitalized soldiers may avoid television or movies 

that remind them of traumatic events, it is less common for patients to overtly avoid reexperiencing the 

traumatic events by refusing to discuss the trauma, 

or feelings and thoughts about the trauma. When this 

overt avoidance occurs, it should be particularly worrisome to the mental health provider and consideration 

for further intervention should be given. 

In addition to symptoms that are consistent with 

acute stress disorder, anxiety may manifest in the 

form of specific fears or phobias, such as a fear of 

falling asleep (usually reported as fear of dreaming), 

fear of being alone (separation anxiety), or fear of being in the dark. Overt anxiety and panic attacks are 

observed infrequently. Often these are aggravated 

in soldiers with prior personal or family histories of 

anxiety disorders.

Rapid eye movement sleep behavior disorders 

are not uncommon where patients report acting out 

combat-related scenes, presumably during rapideye-movement sleep. Hypnogogic and hypnopompic 

phenomena and other perceptual disturbances may 

occur and may represent hyperarousal symptoms. 

The service member has just traveled across multiple 

time zones and may be undergoing frequent painful 

surgical procedures and necessary nursing interventions throughout the day and night (which continue 

to promote disturbance of the sleep–wake cycle). The 

utility of other treatments, such as image rehearsal 

therapy (where dream endings are more positively 

construed), are also being explored to address sleeping 

concerns and nightmares. 

In the acute treatment setting, when these symptoms appear, it may be difficult to make a specific 

anxiety-disorder diagnosis, given that very frequently 

the service member does not meet full criteria for any 

one specific diagnosis. Additionally, there are many 

confounding factors, such as pain, pain medications 

(opiates, benzodiazepines, or anesthetics) or other 

medications or substances, head injuries, and other 

treatment factors that may account for, exacerbate, or 

create any of the aforementioned symptoms. Above 

all else, it is important to determine whether a general medical condition, particularly associated with 

delirium, is not causing or contributing to the anxiety 

symptom. For this reason, very frequently a diagnosis of anxiety disorder not otherwise specified may 

be given if one or more symptoms are particularly 

apparent and troublesome but the patient does not 

meet full criteria for a specific diagnosis. Additionally, 

a diagnosis of adjustment disorder with anxiety may 

be made, although in some cases it is difficult to deem 

that one person’s response is in excess of what might 

be expected for such an extreme situation. 

Later in the course of medical stabilization, almost 

all of these symptoms lessen for most patients but may 

persist for a few. For example, patients may continue 

to reexperience traumatic events, particularly through 

nightmares. Likewise, new anxiety symptoms may 

emerge as patients are exposed to new situations outside of the hospital room. Another common example 

is when they may realize that they have less ability 

to emotionally connect with others and may have 

more social withdrawal, such as difficulty tolerating 

crowded areas. In a few cases, patients have refused to 

leave their hospital rooms altogether when medically 

deemed physically capable. As patients physically heal 

and develop more cognitive reserve, more standardized treatment strategies may be utilized (such as more 

formalized cognitive behavioral therapy) for the identified disorder. They may then participate in supportive 

group therapies or perhaps engage in psychodynamic 

therapy if more developmental and interpersonal 

concerns appear to be affecting the current condition. 

The importance of early and consistent treatment of 

these disorders is borne out by the fact that between 

12.2% and 12.9% of soldiers at WRAMC with serious 

combat injuries returning from OIF or OEF will go on 

to manifest full criteria for PTSD, with the injury itself 

being a major risk factor for ultimate development of 

the disorder.7 Without these interventions it is likely 

that these numbers would be even higher.

The general approach to the acutely battle-injured 

soldier with anxiety begins, as for all patients, with 

an empathic stance that focuses on the building of a 

therapeutic alliance. Building early rapport helps the 

patient identify mental health specialists as part of 

the medical team and facilitates patient comfort with 

providers. Additional social assistance is provided 

where necessary to mobilize and establish a support 

network and resources for the patient in the hospital. 

The medical needs of the patient are reviewed and an 

understanding of the illness or injuries or both from 

the patient’s perspective is explored to help identify 

beliefs and concerns (and perhaps any doubts or misgivings) that the patient may have regarding care or 

prognosis. 

Psychoeducation is provided to help build a framework for treatment and to normalize current feelings 

and emotions. Supportive psychotherapy is offered to 

identify and engage patient strengths and to bolster 

ego defenses. Patients are encouraged to discuss the 

trauma “when they are ready,” at which time providers reinforce what the patient did well throughout the 

traumatic event. Cognitive techniques are employed 

to help patients reframe thoughts about traumatic 

experiences so that anxiety is better understood and 

tolerated. Relaxation techniques may be taught and, in 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

certain instances, hypnosis may be added to help patients achieve a deeper sense of relaxation and mastery 

of emotions. Particular attention is paid to pain control and sleep, as any inadequacy in these areas may 

hinder the patient’s ability to employ effective coping 

strategies. For this purpose, recommendations for the 

adjustment of pain medications or for the addition of 

new ones may be made to the primary medical team. 

Prior to making any medication recommendations, it is 

important to consider the patient’s underlying medical 

condition, current medications, and allergies. Medication interaction checks should always be performed, 

given that most psychoactive medications have the 

propensity for interactions with multiple other drugs 

and antibiotics. 

SSRIs remain the drugs of first choice for PTSD, 

generalized anxiety disorder, panic disorders, and 

social phobia. They may also be utilized for severe, 

prolonged acute stress, and for adjustment disorders, 

although some of the newer non-SSRI antidepressants 

such as venlafaxine and mirtazapine have also been 

used successfully. Of the SSRIs, sertraline and citalopram are generally preferred given their tolerability 

and relatively decreased potential for drug–drug interactions. Benzodiazepines are generally avoided 

where possible, particularly in PTSD, given the lack 

of data to support their use and the potential for addiction and worsening of PTSD in the long term. They 

are, however, occasionally used for the temporary 

relief of severe anxiety and panic attacks. Frequently, 

patients will already have benzodiazepines prescribed 

for other indications such as muscle spasms or phantom limb pain. In this latter case, patients should be 

educated on the effect of benzodiazepines on anxiety 

and the effects should be monitored. Treatment for 

persistent conditions may ultimately extend beyond 

the period of hospitalization. It is therefore important 

on a consult-liaison service to work closely with the 

medical team on aspects of discharge planning so that 

there is a seamless transition of care between inpatient 

and outpatient mental health providers. 

Cognitive Disorders

Approximately one third of service members 

injured in OIF and requiring medical evacuation to 

WRAMC are found to have a TBI. Of these, about half 

are classified as mild TBIs and the other half are rated 

as moderate to severe. Many of the TBIs occur in the 

setting of polytrauma. All service members with an 

injury history that may be associated with a TBI (such 

as an IED blast exposure, a moving vehicle accident, 

or falls) are screened during the initial phase of their 

hospitalization for a TBI by a specialized team from 

the Defense Veterans Brain Injury Center. Additionally, as part of the routine screening by PCLS/PMP 

of all injured service members who are admitted to 

WRAMC, a further psychiatric assessment of these 

inpatients is performed. A multidisciplinary team 

from neurology, physical medicine and rehabilitation, 

psychiatry, physical therapy, occupational therapy, and 

speech pathology provide ongoing assessment and 

treatment of these patients.

The role of the PMP includes clinical assessment 

of the TBI and treatment of associated behavioral 

sequelae. This begins in the intensive care unit (ICU) 

for more severely injured service members who arrive at WRAMC on ventilator support. In addition 

to the common problems of disorientation and frank 

delirium seen in patients with polytrauma as they are 

weaned from sedation, patients with TBIs may take 

considerably longer to wake up, may be more agitated 

and disorganized, and are generally less able to participate in their own care. Family members of injured 

service members with TBI are provided information 

that the prognosis for moderate-to-severe TBI is hard 

to predict and may be very frightening and upsetting 

to loved ones. In addition, therapeutic nihilism in staff 

members treating severe TBIs is not uncommon and 

frequently needs to be addressed by the consultation 

liaison psychiatrist. Recommendations for treatment 

of delirium and agitation often involve modification of 

the intravenous pain regimen, minimization of external 

stimulation, addition of neuroleptic medication, and 

restraint when other modalities fail. Sleep disruption is 

common and may be associated with other symptoms 

of hyperarousal. Preemptive treatment of sleep disruption with low-dose atypical neuroleptics has proven to 

be especially effective in decreasing hyperarousal.

On the medical and surgical wards, psychiatric 

evaluation of TBIs focuses on the ongoing assessment 

of cognitive function and the emotional adjustment of 

service members to their wartime experiences, their 

injuries, and their futures. The interplay of cognitive 

deficits and organic mood and personality changes 

with acute and posttraumatic stress disorders provides 

diagnostic and therapeutic challenges. Conversion 

disorder is not uncommonly seen in the context of 

mild TBI and takes the form of embellishment and 

exaggeration of cognitive deficits, sensory and motor 

abnormalities, gait disturbances, and stuttering.

Case Study 16-3: GQ is a 32-year-old active duty E6 

with 13 years in service. He was injured by an IED explosion 

while on a mission in OIF that resulted in a penetrating head 

injury. At a combat support hospital in Iraq, he underwent a 

left frontoparietal craniectomy for removal of an embedded 

fragment and duraplasty, and placement of an intracranial 

pressure (ICP) monitor. The patient was then transferred 

to Landstuhl Regional Medical Center in Germany where 

his ICP was noted to be increased to 15–22 mm Hg, but 
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Combat and Operational Behavioral Health

interval head computed tomography (CT) was unchanged. 

Patient was noted to be combative when attempts were 

made to wean him off sedation. Once his ICP stabilized and 

the monitor was removed, the patient was transferred to 

WRAMC, where he arrived intubated and sedated. Following the patient’s admission to the WRAMC ICU, his wife was 

seen daily at his bedside by the PCLS staff. Several days 

into the hospital stay, his wife became extremely distraught. 

She reported that she had been told by the ICU house staff 

that her husband’s prognosis was guarded. Additionally, she 

was shown his head CT scan and interpreted the large area 

of skull loss from the craniectomy as massive brain loss. 

She did not know if she could live with her husband “being 

a vegetable.” A meeting with the patient’s wife, PCLS, and 

the ICU team was useful in correcting her misunderstanding 

of the CT scan and providing her with a better understanding 

of his prognosis. The patient was subsequently extubated 

and was initially agitated and moving only his left side. Over 

the next month he made a gradual recovery, with resolution of posttraumatic amnesia and return of speech and full 

motor activity. He denied flashbacks, hyperarousal, anxiety, 

depression, or other symptoms of acute stress disorder, with 

the exception that he had difficulty sleeping. He was treated 

with increasing doses of Seroquel up to 75 mg for his sleep 

difficulty. He actively participated in physical therapy, occupational therapy, and cognitive therapy with speech pathology, 

and was transferred to a Veterans Administration center for 

cognitive rehabilitation. He made an excellent recovery, had 

a cranioplasty for his skull defect, and eventually resumed 

working in his previous capacity, albeit in a nondeployable 

status.

Follow-Up Contact

All patients are given a contact number and encouraged to call the PMP office at WRAMC should 

concerns develop for the patients or their families. 

They are also called 30, 90, and 180 days following 

discharge from the hospital. One of the early goals has 

been to make psychiatry an ally to the patient. When 

patients have returned to their homes they have found 

it easier responding and receiving intervention, and 

when crises occur they appear more willing to accept 

referral recommendations. In general, patients who 

need treatment upon leaving WRAMC are referred to 

resources within the military, veteran’s health system, 

or civilian community. 

The Trauma Patient’s Family

Family members also experience psychological 

trauma as a result of the injury of their loved ones.24–27

Families typically know little about the extent of the 

injuries or their prognosis, and therefore experience 

more anxiety and feelings of helplessness.11 Crisis intervention for the family members of trauma victims 

may be needed.

It is difficult to predict how family members will 

react to the trauma and the injuries sustained by the 

patient. The experience of having a family member 

injured may exacerbate family malfunctioning.17

However, the interventions to assist these families in 

coping with the traumatic event may lessen the family 

member’s chance of developing secondary PTSD.26

Trauma patients need as much support as possible, 

and family members are often better at providing 

emotional support and reassurance to the trauma 

patients than the staff.24 Effective therapeutic family 

interventions may not only help the family members 

cope with the traumatic events but may help the patient as well. The family’s anxieties tend to exacerbate 

the patient’s conflict. Negative family behavior may 

also have a deleterious effect on the nursing staff. But 

if the family remains stable and supportive, the patient’s anxiety is decreased and outcome is improved. 

The family’s built-in support system may need to be 

augmented with professional help.28 The purpose of 

the family crisis intervention is to build up the family’s 

coping skills and resolve symptoms associated with 

psychological trauma. Sharing meals with families of 

other trauma patients, for example, also provides the 

family with additional support.26

Initially it is important that family members of the 

injured soldier have access to food, clothing, and shelter. A family assistance center is available 24 hours a 

day at WRAMC. This alleviates any additional stress 

and allows the family to focus its attention on the 

patient and deal with the ongoing events.26 Each institution needs to provide personnel to help with this 

task. At WRAMC, PMP social workers are advocates 

for patients and their families.

Brief supportive counseling has also been proven 

effective at reducing anxiety in family members of 

trauma victims.11 PMP staff will often spend time 

with family members interviewing and supporting 

them emotionally. Support groups formed specifically 

to assist these families provide an outlet for them to 

address their needs and feelings.28 When developing 

family groups, Harvey and colleagues28 found that 

families were more willing to attend when the group 

focus was on education and families sharing their stories. Families attending these support groups realized 

that they were not alone and were able to support each 

other. Additional benefits the families received from 

attending these groups included the ability to share 

feelings, reduce anxiety, instill hope, and gain a better understanding of their family members’ injuries, 

medical treatments, and hospital procedures. PMP 

social workers also started a group for spouses and 

other family members of injured soldiers to allow for 

empathetic sharing and support. Groups are offered 
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Psychiatric Intervention for the Battle-Injured Medical and Surgical Patient Following Traumatic Injuries

twice weekly for spouses and other family members. 

Topics include fear, frustration, the need to protect the 

injured patient, depression, anger, education, coping 

with disabled spouses, and feelings of alienation and 

disappointment. 

Based on experiences at WRAMC, families are 

also seen by a provider in PMP in the hospital. Family members are assessed to determine how their 

children are adjusting, and how parents educate 

their children about the patient’s injury. Many of 

the techniques used with patients are often effective 

with families. Empathic listening, reassurance, and 

normalization are usually enough to help family 

members through their initial emotional response to 

the trauma. Staff members of the child and adolescent psychiatry service routinely see the families and 

assess their psychological response to the trauma. 

Education and support to the children is provided 

as needed. 

Case Study 16-4: BB is a 35-year-old male with BKAs 

from injuries sustained in OEF. The patient was flown to 

Germany and then air evacuated to WRAMC. Initially his wife 

was very supportive and attentive, but as the rehabilitation 

progressed, greater frustration was observed. Ambivalence 

about her role and problems with her in-laws became prominent. Therapeutic interventions were undertaken and as a 

result she began to understand the normalcy of her behavior. 

This allowed her to understand her conflict and recommit 

herself to the marriage. The wife was given the PMP phone 

number for follow-up. 

There has been relatively little research conducted 

regarding the psychological impact that working 

with trauma victims has on medical staff29,30 and 

the resources available to them. Taylor31 suggests 

that, on average, there are three major disasters per 

week worldwide. By responding to the needs of 

these disaster victims, nurses and clinicians may be 

placing themselves at risk of experiencing secondary 

trauma. Dyergrov32 suggests that among disaster 

workers, 80% are likely to experience emotional 

disturbances following the event, although only 3% 

to 7% are likely to experience significant psychological disruptions. 

The myth that those in the helping profession are 

somehow immune to the stresses experienced by those 

they help, and therefore are unaffected, was debunked 

by Bamber.33 Professionals, however, may be reluctant 

to seek help.34 To help destigmatize mental health, PMP 

has routine visits with the clinical staff. For example, 

groups have been established in which nurses share 

their conflicts. Mutual support is also received. Nurses 

are included as team members in PMP and visit the 

wards to work with the nursing staff. Education about 

stress and responses are given when appropriate, and 

formal lectures are also provided. 

Often overlooked is the stress the physicians experience, which may be exhibited during “curb-side” 

conversations.35 Colleagues at times are wary about 

intervening and invading another’s privacy. Providers 

are often concerned that their records or promotions 

will be affected if they seek help from the PMP. They 

also worry that others might see them as “weak.” For 

instance, a surgeon walking in the hallway asked, “Can 

I ask you a question about one of my colleagues? He 

is not sleeping and has been irritable. What can I give 

or tell him?” While the psychiatrist should respond 

as if the advice is for the surgeon’s colleague, there 

should be an awareness that the question may be about 

the surgeon. After maintaining the relationship, the 

surgeon could be asked if the conversation was really 

about a colleague. The psychiatrist could then offer to 

see the surgeon in the PMP office. In general, offering 

support and time to talk is necessary. 

Physicians are, at times, reluctant to talk about their 

fears and frustrations. Giving lectures to the medical 

staff and maintaining a professional, empathetic relationship are essential to medical and surgical providers 

seeing mental health as a resource for themselves. At 

times, it has been helpful to hold groups for physicians prior to their morning rounds, where support 

is offered and difficult cases are discussed. E-mail 

messages and notes about stress are also distributed 

via department channels. These approaches have been 

extremely helpful.

A similar approach has been undertaken with administration and command staff. Maintaining a close 

working relationship with command is imperative 

for the needs of the service and for its commander’s 

needs as well. Many forget that the commanders are 

under stress and may not have any outlet. Keeping 

them informed, as well as being available for their 

concerns, will help contribute positively to a successful approach. 

Last, but not least, the mental health providers also 

need support. Reinforcement of their skills and keeping them educated about providing new approaches 

is helpful. Maintaining a positive esprit de corps and 

sensitivity to each other’s needs also helps. Giving 

them time off and the use of humor, lunches, and 

dinners may also help. It is imperative that leaders 

keep an open door and be sensitive to the frustrations 

and countertransference issues of the providers. In 

SUPPORTING MEDICAL STAFF WHO CARE FOR THE MEDICALLY INJURED TRAUMA VICTIM
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Combat and Operational Behavioral Health

particular, this is important with younger physicians 

and other staff that may be deployed. Sensitivity to 

these concerns is incumbent upon members of the 

PCLS/PMP staff. 

SUMMARY

Physical injury as result of a trauma is an overwhelming experience that results in a life-changing 

event. Exposure to the trauma of war may result in 

psychiatric sequelae, but exposure to both physical and 

emotional conditions can have a geometric effect on 

psychiatric symptoms. Though most trauma patients 

adjust well and recognize that symptoms dissipate, 

others need psychiatric intervention. Based on past 

experiences, psychiatry staff at WRAMC developed 

an early intervention treatment plan for responding 

to injured soldiers. Traditional debriefing (classical 

incidence stress debriefing) interventions were not 

effective in this population. A new approach, under 

the umbrella of therapeutic intervention for prevention 

of psychiatric stress symptoms, was developed. This 

program entails intervening early without a formal 

consultation, destigmatizing mental health, adhering 

to a biopsychosocial approach, recognizing the importance of the therapeutic alliance using condensed 

aspects of traditional psychotherapeutic techniques, 

reinforcing patient assets, using relaxation or hypnotic 

techniques, prescribing appropriate pharmacology, 

and using empathic exposure. Though the goal is to 

avoid inappropriate pathologizing, treating psychiatric 

symptoms is necessary. 

In an attempt to destigmatize mental health, a subsection (PMP) of the psychiatry service was created. 

Other goals of the intervention are to decrease the 

effect of disabling psychiatric symptoms, facilitate a 

speedy recovery, initiate integration of trauma into 

a normal stream of consciousness, ease symptoms, 

teach mastery or control techniques, and recognize 

and treat psychiatric illnesses early. Being able to refer 

patients for treatment if required after they leave the 

hospital is also a major component of this intervention. 

The development of a program for combat casualties 

necessitates the inclusion of patients’ family members, 

hospital staff, and hospital leadership, as well as the 

mental health team serving this population. Besides 

the immediate positive therapeutic outcomes, a therapeutic alliance facilitates the acceptance of referrals by 

patients and family members upon discharge from 

the hospital. 

Finally, based on the experience at WRAMC, becoming a part of a trauma team and being seen as 

member of PMP further expedited intervention and 

allowed psychiatry assistance for the patient without 

the typical stigmatization. Walking rounds further 

solidified patients, family members, and staff seeing 

PMP service staff as members of the trauma team. A 

similar plan can be developed at any hospital treating 

large volumes of trauma patients.

REFERENCES

1. Wain HJ, Jacaard JT. Psychiatric intervention with medical and surgical patients of war. In: Ursano RJ, Norwood AR, 

eds. Emotional Aftermath of the Persian Gulf War: Veterans, Families, Communities, and Nations. Washington, DC: American 

Psychiatric Press; 1996: 415–442. 

2. Wain HJ, Grammer GG, Stasinos JJ, Miller CM. Meeting the patients where they are: consultation-liaison response to 

trauma victims of the Pentagon attack. Mil Med. 2002;167(9 suppl):19–21.

3. Wain HJ, Stasinos J. Response to bombing victims. Presentation at the State Department, Washington DC; 1999.

4. Wain HJ, Grammer G, Stasinos J, DeBoer C. Psychiatric intervention for medical surgical patients following traumatic 

injuries. In: Ritchie EC, Watson PJ, Friedman MJ, eds. Interventions Following Mass Violence and Disasters: Strategies for 

Mental Health Practice. New York, NY: Guilford Press; 2006: 278–298.

5. Weinstein EA. Disabling and disfiguring injuries. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, 

eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. Textbook of Military Medicine. Washington, DC: Department of the Army, 

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6. Furst SS, ed. Psychic Trauma. New York, NY: Basic Books; 1967.

7. Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163:1777–1783.
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8. Koren D, Norman D, Cohen A, Berman J, Klein EM. Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry. 2005;162(2):276–

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9. Ursano RJ, Norwood AR, eds. Emotional Aftermath of the Persian Gulf War: Veterans, Families, Communities, and Nations. 

Washington, DC: American Psychiatric Press; 1996.

10. Wain HJ, Grammer G, Cozza SJ, et al. Treating the traumatized amputee. Iraq War Clinician Guide. 2nd ed. Palo Alto, 

Calif: National Center for Posttraumatic Stress Disorder; 2004: 50–57. 

11. Lenehan GP. Emotional impact of trauma. Nurs Clin N Am. 1986;21(4):729–740.

12. Schreiber S, Galai-Gat T. Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress 

disorder. Pain. 1993;54:107–110.

13. Mohta M, Sethi AK, Tyagi A, Mohta A. Psychological care in trauma patients. Injury. 2003;34:17–25.

14. Grieger TA. Early predictors of later PTSD and depression in battle-injured soldiers. Paper presented at: American 

Psychiatric Association Meeting; May 24, 2006; Toronto, Canada.

15. Blum HP. Psychic trauma and traumatic object loss. J Am Psychoanal Assoc. 2003;51(2):415–432.

16. Horowitz MJ. Psychological processes induced by illness, injury, and loss. In: Milton T, Green C, Meagher R, eds. 

Handbook of Clinical Health Psychology. New York, NY: Plenum; 1982: 53–67.

17. Landsman IS, Baum CG, Arnkoff DB, et al. The psychosocial consequences of traumatic injury. J Behav Med. 

1990;13(6):561–581.

18. Armfield F. Preventing post-traumatic stress disorder resulting from military operations. Mil Med. 1994;159(12):739–

746.

19. Wain HJ, Bradley J, Nam T, Waldrep D, Cozza S. Psychiatric interventions with returning soldiers at Walter Reed. 

Psychiatr Q. 2005;76(4):351–360.

20. Wain HJ, Gabriel GM. Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries. J 

Am Acad Psychoanal Dyn Psychiatry. 2007;35(4):555–573.

21. 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;351:13–21.

22. Morgan CA 3rd, Krystal JH, Southwick SM. Toward early pharmacological posttraumatic stress intervention. Biol 

Psychiatry. 2003;53(9):834–843.

23. Brende JO. Combined individual and group therapy for Vietnam veterans. Int J Group Psychotherapy. 1981;31(3):367–

378.

24. Solursh DS. The family of the trauma victim. Nurs Clin North Am. 1990;25:155–162.

25. Brown V. The family as victim in trauma. Hawaii Medical J. 1991;50(4):153–154.

26. Flannery RB Jr. Treating family survivors of mass casualties: a CISM family crisis intervention approach. Int J Emerg 

Ment Health. 1999;1:243–250.

27. Alexander DA. The psychiatric consequences of trauma. Hosp Med. 2002;63:12–15.

28. Harvey C, Dixon M, Padberg N. Support group for families of trauma patients: a unique approach. Crit Care Nurse. 

1995;15(4):59–63.
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29. Robbins I. The psychological impact of working in emergencies and the role of debriefing. J Clin Nurs. 1999;8:263–

268.

30. Salston M, Figley C. Secondary traumatic stress effects of working with survivors of criminal victimization. J Trauma 

Stress. 2003;16(2):167–174.

31. Taylor SE. Adjustment to threatening events: a theory of cognitive adaptation. Am Psychol. 1983;38:1161–1173.

32. Dyergrov A. Caring for helpers in disaster situations: psychological debriefing. Disaster Manage. 1989;2:25–30.

33. Bamber M. Providing support for emergency service staff. Nurs Times. 1994;90(22):32–33.

34. Collins S. What about us? The psychological implications of dealing with trauma following the Omagh bombing. 

Emerg Nurse. 2001;8(10):9–13.

35. Wain HJ, Grammer G, Cozza SJ, et al. Caring for clinicians who care for traumatically injured patients. Iraq War Clinician Guide. 2nd ed. Palo Alto, Calif: National Center for Posttraumatic Stress Disorder; 2004: 62–65. 
259

Oral Health Effects of Combat Stress

Chapter 17

ORAL HEALTH EFFECTS OF COMBAT 

STRESS

GEORGIA dela CRUZ, DMD, MPH*; and PAUL COLTHIRST, DDS, MS†

INTRODUCTION

STRESS AND ORAL HABITS 

STRESS AND DENTAL HARD-TISSUE DISEASES

Dental Caries

Dental Erosion

Eating Disorders

Prevention

Treatment

STRESS AND PERIODONTAL DISEASES

Gingivitis

Periodontitis

Necrotizing Ulcerative Gingivitis

Prevention

Treatment

TEMPOROMANDIBULAR DYSFUNCTION

Prevention

Treatment

SUMMARY

*Lieutenant Colonel, Dental Corps, US Army; Office of The Surgeon General, US Army, 5109 Leesburg Pike, Suite 682, Falls Church, Virginia 22041 

† Major, Dental Corps, US Army; Dental Public Health, Department of Leadership Development, US Army Medical Department Center and School, 2250 

Stanley Road, Fort Sam Houston, Texas 78234-6100; formerly, Staff Officer, Dental Command Headquarters, Fort Sam Houston, Texas
260

Combat and Operational Behavioral Health

The average American, if not prepared, will cope with distress by eating more junk food, drinking more alcohol, smoking 

more cigarettes, taking more over-the-counter drugs, or under-the-counter drugs. We are a society that copes with distress 

with some form of oral behavior.

—JO Prochaska, PhD, developer of the Trans-Theoretical Model of Behavior Change 

(interview available at: mms://mediastream.buffalo.edu/content/nur/Part1a.wmv, accessed July 13, 2010)

INTRODUCTION

Approximately 5% to 10% of disease and nonbattle 

injuries among service members result from oral diseases 

or injuries.1

 The rate of dental emergencies is higher for 

units whose soldiers deploy with poor oral health. Oral 

diseases can cause impaired duty performance, work loss, 

restricted activity, poor diet, difficulty pronouncing words, 

inability to sleep, and excruciating pain. If they are not 

prevented or treated early, oral diseases can cause severe, 

life-threatening illness and may even require medical 

evacuation from theater. One recent study of US Army 

soldiers (regular Army, reserve, and National Guard) 

medically evacuated from the Central Command area 

of responsibility during 2003 and 2004 found that oral 

disease accounted for 42% of oral-facial evacuations.2

STRESS AND ORAL HABITS

Many Americans have a low level of health literacy 

and perceive oral health as less important and separate 

from general health.3

 Advances in dental research since 

the 1950s have shown that nearly all oral disease is 

preventable, yet many people continue to have a fatalistic view that “dental problems” are inevitable, of 

mysterious origin, and can be ignored as long as they 

are not unaesthetic or painful. Many service members 

join the military with these erroneous beliefs about oral 

diseases, viewing oral hygiene as mainly cosmetic and 

unnecessary during field training or operations. 

The primary causes of oral diseases during deployment are bacterial or viral infections that are initiated 

or exacerbated by the effects of poor oral hygiene, poor 

diet, or substance use. Self-care and hygiene habits are 

often the first things to break down when a soldier is 

deployed to an austere environment or experiences 

overwhelming stress. Many of these soldiers also turn 

to harmful oral habits such as using tobacco or eating 

and drinking nutrient-poor beverages and foods that 

are high in simple carbohydrates. 

According to the 2006 Department of Defense 

Survey of Health-Related Behaviors in the Reserve 

Component,4

 nearly 45% of service members admitted 

to eating as a way to cope with stress. Women were 

significantly more likely than men to eat as a coping 

strategy (51.8% vs 42.5%), while more men than women reported using cigars or smokeless tobacco (11.4% 

vs 3.6%). Reserve-component men and women were 

similar in their use of cigarettes (19.4%) and alcohol 

(24.9%) for coping. Results of the 2008 Department of 

Defense Survey of Health-Related Behaviors Among 

Active Duty Military Personnel5

 shows that men were 

significantly more likely to smoke cigarettes (28.6%) 

or drink alcohol (34.5%) for coping than were women 

(21.0% and 25.2%, respectively). Comparisons between 

the services show that more service members in the 

Marine Corps (39.9%), the Army (35.6%), and the Navy 

(33.7%) have a drink to cope with stress than do service 

members in the Air Force (25.0%). The same pattern is 

seen for smoking, with 33.2% of Marine Corps, 30.8% 

of Army, 27.9% of Navy, and 18.8% of Air Force service 

members lighting up a cigarette to cope with stress. 

Women, on the other hand, are still significantly more 

likely to use eating as a coping mechanism (56.2%) 

than are men (45.7%). Service members in the Navy 

and Army are significantly more likely to use eating as 

a coping mechanism (49.6% and 48.2%, respectively) 

than those in the Air Force or Marine Corps (45.1% 

and 44.5%, respectively). The combination of poor oral 

hygiene with harmful oral habits such as tobacco use 

and increased intake of refined carbohydrates causes 

oral disease (Figure 17-1). 

Figure 17-1. Plaque accumulation, tobacco staining, gingival inflammation, and generalized caries resulting from a 

combination of inadequate oral hygiene, tobacco use, and 

refined carbohydrate intake.
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Oral Health Effects of Combat Stress

Changes in diet during deployment or other stressful situations can cause service members to suffer from 

dehydration and micronutrient deficiencies that can 

lead to skin conditions, stress fractures, anemia, and 

other conditions.6–11 Because the oral epithelium has a 

high rate of cellular turnover, these same deficiencies 

can affect oral health by preventing the oral epithelium 

from renewing or repairing itself. As a result, the first 

signs of micronutrient deficiency can appear in the 

mouth, and may present as glossitis, angular cheilitis, 

stomatitis, and gingivitis. Undernutrition can also exacerbate oral infections and has been associated with 

increased progression of periodontal disease.12 Vitamins A, C, D, E, B2

, B6, B12, niacin, and folic acid, and 

minerals such as zinc, iron, magnesium, and calcium 

are essential for repairing oral epithelium, maintaining 

periodontal attachment, preventing demineralization 

of bones and teeth, and ensuring an adequate amount 

of saliva of sufficient quality to protect the oral cavity. 

In addition to enabling taste, mastication, and digestion, saliva is critical for defense against oral diseases. 

Compromised saliva composition or flow impairs or 

eliminates its antifungal, antiviral, and antibacterial 

activities and prevents it from protecting the teeth 

from demineralization by acids from oral bacteria or 

foods and beverages. 

STRESS AND DENTAL HARD-TISSUE DISEASES

When eating is used as a coping mechanism for 

stress, it often involves the frequent consumption 

of foods containing organic acids and simple carbohydrates such as sugar and starch. Between-meal 

consumption of these foods or beverages (ie, sports 

drinks, energy drinks, or soda) promotes dental caries 

and dental erosion. 

Dental Caries

 The majority of dental emergencies during deployment have been for conditions resulting from dental 

caries.13–18 Exact incidence of new disease is unknown, 

but a pilot study19 of soldiers deployed in Operation 

Iraqi Freedom for 6 months during 2003 found that 

the number of carious lesions increased by 156%, and 

the severity of disease, as measured by the number 

of tooth surfaces involved, increased by 183% over 

predeployment statistics. 

Dental caries is caused when poor oral hygiene 

allows uncontrolled growth of bacteria in dental 

plaque on tooth surfaces (Figure 17-2). The bacteria 

rapidly metabolize the simple carbohydrates (starches 

or sugars) in the diet into destructive acids (lactic acid). 

Fermentable carbohydrate metabolism supports the 

colonization of more bacteria on the tooth surface, 

further increasing the amount of acid produced. Following exposure to fermentable carbohydrates, plaque 

pH falls below 5.5, the critical pH for maintaining the 

structural integrity of the mineralized dental tissue. 

It can take 30 to 40 minutes for the pH to rise again, 

depending on the flow rate and buffering capacity 

of the individual’s saliva. As a result, the amount of 

bacterial acid produced in any 24-hour period mirrors 

the frequency and duration of exposure to fermentable 

carbohydrates more closely than the total amount of 

carbohydrate consumed. 

Starches do not directly serve as substrate for oral 

bacterial fermentation. Starch granules in grains, vegetables, potatoes, and beans are damaged when they 

are subjected to heat and mechanical forces, producing 

a gelatinized starch. This starch is further broken down 

by salivary and bacterial amylases into sucrose, maltose, and maltotriose—substances that are available 

for bacterial acid production.20 As a result, untreated 

whole grains and raw vegetables have lower cariespromoting potential than heat-processed foods like 

white breads, crackers, chips, snacks, and dry cereal. 

Foods that contain sugar plus starch destroy dental 

enamel more rapidly than pure sugar foods because 

the starch acts like digestible glue, keeping the sugar in 

close contact with the tooth surface for longer periods 

of time. Teeth that have low levels of fluoride in the 

enamel are more vulnerable to these acids, and decay 

can begin and progress quite rapidly. Without regular 

exposure to fluoride, sugar consumption is a strong 

indicator of caries risk.21

Figure 17-2. Extensive accumulation of bacterial plaque after 

cessation of oral hygiene. Gingiva is inflamed and several 

carious lesions are evident. 

Photograph: Courtesy of Captain Andrew Marshall, US 

Army Dental Corps.
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Combat and Operational Behavioral Health

Dental Erosion

Dental erosion, or erosive tooth wear, is described 

as “the loss of dental hard tissue either through 

chemical etching and dissolution by acids of nonbacterial origin or by chelation.”22(p243) The prevalence of 

dental erosion is increasing, particularly in younger 

populations.23,24 Nonbacterial acids that cause erosion 

primarily come from two sources: gastric acids or diet. 

Caffeinated sodas, sports drinks, and energy drinks are 

commonly used in theater for hydration, to maintain 

alertness, or for simple enjoyment. These flavored 

beverages often contain polybasic organic acids such 

as citric acid, phosphoric acid, malic acid, and tartaric 

acid. Popular beverages that fall into this category 

include soft drinks, sports drinks, energy drinks, and 

sweetened, bottled tea blends. Other types of acidic 

drinks include apple or citrus fruit juice. Acidic foods 

include citrus, pineapple, and sour candies. Any of 

these acidic foods and beverages can accelerate the 

progression of dental caries. Organic acids accelerate 

the progression of decay by chemically eroding the 

dental enamel25 (Figure 17-3). Polybasic acids have a 

unique buffering capacity and can maintain an acidic 

pH even with marked dilution. This high titratable acid 

level multiplies the actual number of hydrogen ions 

available for interaction with the tooth surface, and 

is thought to be an important reason for their erosive 

properties. The chemical structure of polybasic organic 

acids also gives them the ability to chelate calcium at 

higher pHs, so they can erode dental enamel even in 

a neutral environment.26

Exposure to gastric acids is caused by either gastroesophageal reflux disease (GERD) or eating disorders that involve self-induced vomiting. Exposure to 

gastric acids is one of the most destructive processes 

that can affect the teeth. Stomach acids demineralize 

the outer layers of tooth enamel, leaving behind the 

protein matrix, which is then easily removed with 

brushing. GERD is the most common gastrointestinalrelated diagnosis given during office visits, and affects somewhere between 10% to 20% of the Western 

population.27 The disorder causes erosion of the lingual 

and occlusal surfaces of the teeth, affecting the posterior teeth most severely. In the early stages, affected 

teeth exhibit a smooth, glazed appearance. Damage 

generally progresses to the development of a “dished 

out” appearance and the exposure of the dentin layer 

(Figure 17-4). Over time the affected teeth can become 

weakened and may develop thermal sensitivity.28 Patients with GERD are usually prescribed proton pump 

inhibitors and must avoid eating certain foods, as well 

as sleeping within a few hours of eating, exercising, 

or bending over. Disruption of dietary or medication 

routines by high operations tempo or combat situations may cause recurrence of GERD symptoms and 

repeated exposure of the dentition to gastric acids. 

Figure 17-3. Generalized demineralization and loss of 

enamel on the facial surfaces of teeth just above the gingival 

margin in the absence of gingival inflammation is often an 

indication of frequent use of sugared beverages that contain 

organic acids.

Photograph: Courtesy of Captain Andrew Marshall, US 

Army Dental Corps.

Figure 17-4. Erosion of enamel and exposure of the dentin 

layer in a patient with gastroesophageal reflux disease. 

Photograph: Courtesy of Bennett T Amaechi, Associate Professor and Director of Cariology, University of Texas Health 

Science Center at San Antonio.
263

Oral Health Effects of Combat Stress

Eating Disorders

In most cases, dental hard-tissue damage is unlikely 

to signify anorexia or bulimia, except in those with 

an already established diagnosis who experience a 

recurrence under stress. Oral manifestations associated with eating disorders may include one or more 

of the following29:

	 • smooth erosion of the enamel or perimylolysis,

	 • traumatized oral mucosal membranes and

pharynx,

	 • variations in the periodontium,

	 • enlargement of the parotid or submandibular

salivary glands,

	 • xerostomia (dry mouth due to reduced salivary

flow), and

	 • dental caries.

When vomiting occurs repeatedly over time, 

tooth enamel becomes thin and eroded, resulting in a 

smooth, glassy appearance. In the case of eating disorders, these changes are most commonly seen on the 

lingual, occlusal, and incisal surfaces of the maxillary 

teeth. When confined to these areas, the condition is 

termed “perimylolysis” (Figures 17-5 and 17-6). These 

areas of the teeth are more susceptible to erosion due 

to the combined chemical and mechanical effects of 

regurgitated gastric acids and their retention on the 

surface of the tongue. Erosion is usually not clinically 

detectible until vomiting behavior has occurred for 

about 2 years. However, the daily frequency of selfinduced vomiting is one of the main determinants of 

the rate of progression and degree of dental erosion. 

As is the case with GERD, erosion may eventually affect the occlusal and facial surfaces of teeth, resulting 

in exposure of the underlying dentin and decreased 

vertical dimension (overclosure; Figure 17-7). 

Patients with eating disorders may also develop 

diet-caused dental erosion in other areas of the 

teeth. Several studies have reported that people with 

restrictive anorexia tend to favor highly acidic, lowFigure 17-5. Erosion of the lingual, occlusal, and incisal surfaces of the maxillary teeth in a patient with bulimia. 

Photograph: Courtesy of cosmetic dentist Dr Craig Mabrito, 

Houston, Texas.

Figure 17-6. Translucency of the maxillary central incisors 

due to erosion in a patient with bulimia.

Photograph: Courtesy of cosmetic dentist Dr Craig Mabrito, 

Houston, Texas.

Figure 17-7. Occlusal wear and dentin exposure due to erosion in a patient with bulimia. 

Photograph: Courtesy of cosmetic dentist Dr Craig Mabrito, 

Houston, Texas.
264

Combat and Operational Behavioral Health

calorie foods, particularly raw citrus.29–31 If exposure 

is frequent, these foods tend to cause erosion on the 

buccal or facial surfaces of the tissue, in contrast to 

perimylolysis (Figure 17-8).

Stomach acids may irritate the gingival tissue if 

exposure is frequent, but controlled studies of gingival 

inflammation in patients with eating disorders have 

produced conflicting results.32,33 A more common cause 

of gingival inflammation in patients with eating disorders appears to be a lack of interest in oral hygiene, 

which can accompany depression. Also, alveolar bone 

support of the teeth may be compromised in some 

patients. Patients with severe disease experience early 

bone loss or osteoporosis as a result of changes in their 

estrogen and cortisol levels, and are probably at risk 

for accelerated alveolar bone loss.

Trauma to the oral mucous membranes or the 

oropharynx may also occur in patients who engage in 

binge eating or self-induced vomiting. The rapid ingestion of food associated with binge eating may cause 

trauma, as may the force of regurgitation. Objects used 

to induce vomiting may also injure the soft palate.

Salivary gland enlargement is seen in approximately 10% to 50% of patients who binge eat and purge 

by vomiting. The gland most frequently involved is 

the parotid gland, and swelling usually occurs 2 to 6 

days after bingeing/purging behavior. The enlargement often becomes persistent as the eating disorder 

progresses. The swelling may give a square, widened 

appearance to the mandible. However, the involved 

Figure 17-8. Erosion of the facial enamel and exposure of 

the underlying dentin. 

Photograph: Courtesy of Bennett T Amaechi, Associate 

Professor and Director of Cariology, Department of Community Dentistry, University of Texas Health Science Center 

at San Antonio.

gland is usually soft and painless upon palpation and 

has a patent duct, normal salivary flow, and an absence 

of inflammation, both clinically and histologically. 

Other histological characteristics include greater acinar 

size, increased secretory granules, fatty infiltration, 

and fibrosis. The exact cause of the enlargement is not 

known, but individuals who purge by methods other 

than vomiting do not experience salivary gland enlargement. Hypothesized reasons include autonomic 

stimulation of the glands by activation of the taste 

buds or cholinergic stimulation of the glands during 

vomiting.29

Antidepressants, which are frequently used to 

treat anorexia nervosa, usually cause xerostomia, 

and patients with xerostomia are more susceptible to 

developing carious lesions. Risk for dental caries may 

also be increased in patients whose bingeing episodes 

frequently involve high-calorie, high-carbohydrate 

foods. As a general rule, however, patients with eating disorders who primarily practice restriction or 

self-induced vomiting do not experience an increase 

in caries rates.29

Prevention

Nearly all dental caries is preventable with the use 

of good personal health habits (proper diet and nutrition, oral hygiene, and avoiding substance use). Daily 

oral hygiene is essential for the removal of harmful microorganisms and maintenance of oral health. Soldiers 

must be trained in proper field oral hygiene. Brushing 

after meals with fluoride toothpaste is the most effective caries prevention method. Soldiers who have been 

diagnosed with GERD should attempt to maintain or 

reestablish medication and dietary restrictions. 

To prevent tooth decay, soldiers must use combat 

stress control techniques to help cope with the stresses 

of deployment, rather than relying on harmful dietary 

habits. Techniques such as talking, exercise, quick relaxation, deep relaxation, and cognitive exercises can 

all be used to relieve combat stress without harming 

oral health.34,35

Use of gum or mints that contain xylitol as the first 

ingredient, three to five times a day, between meals 

or after snacks also prevents dental decay.36 Xylitol 

is a naturally occurring sweetener found in fruits, 

vegetables, and some other plants. It has about half 

the calories of sugar but is just as sweet. Xylitol prevents harmful bacteria from using starchy or sugary 

food particles to create acids that cause dental caries. 

It works synergistically with fluoride to prevent decay and promote remineralization of damaged tooth 

structure. Xylitol gum is distributed in theater dining facilities in the accessory pack of the MRE (meal, 
265

Oral Health Effects of Combat Stress

ready-to-eat). Chewing xylitol gum for about 5 minutes 

regularly after meals and snacks should help prevent 

decay. 

For both oral health and weight management, free 

sugar intake from foods and beverages should be less 

than 10% of energy intake (less than 41 g/day).37 On 

average, people who consume over 55 grams of sugar 

a day are at high risk for dental caries. The frequency 

of free sugar intake should be less than five times a 

day. Cariogenic foods and beverages can be combined 

with protective foods (cheese, tea, protein, high-fiber 

foods, etc) to prevent dental caries.38 Soldiers should be 

encouraged to drink fluoridated water for hydration 

between meals, and limit consumption of foods and 

drinks that contain harmful polybasic organic acids 

to mealtimes. Soldiers can also mitigate the effects of 

foods and beverages that have a high organic-acid or 

refined-carbohydrate content by rinsing their mouths 

with water after ingestion. 

Patients who experience xerostomia are at increased 

risk for dental caries, and should be advised to use artificial saliva preparations to lubricate the oral tissues, 

avoid cariogenic foods or drinks, and use sugarless or 

xylitol-containing candies or mints. Sucking on these 

items can stimulate increased salivary flow, which may 

buffer oral acids. Increased saliva flow also increases 

the concentration of calcium, phosphate, and hydroxyl 

ions, which may aid remineralization of early carious 

lesions. Xylitol may also be beneficial because of its 

bacteriostatic properties. 

Treatment

Patients should be referred to a dentist for treatment 

of dental caries. Soldiers who experience recurrence of 

GERD symptoms for any reason should be seen by a 

dentist as soon as possible. To prevent chemical damage to dental hard tissues by stomach acids, dentists 

may fabricate a thin plastic stent that covers the dentition. The stent is to be worn at night or at times when 

reflux symptoms are most likely to occur. Early referral 

of eating-disorder patients to a psychiatric therapist 

can reduce the risk of further damage to the teeth and 

the oral cavity. Patients should be referred to a dentist 

for an evaluation of dental erosion, salivary flow rate, 

and oral mucosa condition. Comprehensive dental 

procedures should not be performed until vomiting 

behavior is significantly improved or the patient has 

recovered completely; until then, proper home care is 

the best treatment.

All patients whose oral cavity is exposed to gastric 

acid should be counseled on several important principals of home care29,33: 

	 •	 Toothbrushing should never be performed

immediately after the mouth is exposed to 

stomach acid because demineralized enamel 

has been shown to be vulnerable to removal 

by abrasive forces.

	 •	 Following acid exposure, patients should

rinse with a buffering or alkaline solution 

to neutralize the acid and allow the saliva to 

remineralize the teeth, thereby reducing damage from demineralization. Options include 

0.5% sodium fluoride sodium bicarbonate in 

water, liquid antacids, slightly alkaline mineral water, or plain water. 

	 •	 If acid exposure happens repeatedly on a daily

basis, a neutral sodium fluoride mouth rinse 

or prescription fluoride gel may be necessary 

to prevent dental erosion. 

	 •	 Acidic foods and drinks should be avoided,

including citrus, pineapple, and lemon 

candies; apple or citrus fruit juice; alcohol 

(particularly white wine); and drinks that 

contain polybasic organic acids such as citric, 

phosphoric, malic, and tartaric.10,11

	 •	 Patients who experience xerostomia should

be advised to use artificial saliva preparations 

to lubricate the oral tissues, avoid cariogenic 

foods or drinks, and use sugarless or xylitolcontaining candies or mints. Sucking on these 

items can stimulate increased salivary flow, 

which may buffer oral acids. 

Stress and Periodontal Diseases

Gingivitis

Neglect of oral hygiene is common in stressful operational environments. Failure to properly remove 

plaque from the teeth and gums for a week or more 

usually results in the development of gingivitis in 

response to bacteria (Figure 17-9). The previously mentioned evaluation of soldiers deployed to Iraq showed 

that these service members experienced a significant 

worsening of their average periodontal screening and 

recording scores after 6 months of deployment.19 If left 

untreated, gingivitis associated with tenderness and 

bleeding gums may discourage soldiers from performing normal oral hygiene. 

Acute presentations of gingivitis can be managed by 

improved oral hygiene and the use of an antimicrobial 

mouth rinse. Soldiers with extreme gingival tenderness 

may be encouraged to reestablish oral hygiene proce-
266

Combat and Operational Behavioral Health

Figure 17-9. A case of gingivitis.

Photograph: Courtesy of Colonel Dave Reeves, US Army 

Dental Corps, Consultant to The Surgeon General for Periodontology, and Chief, Periodontics, Fort Hood, Texas.

dures using viscous lidocaine on their toothbrushes 

rather than a dentifrice.

Periodontitis

Untreated gingivitis may progress to periodontal 

disease (Figure 17-10). The risk of periodontal disease 

has been studied for both men and women (Figure 17-

11), and several risk factors have been identified,39–42

such as gram-negative anaerobic bacteria, smoking, 

diabetes mellitus, a genetic tendency to produce increased levels of proinflammatory mediators, and use 

of hormone-mimicking medications. 

Periodontitis has been described as “a complex disease in which disease expression involves 

intricate interactions of the oral biofilm with the 

host immunoinflammatory response and subsequent alterations in bone and connective tissue 

homeostasis.”43(p1560) Classification of periodontal 

disease is based on two clinical factors: inflammation and loss of supporting tissue.44 Inflammation 

features typically seen are redness, edema, and 

bleeding on probing. Loss of supporting tissue 

is usually measured as increased probing depth, 

decreased attachment level, or alveolar bone loss. 

Even with the presence of periodontal pathogens, the 

pathogenesis of periodontitis cannot occur without 

immune and inflammatory responses, which are 

in turn shaped by both intrinsic (eg, genetics, age, 

systemic disease) and extrinsic (eg, toxins, tobacco, 

plaque) host factors45 (Figure 17-12). How much bone 

loss occurs depends largely on the level of inflammatory mediators present in gingival tissue. 

Alveolar bone destruction occurs after activation 

of the pathogenesis pathways and the penetration of 

inflammatory mediators deep into gingival tissue, near 

alveolar bone. Several proinflammatory cytokines are 

responsible for bone resorption, such as interleukin-1, 

-6, -11, and -17; tumor necrosis factor-α; leukemia 

inhibitory factor; and oncostatin M.45 When an inflammatory response occurs, periosteal osteoblasts 

are stimulated by proinflammatory cytokines and 

other mediators. Once the osteoblasts are stimulated, 

Figure 17-10. Gingival erythema, edema, and recession in 

conjunction with blunting of the interdental papilla are 

evident in this patient with periodontal disease. 

Photograph: Courtesy of Lieutenant Colonel Georgia dela 

Cruz, US Army Dental Corps, Falls Church, Va.

Female Male

Age Group

25–34 35–44 45–54 55–64 65–74 75+

40

35

30

25

20

15

10

5

0

Percentage of People With Disease

Figure 17-11. Prevalence of periodontal disease. Males are 

more likely than females to have at least one tooth site with 

6 mm or more of periodontal loss of attachment.

Adapted from: US Department of Health and Human Services. The Surgeon General’s Report on Oral Health. Washington, 

DC: USDHHS; 2000: 65.
267

Oral Health Effects of Combat Stress

changes in the overall cell surface occur that increase 

the expression of a protein called “receptor activator 

of nuclear factor-κ B ligand (RANKL).”45 RANKL can 

be found on the surface of many other cells, including fibroblasts, T lymphocytes, and B lymphocytes. In 

the noninflammatory state, there is a balance between 

osteoclastic and osteoblastic processes determined by 

the proportion of RANKL. However, during an active 

inflammatory response, the proinflammatory mediators increase the expression of RANKL while at the 

same time decreasing other surface protein production 

in osteoclast precursor cells, triggering the formation 

of mature osteoclasts. Alveolar bone resorption by 

these osteoclasts leads to destruction of the supporting structures of the teeth, which, in the absence of 

intervention, leads to tooth loss.45

Women’s risk of developing gingival inflammation 

or periodontal problems may be increased by the 

higher levels of estrogen and progesterone associated 

with the menstrual cycle and use of oral contraceptives.46,47 Gingival tissues may become tender and 

swollen, and may bleed during brushing. Human 

gingiva has specific high-affinity estrogen receptors 

and can function as an estrogen target tissue. The 

stratified squamous epithelium of the oral mucosa 

Environmental and Acquired Risk Factors

(poor oral hygeniene, subgingival calculus, tobacco 

smoking)

Connective 

tissue and bone 

metabolism

Clinical signs of 

disease 

initiation and 

progression

Host Factors

Genetic risk factors, age, systemic disease

Antigens,

lipopolysaccharides, 

other virulence 

factors

Antibodies

PMNs

Cytokines

Prostanoids

Matrix 

metalloproteinases

Host immunoinflammatory 

response

Microbial 

challenge

(gram-negative 

anaerobic 

bacteria)

Figure 17-12. Model of periodontitis depicting the multifactorial nature of periodontal disease. A change in any one factor 

can result in clinical signs of the disease. 

PMN: polymorphonuclear leukocytes

Data sources: (1) Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction. Periodontology 2000. 

1997;14:9–11. (2) US Department of Health and Human Services. The Surgeon General’s Report on Oral Health. Washington, DC: 

DHHS; 2000. (3) Gluck G, Morganstein W. Jong’s Community Dental Health. 5th ed. St Louis, Mo: Mosby; 2003: 185–187.

and gingiva responds to ovarian hormone levels, with 

alterations in maturation and keratinization. Estrogen 

is involved in the regulation and maintenance of collagen synthesis and has been associated with gingival 

hyperplasia.

Estrogen and progesterone also promote changes 

in the microcirculatory system of the gingiva. The 

endothelial cells and pericytes of the venules swell, 

granulocytes and platelets adhere to the vessel walls, 

microthrombi form, and perivascular mast cells are 

disrupted.46 The microvasculature proliferates and 

becomes more permeable, causing gingival edema 

and increasing the flow of gingival crevicular fluid. 

The resulting fluid also contains elevated levels of 

sex hormones, polymorphonuclear leukocytes, and 

increased levels of prostaglandin E2. Anaerobic bacteria 

(eg, Bacteroides melaninogenicus, Prevotella intermedia, 

and Porphyromonas gingivalis) may be present and 

proliferate under these conditions.

The increase in bacteria production is a result of 

two factors: (1) some bacteria associated with gingival 

inflammation are able to metabolize steroid hormones 

and use them for energy production, thereby directly 

increasing their numbers; and (2) increased estrogen 

and progesterone levels also depress T-cell responses 
268

Combat and Operational Behavioral Health

and decrease neutrophil chemotaxis and phagocytosis. 

This impaired immune response allows bacteria in the 

gingival crevice to proliferate without restraint.

Proliferating bacteria can cause increased levels of 

bacterial endotoxins, which can increase inflammation 

and trigger bone loss from the periodontium. Oral 

contraceptives, especially those containing progesterone, have been associated with an increased risk of 

periodontal bone loss.47,48 No studies have been done 

on Depo-Provera (medroxyprogesterone acetate [the 

Upjohn Company, Kalamazoo, Mich]) and periodontal 

bone loss.

Necrotizing Ulcerative Gingivitis

When soldiers are placed under severe stress, increased cortisol levels can compromise immune function. Under these conditions, gingivitis can progress 

to acute necrotizing ulcerative gingivitis, an extremely 

painful inflammation accompanied by necrosis of the 

interdental gingiva and a fetid odor (Figure 17-13).

Prevention

Noncommissioned officers should ensure that the oral 

hygiene routine of all troops includes the following:

	 •	 toothbrushing, once daily at a minimum, preferably twice daily, with fluoride toothpaste to 

prevent dental caries and gingival problems;

	 •	 flossing daily, which is also effective in preventing gingival or periodontal problems; 

and

	 •	 rinsing several times a week with an antimicrobial mouthwash containing thymol 

or chlorhexidine gluconate (for those with 

chronic periodontal conditions).

Treatment

Acute presentations of necrotizing periodontitis 

should be referred to a dental professional. In addition 

to reestablishing oral hygiene procedures with viscous 

lidocaine hydrochloride and an antimicrobial mouthwash, acute periodontal disease usually requires the 

removal of plaque-retentive factors, such as calculus 

or defective restorations, from the crown and root 

surfaces of the teeth. 

Stress can produce temporomandibular dysfunction 

(TMD) symptoms when it causes patients to clench 

or brux their teeth more frequently, either at night or 

during the day. Masticatory muscle spasms and pain 

may result. Other known causes of TMD symptoms 

include injury to the temporomandibular joint from 

blunt force to the face, arthritis, joint overload, or 

repetitive loading (usually because of bruxism or 

grinding of the teeth). 

Although the overall incidence of the condition is 

low, TMD affects both men and women. According 

to a 1994 triservice recruit comprehensive oral health 

survey,49 approximately 3.5% of female recruits were 

found to have some type of orofacial pain or limited 

mandibular movement sufficient to require referral 

or treatment for TMD. The incidence for women was 

significantly higher than that for men (1.5%). Civilian 

studies50,51 have consistently shown an increased incidence of TMD (1.5- to 2-fold higher) in women compared with men, and most patients treated for TMD

are women (80%). Age plays a strong role in women. 

Symptoms begin after puberty and peak during the 

reproductive years, with prevalence highest among 

women aged 20 to 40. Gender and age distributions of 

TMD expression strongly suggest a link to the female 

hormonal system. Some studies51–53 have shown that 

women who use oral contraceptives may be at increased risk compared with women who do not. TMD

pain levels increase during menstruation.54,55 Current 

studies investigating the relationship of increased risk 

with the presence of estrogen receptors in the temporomandibular joint structures (particularly the synovial 

Figure 17-13. Gingival edema, erythema, and cratering of the 

interdental papilla and purulent exudate are visible in this 

patient with acute necrotizing ulcerative gingivitis. 

Photograph: Courtesy of Dr Carl Allen, Professor and Director, Oral and Maxillofacial Pathology, Ohio State University 

College of Dentistry.

Temporomandibular Dysfunction
269

Oral Health Effects of Combat Stress

lining cells, the articular disc, and the chondrocytes) 

have produced contradictory results.56,57

Prevention

TMD can be prevented by avoiding opening the 

mouth too wide during eating or yawning, and avoiding frequent, prolonged masticatory activity associated 

with pervasive oral habits such as jaw clenching, gum 

chewing, cheekbiting, or nailbiting.

Treatment

Acute open lock (an internal joint derangement 

that prevents closing the mouth) can cause extreme 

pain and should be immediately referred to a dental 

provider for reduction of the dislocation. If the provider is unable to reduce the dislocation due to severe 

muscle spasm or extreme pain, then the patient must 

be referred to an oral and maxillofacial surgeon for 

sedation prior to reduction of the dislocation. An acute 

closed lock (where the mouth is prevented from opening) warrants an immediate referral for evaluation by 

an oral and maxillofacial surgeon or an orofacial pain 

specialist because early intervention beyond conservative therapy (such as arthrocentesis) may be necessary. 

For all other cases, conservative therapy for an acute 

condition should focus on reducing joint loading and 

inflammation. Attempts should be made to relax the 

muscles as much as possible. The patient should use 

ice or cold packs for the first 24 to 48 hours, adhere 

to a soft diet, and avoid gum chewing. After the first 

24 to 48 hours, the patient should apply moist heat 

several times a day. Gentle stretching exercises of the 

mastication muscles should be performed after heat 

application. The patient should continue to avoid gum 

chewing and adhere to a soft diet for several days to 

limit masticatory activity. 

Pharmacological interventions should begin as 

soon as possible with analgesics, preferably nonsteroidal antiinflammatory analgesics. Patients with 

more severe TMD may also require short-term use of 

skeletal muscle relaxants. Because low-dose tricyclics 

improve sleep, they may be effective in decreasing 

pain from nocturnal bruxism. If symptoms recur, the 

patient should initiate moist heat application, stretching therapy, and use of nonsteroidal antiinflammatory 

drugs. Normally, this treatment prevents the development of more severe problems. 

Ideally, TMD patients should be referred to a dentist 

for a comprehensive evaluation of contributing factors 

from diet, occlusion, oral habits, and stress. However, 

because no national standards exist for TMD curricula 

at the predoctoral level, finding a knowledgeable practitioner may be difficult.58 Initial evaluation for acute 

TMD pain from trauma must rule out fractures, tears, 

and articular disc displacement. Examination of the occlusion and oral habits may show whether the patient 

would benefit from wearing an appliance (eg, a bite 

plate) every night to prevent or minimize the effects 

of jaw movements during sleep. 

If symptoms do not resolve, patients should be 

referred to an orofacial pain specialist, who can 

determine if the patient would also benefit from 

cognitive-behavioral skills training and biofeedback 

(eg, relaxation techniques) to decrease muscle jaw tension, decrease stress, increase awareness, and prevent 

diurnal tooth grinding or clenching incidents. Studies 

have shown that early intervention using a biopsychosocial approach is effective in reducing TMD pain and 

decreasing the progression of the disorder to chronic 

stages, as well as decreasing depression, increasing 

positive coping behaviors, and significantly reducing 

TMD-related healthcare costs.59,60

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56. Campbell JH, Courey MS, Bourne P, Odziemiec C. Estrogen receptor analysis of human temporomandibular disc. J 

Oral Maxillofac Surg. 1993;51:1101–1105. 

57. Abubaker AO, Raslan WF, Sotereanos GC. Estrogen and progesterone receptors in temporomandibular joint discs of 

symptomatic and asymptomatic persons: a preliminary study. J Oral Maxillofac Surg. 1993;51:1096–1100.

58. Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: a survey of US and Canadian dental 

schools. J Am Dent Assoc. 2007;138:231–237.

59. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E 3rd. Efficacy of an early intervention for patients with acute 

temporomandibular disorder-related pain: a one-year outcome study. J Am Dent Assoc. 2006;137(3):339–347.

60. Stowell AW, Gatchel RJ, Wildenstein L. Cost-effectiveness of treatments for temporomandibular disorders: biopsychosocial intervention versus treatment as usual. J Am Dent Assoc. 2007;138:202–208.
275

Resetting the Force: Reentry and Redeployment

Chapter 18

RESETTING THE FORCE: REENTRY AND 

REDEPLOYMENT

KRIS A. PETERSON, MD*; and MICHAEL E. DOYLE, MD†

INTRODUCTION

BACKGROUND

REENTRY CHALLENGES BY POPULATION

Regular Army

National Guard and Army Reserve

Family Members of Regular Army, Reservists, and National Guard Members

REDEPLOYMENT PROGRAMS

SUMMARY

ATTACHMENT: HEALTH ASSESSMENT FORMS

*Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, Madigan Army Medical Center, Tacoma, Washington 98431; formerly, Child and 

Adolescent Psychiatry Consultant to The Surgeon General, US Army 

†

Lieutenant Colonel, Medical Corps, US Army; Deputy Commander for Clinical Services, USAMEDDAC West Point, 900 Washington Road, West 

Point, New York 10996

This chapter was previously published as: Doyle ME, Peterson KA. Re-entry and reintegration: returning home after combat. Psychiatric 

Quarterly. 2005;76:361–370. Adapted with permission of Springer. 
276

Combat and Operational Behavioral Health

The capacity of Soldiers for absorbing punishment and enduring privations is almost inexhaustible so long as they believe 

they are getting a square deal, that their commanders are looking out for them, and that their own accomplishments are 

understood and appreciated.

—General Dwight D Eisenhower, 1944

INTRODUCTION

Soldier life in the US Army is structured by the 

cycles of predeployment, deployment, and postdeployment. Management of behavioral health in each 

phase is a continuous process, with features unique to 

each phase. Soldiers redeploying from combat to their 

home units face a number of stressors that may affect 

postdeployment adjustment. Among the factors that 

influence stress levels are the nature of the conflict, 

level of national support, family support and family 

stability, and the soldier’s component (regular Army, 

National Guard, or US Army Reserve). 

“Resetting the force”—reentry, reintegration, recovery, and reconstitution—has become an essential 

operation of the postdeployment phase of the cycle. 

Resetting the force can be thought of as personal or 

soldier maintenance. Just as equipment needs to be 

repaired or refurbished after deployment, and maintained throughout its use to prevent breakdown, so, 

too, do soldiers need ”maintenance” in the form of support before, during, and after deployment. This chapter will look at processes developed by the military 

over the course of the global war on terror (GWOT) 

to reset the force by assisting soldiers in reentry and 

reintegration. 

Resetting the force includes many concepts; for 

example, implicit in maintaining a ready deployable 

force is making soldiers available for contingency 

operations while simultaneously sustaining garrison operations. Early inclusion of families and 

communities into the planning for reentry and 

reintegration, normalization (nonmedicalization 

of distress), destigmatization of behavioral health 

problems, and assistance for behavioral health 

needs, including easy access to a behavioral health 

professional and education of soldiers and families 

on resources and benefits, are other essential elements in this process. 

The military recognizes resetting the force as a vital 

part of the return to readiness, as important as preparing soldiers for deployment. This concept acknowledges that recovery after a deployment maintains 

the soldier and is part of the preparation process for 

future deployments. Soldiers recover and return to 

combat readiness as the next round of deployments 

approaches. The effectiveness of the reintegration 

process strongly affects the state of individual and unit 

readiness. Thus, stakeholders include the soldier; the 

soldier’s family, unit, and local community; the Army; 

and all of US society. These identified stakeholders 

provide context to resetting the force and shape its 

outcome. 

 Recognizing this, Army leadership (under G1), 

in concert with behavioral health professionals, developed an intensive program to reach all returning 

soldiers—active duty, reserve, and National Guard—

who were mobilized and deployed to combat zones. 

The Deployment Cycle Support Program (DCSP) directs as much attention to the postdeployment phase as 

the Army historically has to the actual deployment and 

run-up to it. The DCSP brings balance to the varying 

soldier, unit, and family needs within the deployment 

cycles or continuum. 

Background

Accounts of wars throughout recorded history 

frequently include descriptions of the physical and 

emotional suffering of the combatants. The GWOT, 

Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) will likely continue this trend. Scientific study of the emotional and psychiatric impact 

of combat operations is extensive up to and including 

the Persian Gulf War. Publications since then include 

numerous reports on peacekeeping operations1,2 and 

a recent article on symptoms of posttraumatic stress 

disorder in OIF/OEF soldiers and marines.3

For OIF/OEF, reentry—or returning home after 

combat—and reintegration have received attention 

in the media, but rigorous scientific study has not 

yet occurred. Moreover, the media attention has been 

primarily negative: individual incidents of criminal 

behavior with deployment experience implicated as 

the cause, an anticipated epidemic of posttraumatic 

stress disorder as thousands of service members demobilize following the war, and problems with soldiers’ 

follow-up medical care, infrastructure at major medical 

centers, and the physical disability system. 

In the 1995 textbook War Psychiatry,

4

 Faris Kirkland 

discusses at length the impact on soldiers primarily, 

and on society to a lesser extent, of troops returning 

home after conflict. Kirkland divides US involvement 
277

Resetting the Force: Reentry and Redeployment

in numerous conflicts and armed interventions into 

three categories: major wars, limited actions, and 

rapid-deployment operations. Major wars are those 

defined by large-scale mobilizations against a defined, 

“evil” and dehumanized enemy, fought by “champions 

of the people” for the greater good, in which reentry 

of the combatant into civilian life is accomplished by 

demobilization. Demobilization places responsibility 

for reentry and reintegration squarely on society at 

large, making it “a societal, not military problem.” 

In major wars the soldier and family impact involves 

less conflict. The societal embrace of soldiers doing 

their duty in the face of a dehumanized enemy, fighting for a greater good, validates the soldier’s actions 

and modifies the negative psychological sequelae of 

combat. Resetting via acknowledgment of meaningful actions and sacrifices “not in vain” is more readily 

accomplished.4

Limited wars are those requiring only a fractional 

commitment of national resources; they are conducted 

in a different psychopolitical climate than major wars.4

National interests frequently serve as the pretext for 

action, civilian inconvenience and involvement are 

modest, and ambivalence about the cause pervasive. 

Numerous factors complicate reentry of service members, significantly, the absence of national consensus, 

lack of validation of soldiers’ efforts, and the return of 

soldiers individually from theater. “Soldiers were not 

able to process their experiences with the comrades 

with whom they had trained and fought.”4(p293) Reentry 

management in modern limited wars has been shouldered by society. Following the Korean War, soldiers 

met indifference; following Vietnam, hostility.4 Thus 

far public ambivalence has greeted returning OIF and 

OEF troops: praise for heroism, countered by belief in 

the moral injustice of the war, coupled with the portrayal of soldiers as pawns trapped in a commitment 

to serve. 

In limited wars, wherein society does not identify 

with the soldier and is neutral or even negative toward 

a soldier’s sacrifice, the psychological impacts land 

more heavily upon both soldier and society. “Psychiatric casualties increase greatly when the soldier feels 

isolated, and psychological and social isolation from 

home and society was one of the results of the growing 

antiwar sentiment in the United States,” such as during the Vietnam War.5

 Furthermore, in Vietnam, one 

consequence of soldiers’ alienation was an increase 

in “Dear John” letters.5 OIF and OEF reflect similar 

dynamics; the divorce rate for soldiers, and the officer 

corps in particular, rose rapidly in the first 3 years of 

the conflict, leveled off, and then rose again.

Psychiatric casualty rates in Vietnam “were similar 

to home-front approval ratings for the war, and an 

argument can be made that psychiatric casualties can 

be impacted by public disapproval.”5(p278) In multiple 

studies two factors show up again and again as critical 

to the magnitude of the posttraumatic response. First 

and most obvious is the intensity of the initial trauma. 

The second, and less obvious but absolutely vital, factor is the nature of the social support structure available to the traumatized individual.5

 Society accepting 

as necessary soldiers’ behavior in combat—killing, 

managing violence—vitalizes resetting the force and 

mitigates the psychological impact of combat. In contrast, the decline in public support for the war in Iraq 

as well as negative media attention may contribute to 

difficulties in reentry and reintegration for redeploying 

and demobilizing service members. Leaders and citizens, locally and nationally, who comment that a war 

is unjust, based on a lie, or in vane, make the soldier’s 

task to refit and reset more difficult. It is consequently 

important for leaders to speak up about the justness of 

the fight, identify what the country is fighting for, and 

outline the strategic successes. Reset must encompass 

not just an acceptance of but accolades for soldiers’ 

accomplishments.

The third form of combat, the rapid-deployment 

operation, is enacted for national interest by a professional military cohort that has trained together but 

must rapidly transition from training to combat mode 

and back again to prepare for the next deployment scenario.4

 Soldiers involved in these actions seldom have 

time to consider or internalize virtues of the cause, but 

instead must rely on horizontal and vertical cohesion 

Major War

• Large scale

• Moral superiority

• Fought by champions

• National will validates 

 soldiers’ efforts

• Society manages reentry

OIF/

Limited War OEF

• Fractional commitment

 of national will

• National interest

• Modest inconvenience

• Individualized reentry

• Societal indifference

RapidDeployment 

Operation

• National interest

• Professional military

• Cohort reentry

• Unit-level validation

• Repeated deployments

Figure 18-1. The characteristics of major wars, limited wars, 

and rapid deployment operations overlap in Operation Iraqi 

Freedom (OIF) and Operation Enduring Freedom (OEF).
278

Combat and Operational Behavioral Health

within their units for validation.4 Responsibility for 

reentry and reintegration rests primarily on the unit 

and military. The ability of these soldiers to rely on unit 

cohesiveness and esprit de corps significantly impacts 

deployment readiness.4

Special forces operations employed in GWOT as 

well as during the Cold War fall under this construct. 

The resetting of these combat teams is made easier 

through the unit cohesion and esprit de corps developed during their specialized training. Conversely, frequent deployments, toxic environments, and combat 

losses take a toll. The stigma of having a behavioral 

health problem is amplified because these soldiers 

may feel they cannot rely upon distressed members. 

Consequently, seeing behavioral health practitioners 

for assistance in a reset is made even more difficult in 

this group. Typically, special forces soldiers reach out 

to chaplains and leaders for these needs. Increasingly, 

however, regular forces follow the same behavior pattern, and the factors that mitigate distress in the special 

operations population may not exist as robustly in the 

regular forces community. 

History may determine where GWOT, OIF, and OEF 

fall among the models discussed. These related conflicts have been framed as a major war against a great 

evil but executed as a limited war by an increasingly 

professional and full-time military that must prepare 

for return-to-combat while planning its return home. 

OIF and OEF also entail the largest call-up of reserve 

forces since World War II, with 18-month mobilization orders for the National Guard, and 2- to 3-year 

mobilizations for reservists. These groups also face the 

increasing pressures of the deployment cycle. Figure 

18-1 depicts this overlap between major, limited, and 

rapid deployment operations, with elements of each 

apparent in OIF and OEF. 

REENTRY CHALLENGES BY POPULATION

The unusual spectrum of the GWOT, OIF, and OEF 

conflicts presents multiple challenges to reentry and 

reintegration for the three separate populations of 

regular Army soldiers, National Guard and reserve 

soldiers, and family members. 

Regular Army

The DCSP, resulting from the peacekeeping operations of the 1990s and the development of concepts 

based on expeditionary force practices among Army 

leadership, reflects recognition that in the post-Cold 

War era, soldiers are in predeployment, deployed, 

or postdeployment states at any given time. And so 

are family members. The DCSP plan, dated May 2, 

2004, disseminated and operationalized Army-wide, 

includes a return-to-readiness—termed “recovery” 

or “reconstitution”—period (Figure 18-2). The plan 

is intended to assist soldiers in reentry and reintegration and restore them and their units to combat 

readiness:

Reintegration training for both the Soldier and his/

her family is an essential task for all units’ return to 

readiness plans. It is as important as any other training or personnel action the Soldier undertakes. Reintegration entails three components; the single Soldier 

and his/her assimilation back into a garrison environment; the married Soldier and his/her assimilation with his family; and the family of the deployed 

Soldier.6

Reintegration training is not a single session but a 

continuous and, at times, parallel process: 

	 •	 Reintegration training occurs in advance of

soldiers’ return to home station, often intheater or at the location to which soldiers 

have been deployed. 

	 •	 Rear detachment leaders coordinate with the

installation to provide reintegration training to families of deployed soldiers as well. 

Although the training is voluntary for family 

members, units encourage participation. Units 

publicize training sessions and conduct them 

at times that allow maximum family member 

participation. The training also includes takehome information about what families might 

expect during the homecoming of their combat veteran.6

	 •	 The reconstitution phase starts upon a soldier’s arrival at home station after deployment. Commanders establish a half-day 

schedule to “facilitate family reintegration and 

to commence administrative tasks required 

upon return.”6 Half-days occur through the 

first 10 days, and during this time the soldier’s 

duties entail “administrative functions, Soldier and leader professional education, and 

family reintegration.”6

Rear detachment commanders and personnel 

provide support and training resources for reintegration in advance of the unit’s return. They ensure that 

“suitable time is allocated for family reintegration 

activities both for the married and single Soldier.”6

Leaders will “execute family reintegration counseling for all redeploying Soldiers. To the greatest extent 
279

Resetting the Force: Reentry and Redeployment

PDHRA

Reintegration Tasks

Day 0 Pass Pass Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10

Day180

Day -60 Day -30 Day -3 Day -2 Day -1

{

RecepFlight 

{

tion

Pass

{{

Days 1–10 Do Not Include Weekend Days (Protected)

Redeployment Tasks

{

In Transit

{

Key Components

• Commander’s program

• Structured decompression/reintegration

• Mental health risk stratification program prior to departure from theater

• Active tracking and monitoring, which involves cordination between

 BCT/division and the local AMEDD resources

• Tailored to both active and reserve components

possible, this counseling will occur in theater, prior 

to the Soldiers redeploying.”6 Units are expected to 

sustain needed family reintegration training following soldiers’ return, based on unit sensing sessions, 

command climate surveys, and feedback to the unit 

leadership from installation support agencies and 

healthcare providers. 

At-risk soldiers are identified by commanders prior 

to returning home to “ensure that they receive tailored 

training and/or assistance based on their particular 

circumstances.”6

 The Army identifies soldiers-at-risk 

by marital difficulties or difficulties with fiancés, 

financial difficulties, problems with alcohol or substance abuse, medical problems, and problems such as 

depression or anxiety reported by the soldier during 

pre- and postdeployment screening. This list is not 

all-inclusive and other issues might identify a soldier 

as at risk as well.6

Lastly, as directed March 26, 2007,7 all redeploying 

soldiers undergo a health reassessment 3 to 6 months 

after redeployment. This reassessment includes general health questions, seeking to address medical issues 

Figure 18-2. Key components in decompression and reintegration. 

BCT: brigade combat team

AMEDD: Army Medical Department

PDHRA: Post-Deployment Health Re-Assessment

not identified at the initial screening, but also presents 

soldiers with the opportunity to seek treatment for any 

behavioral health concerns that may have arisen since 

the initial screening.

National Guard and Army Reserve

As advocated by the “One Army” concept of 

seamlessness among components, requirements of 

the DCSP apply equally across active duty, National 

Guard, and reserve units. Reserve and National Guard 

soldiers are demobilized, like soldiers from World War 

II or Korea; their reentry and reintegration is largely 

shouldered by their communities; and medical care is 

provided by the Department of Veterans Affairs (VA) 

hospital nearest their home.

Reentry anxieties abound among these soldiers. 

Many have lost their jobs or fear the possibility of job 

loss, despite legislative protections. Sole proprietors 

and small-business owners are particularly at risk. A 

frequently noted concern is that soldiers feel different 

than they did before deployment. Other issues faced by 
280

Combat and Operational Behavioral Health

demobilizing reservists and Guard members include 

a sense of isolation from peers, estrangement from 

family and friends, and a loss of common purpose. 

The bonds forged in combat and other operations may 

remain if the Guard unit has a localized base; however, 

this is often not the case. 

Case Study 18-1: Specialist A presented for care shortly 

after being notified of his imminent release from active duty. 

The soldier expressed fears that he would respond negatively 

or even violently in his work environment when confronted 

with inevitable conflicts. “I’m not ready to go home. Most of 

the guys where I work are Middle Eastern; I’m afraid I will 

go off on them.” 

Demobilizing reservists and National Guard personnel often return to their home unit stations as soon as 

4 days after arriving at the demobilization site. This 

facilitates a quick reunion for them and their families; 

however, follow-up care and monitoring may be scarce 

in the home communities. Thus, these soldiers may find 

themselves in a difficult situation: either remain on active 

duty, separated from family and loved ones, to address 

medical questions, or ignore the medical issues and return 

home. Washington state sought to redress these issues in 

November 2004 when it established a memorandum of 

agreement with multiple federal agencies to 

augment the ongoing, comprehensive effort to ensure military service members and their families are 

honored for their valuable and honorable service to 

our country. It is recognized that the Department of 

Defense and the U.S. Department of Veterans Affairs 

are providing world-class transition service . . . to 

deal with the multitude of medical and mental conditions associated with war. This agreement will focus 

primarily on “after active-duty” and deal with problems and issues military members often face several 

months or years following military service.8

This agreement and its accompanying programs aim 

to shore up local reintegration and reentry of returning 

service members. Features include

	 •	 ensuring that each returning veteran receives

a letter from the governor, the adjutant general, and the director of the Washington State 

Department of Veterans Affairs thanking 

them for their service and encouraging them 

to seek their various veteran benefits and 

entitlements;

	 •	 follow-up letters at 3 and 6 months;

	 •	 a family activity day, held within 3 to 6 months

following return, conducted by teams consisting of representatives from the VA, Veterans 

Benefits Administration, Veterans Health Administration, and Washington Employment 

Security Department; accredited veteran services officers; and mental health professionals 

for the purpose of providing information to 

assist veterans and their family members with 

reintegration; and

	 •	 a family support program providing education about VA services and benefits in classes 

for family members of deployed service members, conducted by accredited veteran services 

officers at local armories and sponsored by the 

command.8

Like those on active duty, reserve component soldiers receive the health reassessment screening at 3 to 

6 months postdeployment. Specific questions on the 

screening aim to measure the presence and impact 

of posttraumatic stress disorder. If the reassessment 

identifies healthcare needs, soldiers are offered care 

through military medical treatment facilities, VA medical centers or veterans’ centers, TRICARE providers, 

or community-based healthcare organizations established by the Army. Part of this intervention plan are 

behavioral healthcare providers, who further assess 

soldiers’ needs and ensure that care is offered. 

Family Members of Regular Army, Reservists, and 

National Guard Members

The Deployment Health Clinic at Madigan Army 

Medical Center, Tacoma, Washington, like similar 

clinics at other military treatment facilities, recognizes 

that family preparedness for deployment is essential to 

ensuring soldier readiness for deployment. With this 

in mind, the Deployment Health Clinic developed the 

Army Family Readiness Course, which is an online 

resource for soldiers and family members. This has 

evolved over time into additional resources for soldiers 

and family members now embodied in the efforts of 

the Technology and Telehealth Initiative from the Department of Defense. 

 Case Study 18-2: Ms B is a 32-year-old spouse of an 

infantryman. The couple arrived at Fort Lewis, Washington, 

3 months prior to his deployment to Iraq. His previous assignment was in Korea, where his 12-month tour had been 

extended to 15 months. Ms B presented feeling overwhelmed 

at being separated from her spouse so soon and for yet 

another year. The couple had four children, ages 3 to 13. 

Ms B had significant back pain, anxiety, and a history of 

depression. Following her spouse’s return from Iraq, where 

he had served as a squad leader for an infantry squad with 

numerous combat encounters, she reported, “He tells me 

everything. I thought he’d keep it inside. I thought I’d be better 

when he came home, but I still can’t sleep.”
281

Resetting the Force: Reentry and Redeployment

During deployment, family members of regular 

Army soldiers usually have the benefit of support from 

the on-post community, support that is often not available for National Guard members or reservists. However, 

family members of National Guard and reserve soldiers 

may have greater access to family and long-standing 

community relationships that regular Army families 

do not. Regardless of component, home-front stability 

is key to soldier readiness. Family instability, which 

generally increases at deployment, distracts the service 

member, and absence of a family care plan often results 

in administrative separation of deploying soldiers. 

Often, however, the greatest challenge to families is 

the return of the deployed soldier. When the returning 

soldier reclaims prior responsibilities, the spouse may 

be left feeling that his or her efforts during deployment 

are invalidated. Months of adaptation and coping are 

upended, giving rise to such questions as:

	 •	 Who now pays the bills, takes out the trash,

mows the lawn?

	 •	 Who disciplines the children? How?

	 •	 Who gets the remote?

	 •	 Are there problems with intimacy?9 

Redeployment Programs

Commanders’ plans for resetting the force have 

varied, but they generally intend to provide a broadbased and inclusive assessment of the mental wellbeing of soldiers deploying to and returning from 

combat. In the Army’s first resetting iteration, the 

Walter Reed Army Institute of Research developed a 

postdeployment questionnaire that was filled out by 

soldiers upon or near redeployment and often in theater. This questionnaire became known as the Health 

Risk Appraisal questionnaire (HRA I). Subsequently, 

many local institutions and commands broadened the 

questionnaire and, through consensus, standardized 

its contents to create the HRA II. Soldiers completed 

the HRA II prior to deployment and upon return 

from a combat theater. Based on these assessments, 

interventions could be carried out to assist resetting 

soldiers in need. For example, a soldier who started 

smoking in the combat theater might express interest 

in smoking cessation. The request would be identified 

on the HRA II, and follow-up contact and treatment 

interventions arranged. 

Further evolution of the resetting efforts occurred 

over time, with different programs being implemented 

on different military posts. Ultimately, Army leadership adopted a standardized schedule and format for 

the predeployment and postdeployment assessments 

and the postdeployment health reassessment (see 

Attachment). In addition to the health assessments 

administered upon deployment, redeployment, and 

3 to 6 months postdeployment, the DCSP supports 

behavioral health by surveillance for trends and compliance, treatment referrals when indicated, and, most 

importantly, making it mandatory that soldiers have 

the opportunity to complete all assessments (although 

completion is voluntary).

The Army initially delegated treatment decisions to 

local medical treatment facilities. Arguably the most 

comprehensive of these efforts is a program called the 

Soldier Wellness Assessment Pilot Program (SWAPP), 

deployed initially at Fort Lewis, Washington (Exhibit 

18-1).

In general, military treatment facility reintegration 

programs operate as follows: Returning soldiers are 

assigned a care manager (usually a social worker) if 

medical or behavioral health issues are identified on 

the postdeployment health screening. The care manager assists the soldier in scheduling needed follow-up 

and then in keeping those appointments. This often 

requires coordination with the soldier’s command 

to ensure that the needed time is given. Those who 

need ongoing care are assigned case managers, who 

monitor the progress of the soldier’s therapy with a 

goal of full return to duty. Soldiers with identified 

behavioral health concerns that may limit duty are 

assisted by case managers in concert with behavioral 

health professionals. 

However, soldiers may also present with behavioral 

health concerns to the local behavioral health clinic, 

where those recently deployed are offered a wide 

variety of therapeutic modalities. These may include 

one-to-one supportive, insight-oriented, or cognitive/ 

behavioral therapy, as well as group therapies such 

as postdeployment adjustment groups, interpersonal 

process groups, depression groups, groups focused 

on adjustment to military life, or groups focused on 

life skills or anger management. Marital and family 

therapies are also offered in a variety of modalities. 

Medication management is also available when appropriate. Treatment for posttraumatic stress disorder, 

consistent with treatment guidelines based on the 

literature, is also offered.10

The expectation of wellness and recovery remains 

an integral part of any treatment program. For many, 

use of reassurance is efficacious. Practitioners should 

use language such as: “What you are experiencing now 

is an expected consequence of your combat tour. It will 

get better with time. However, the following may be 

helpful in this process. . . .”
282

Combat and Operational Behavioral Health

EXHIBIT 18-1

SOLDIER WELLNESS ASSESSMENT PILOT PROGRAM 

Interventions to reset the force have been in development since soldiers began redeploying to combat operations in 

Afghanistan and Iraq. A program that has gained significant acceptance and captured the commander’s intent is the 

Soldier Wellness and Assessment Pilot Program (SWAPP) at Fort Lewis, Washington. SWAPP is a useful model built 

on the Deployment Cycle Support Program’s intents to 

	 •	 standardize predeployment and postdeployment health risk assessments, with an identical process before

and after deployment;

	 •	 encompass a broad definition of health and wellness, including physical, emotional, spiritual, financial, and

legal needs; 

	 •	 make data transparent to commanders and medical staff; and

	 •	 ensure a face-to-face encounter with a licensed provider for each soldier assessed.

Participation in SWAPP is voluntary. Many commanders and soldiers view the program as an opportunity to establish a broad-based overview of physical, emotional, and spiritual wellness. The assessment is scheduled for completion between 90 and 180 days after return, and 45 to 125 days prior to departure. As seen in Figure 18-3, soldiers 

check in and begin with a face-to-face encounter that introduces aspects of the program and attempts to destigmatize the resetting process. It is made clear that the process is voluntary. 

Soldier 

Feedback 

Questionnaire

Health Risk 

Appraisal

(HRA II) Psychologist

Social Worker

Chaplain

Substance

Abuse

Counselor 

Medical

Chaplain

Tobacco

Cessation 

Injury

Prevention 

Occupational

Health 

I CORPS

Units

Mental 

Wellness 

Nurse

Practitioner

(Exit Interview) 

Clinic

Appointment(s) 

Med/

Prevention Battlemind II 

Blood

Pressure 

Check-in 

Figure 18-3. Soldier Wellness and Assessment Pilot Program flow chart.

 (Exhibit 18-1 continues)
283

Resetting the Force: Reentry and Redeployment

Exhibit 18-1 continued

Soldiers complete the health risk appraisal (HRA II) questionnaire in several venues, administered on computer 

kiosks, and results are forwarded to providers. The questions encompass the postdeployment health reassessment 

questions in form DD 2900 (see Attachment). HRA II has 76 questions used to identify risk in soldiers, who are 

categorized as being at high, moderate, and low risk for disease or mental health conditions. If soldiers are high 

risk, 60 minutes is allotted for a face-to-face meeting with a credentialed provider, and a soldier at moderate risk is 

allotted 30 minutes. Credentialed providers include psychologists, psychiatrists, social workers, psychiatric nurse 

practitioners, and chaplains. Licensed practical nurses and occupational and preventive medicine professionals are 

also on site to assess needs unrelated to mental health, such as tobacco cessation and medical referrals. 

As the program matures, its data will be accessible, comparable, and transparent, allowing for longitudinal followup. Currently data pertaining to form DD 2900 are sent to the Army Medial Surveillance Activity to be entered 

into the Defense Medical Surveillance System. Feedback from this system is sent to commanders via a Web-based 

report that is compliant with the Health Insurance Portability and Accountability Act of 1996. The data provided 

to commanders include diagnoses by type and prevalence, deployment-related conditions, safety issues, legal and 

financial problems, and the overall state of morale. 

As Figure 18-3 demonstrates, SWAPP is resource intensive. Though it is not used Army-wide, its elements are 

encompassed in return processing at other duty stations, and it serves as a model for many other programs in the 

military. Initial feedback and response from commanders and soldiers alike has been positive. Efforts to expand the 

SWAPP program to other Army posts are underway. 

Case Study18-3: Staff Sergeant C had recently been 

evacuated from Iraq following an improvised explosive device explosion in which he sustained an injury to his leg. His 

physical recovery was progressing well and he was hopeful 

for a full recovery. However, he complained of increasing 

awareness of disrupted sleep due to nightmares. He stated 

that he’d had them start before being injured and leaving Iraq 

and thought they’d go away once he was home. But now, 

some 2 months later, the nightmares persisted. Typically they 

involved combat operations and often centered on having 

to make a choice such as kill or be killed, killing, and then 

discovering the victim was a child.

Other soldiers often complain of hypervigilance 

while driving—fearing every piece of trash is an 

improvised explosive device or other drivers are potential suicide bombers. For many, the lack of sleep 

alone, without nightmares, represents a problem; often 

soldiers’ spouses report these concerns. Recognizing a more pervasive need to normalize experiences 

and assist redeploying soldiers in adapting what is 

a normal and acceptable behavior and response in 

the combat zone to what is normal and acceptable at 

home, the Army developed and introduced Battlemind 

training.

The Battlemind program (Exhibit 18-2) is another 

intervention with a renewed emphasis on normalizing anticipated feelings and reactions during the 

deployment cycle. “Battlemind” is the soldier’s inner strength and ability to face fear and adversity in 

combat with courage. Components are designed to 

build self-confidence and mental toughness. However, 

although Battlemind skills are helpful in combat, they 

Buddies (cohesion) 

Accountability 

Targeted aggression 

Tactical awareness 

Lethally armed 

Emotional control 

Mission operational security 

Individual responsibility 

Nondefensive (combat) driving 

Discipline and ordering 

Adapted from: US Army. Battlemind Web site. 

http://www.Battlemind.army.mil. Accessed March 

31, 2010.

EXHIBIT 18-2

Battlemind

may cause problems on returning home; for example, 

tactical awareness in a combat zone might become hypervigilance at home. Battlemind training is a method 

of aiding soldiers in transitioning to home-front living. 

Battlemind training emphasizes that
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Combat and Operational Behavioral Health

	 •	 Battlemind “injuries” (ie, a maladaptive

response to a formerly dangerous situation) 

can occur in any soldier when combat skills 

are not adapted to the home;

	 •	 getting help for a Battlemind injury is NOT a

sign of weakness; and

	 •	 it takes courage to ask for help and it takes

leadership to help a fellow soldier get help. 

The training, conducted upon redeployment, initially consists of an educational brief that emphasizes 

Battlemind concepts. Retraining after 3 to 6 months 

includes scenario-driven vignettes and videos that recreate typical situations experienced by redeployed soldiers and suggested ways of handling these issues. 

The programs and procedures outlined above work 

towards improving communication between soldiers 

and family members in an effort to resolve crises and 

mitigate distress. The inclusion of these programs in 

command-sponsored and command-driven operations plans and memoranda of understanding highlights a number of important considerations:

	 •	 Planners must integrate families and communities early into the planning for reentry 

and reintegration.

	 •	 Distress during this time is expected and

should not be medicalized.

	 •	 Behavioral health professionals should be

available to soldiers and families following 

return from combat.

	 •	 Education of families about available resources and benefits is as important as training 

soldiers.

Services for family members need to be easily accessible, perhaps even more so when the soldiers are 

deployed. Families with preexisting mental health 

needs frequently have increased demands, and those 

who did not demonstrate preexisting problems might 

also need services. Often sources in the community are 

not readily available or sufficient, even in more populated areas. With active duty mental health professionals deployed, the increased demand for services from 

family members at home may tax behavioral health 

resources beyond capabilities. For example, at the 

Madigan Army Medical Center outpatient psychiatry 

clinic, patient contacts for fiscal year 2001 numbered 

approximately 8,000; the same number was logged 

during just the first 6 months of 2005. 

Summary

In current and projected future operations, the 

burden of soldier reentry and reintegration will be 

borne equally by the Army and society, who must 

collaborate to ensure that maximal benefits to the 

soldier, family members, and society are realized. 

Since the beginning of GWOT, OEF, and OIF, the US 

Army has developed and refined its efforts to reset 

the force, reaching out to all returning and redeploying service members with a variety of mental and 

behavioral health initiatives. How well these efforts 

are working must be tracked and analyzed, so that 

the programs may continue to evolve to serve the 

changing needs of soldiers, families, the Army, and 

US society.

REFERENCES

1. Adler AB, Castro CS. US Soldiers and Peacekeeping Deployments. Heidelberg, Germany: US Army Medical Research 

Unit-Europe; 2001. Research Report.

2. Schumm WR, Bell DB, Knott B. Characteristics of families of soldiers who return prematurely from overseas deployments: an assessment from Operation Restore Hope (Somalia). Psychol Rep. 2000;86(3 Pt 2):1267–1272.

3. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers 

to care. N Engl J Med. 2004;351(10):13–22.

4. Kirkland FR. Postcombat reentry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. 

In: Zajtchuk R, Bellamy RF, eds. Textbooks of Military Medicine. Washington, DC: Department of the Army, Office of 

The Surgeon General, Borden Institute; 1995: 291–317.

5. Grossman D. On Killing: The Psychological Cost of Learning to Kill in War and Society. New York, NY: Little Brown and 

Company; 1995.

6. I (US) Corps OPLAN 04-10 (Return to Readiness). Unclassified. Fort Lewis, Wash. April 2004.
285

Resetting the Force: Reentry and Redeployment

7. Peter Geren, Acting Secretary of the Army. Deployment Cycle Support (DCS) Directive. Washington, DC: US Department 

of the Army. Memorandum, March 26, 2007. Available at: http://www.armyg1.army.mil/dcs/docs/DCS%20Directive.

pdf. Accessed September 15, 2009.

8. Memorandum of Understanding Between Washington State Military Department, Washington State Department of 

Veterans Affairs, Washington State Employment Security Department, US Department of Veterans Affairs, Benefits 

Administration, US Department of Veterans Affairs, Health Administration, US Department of Labor, Association of 

Washington Business, Governor’s Veterans Affairs Advisory Committee, November 2004.

9. Robertson M, Humphreys L, Ray R. Psychological treatments for posttraumatic stress disorder: recommendations for 

the clinician based on review of the literature. J Psychiatr Pract. 2004;10:106–118. 

10. Getting Back Together (Homecoming/Reunion) [videotape]. Washington, DC: US Army; 1994. US Army training video 

TVT20-1048. 
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ATTACHMENT: HEALTH ASSESSMENT FORMS
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Treatment of Deployment-Related Posttraumatic Stress Disorder

Chapter 19

treatment of deploymentrelated posttraumatic stress 

disorder

JOSEF I. RUZEK, PhD*; JEFFREY S. YARVIS, PhD†; and STEVEN LINDLEY, MD, PhD‡

INTRODUCTION

PSYCHOLOGICAL THEORIES OF POSTTRAUMATIC STRESS DISORDER AND

TREATMENT

TREATMENT OF DEPLOYMENT-RELATED POSTTRAUMATIC STRESS 

DISORDER

ASSOCIATED PROBLEMS IN POSTTRAUMATIC STRESS DISORDER 

TREATMENT

AREAS OF IMPAIRED FUNCTIONING

TREATMENT OUTCOME RESEARCH

TOWARD IMPROVEMENT OF POSTTRAUMATIC STRESS DISORDER SERVICES

Summary

*Director, Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Health Care System, 

795 Willow Road, Menlo Park, California 94025

†Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland

‡Director of Outpatient Mental Health, Department of Veterans Affairs Palo Alto Health Care System, 795 Willow Road, 116R/MHC, Menlo Park, 

California 94025; and Associate Professor, Department of Psychiatry, Stanford University, Palo Alto, California
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INTRODUCTION

Posttraumatic stress disorder (PTSD) is the most 

common and conspicuous psychiatric problem associated with the stress experienced by soldiers in combat. 

By definition, diagnosis of PTSD requires exposure to 

a traumatic event that involves experiencing, witnessing, or being confronted by death or serious injury to 

self or others; a response of intense fear, helplessness, 

or horror; and development of a set of symptoms that 

persist for at least a month and cause significant impairment of functioning.1

 Some factor analytic studies 

have demonstrated four basic dimensions of PTSD 

symptoms2—(1) reexperiencing (nightmares, flashbacks), (2) avoidance (efforts to avoid thinking about 

the trauma), (3) numbing of general responsiveness 

(restricted range of affect), and (4) hyperarousal (exaggerated startle response)—but some suggest other 

complex relationships between symptoms.3

Most individuals who develop chronic PTSD experience immediate distress that then persists over 

time.4 However, a small, but significant, number of 

individuals report increases in PTSD symptoms over 

time (delayed onset PTSD5). In retrospective studies of 

the course of PTSD, three different patterns have been 

identified: (1) high levels of symptoms after the war 

followed by recovery, (2) chronic symptoms persisting 

until the time of the assessment, or (3) relapsing-remitting symptoms.6

 Heterogeneity, of course, was also 

observed in a longitudinal study of a large community 

sample of Vietnam veterans. Koenen et al7 found that 

only 5.3% of veterans met PTSD criteria in both 1984 

and 1998, whereas 6.5% and 5.2% met criteria in 1984 

and 1998, respectively.

Current data suggest that approximately 5% to 

20% of armed forces personnel deployed for combat, 

peacekeeping, or humanitarian disaster relief will 

develop PTSD following their tour of duty.8–12 Among 

Vietnam veterans, as reported in the National Vietnam 

Veteran Readjustment Study,13 the lifetime prevalence 

for full PTSD was 30.9% for male veterans and 26% 

for female veterans. At the time of that study, 15.2% 

were currently suffering from PTSD. Reanalysis of 

the survey data, applying criteria revised to reflect 

changes in diagnostic criteria, indicates that 18.7% of 

the veterans had developed war-related PTSD during 

their lifetimes and 9.1% were currently suffering from 

PTSD 11 to 12 years after the war.9

 Despite the impact 

of methodology and deployment experiences on exact 

estimates of symptomatology, these findings represent 

significant rates of distress that often persist over long 

periods of time14 and reflect a significant public health 

problem.

In considering the problem of PTSD, it should also 

be acknowledged that problematic reactions to trauma 

are not limited to full-blown disorder. A considerable 

percentage (ie, 10%–25%) of those not meeting threshold diagnostic criteria for PTSD experience significant 

subsyndromal symptoms15 that may require treatment. 

Subthreshold, or partial, PTSD is associated with significant levels of impairment of social, occupational, 

and family functioning,15–19 often similar to those reported in individuals with full PTSD. (Yarvis et al18

conservatively defined subthreshold PTSD as having 

met the Diagnostic and Statistical Manual, 4th edition, 

criteria for the re-experiencing cluster and at least one 

other symptom cluster). Subthreshold presentations 

of PTSD are also associated with rates of help-seeking 

behaviors similar to those found with individuals 

who meet all the diagnostic criteria.16,20,21 These findings raise questions about the clinical significance of 

subthreshold PTSD and the diagnostic cutoffs. Those 

being diagnosed with PTSD may fall on the upper end 

of a stress-response continuum instead of representing 

a discrete clinical syndrome.22

Individuals diagnosed with PTSD almost always 

experience additional concurrent mental health disorders, such as substance use disorder, other anxiety 

disorders, and major depressive disorder.13,23–25 In the 

National Comorbidity Survey,25 88% of men and 79% 

of women with a lifetime history of PTSD met criteria 

for at least one other disorder. PTSD is also associated 

with significant levels of functional impairment and 

disability in civilian and veteran populations.10,11,20,26–37

The extent and number of symptoms can often predict 

physical and mental health problems.38 The persistence 

of PTSD as much as 30 years after trauma exposure 

is associated with continuing family problems and 

reduced happiness and life satisfaction.39

Risk factors for development of PTSD include 

characteristics of the traumatic event itself, pretrauma 

factors, and posttrauma factors. Event characteristics 

that increase the risk for chronic PTSD include type of 

trauma, greater amount of exposure, injury, involvement in atrocities, and perceived life threat.13,40–43

Degree of exposure to potentially traumatic combat 

events during deployment is strongly associated with 

development of PTSD.44 Military sexual trauma is more 

strongly associated with PTSD than premilitary or 

postmilitary sexual trauma45 or other traumas.46 In a 

sample of female veterans seeking treatment for stress 

disorders, sexual stress was found to be almost four 

times as influential in the development of PTSD as 

duty-related stress.47 In veterans, predisposing factors 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

have included non-Caucasian ethnicity, lower intelligence or education, younger age at exposure, lower 

socioeconomic status, family problems in childhood, 

pretrauma psychopathology, and childhood behavior 

problems.13,40,41,48 Postevent factors that predict chronic 

PTSD in veterans include low levels of social support, 

negative homecoming experiences, poor coping, and 

adverse life events posttrauma.40,41,48,49 Although many 

risk factors exert a similar effect in military and civilian 

populations, trauma severity and posttrauma social 

support may be more important in military than in 

civilian samples.50 

PSYCHOLOGICAL THEORIES OF POSTTRAUMATIC STRESS DISORDER AND TREATMENT

Conceptions of the etiology of PTSD, both psychosocial and biological, have implications for the understanding of treatment. Many theories have focused on 

the intense fear often experienced during traumatic 

events and the impact of fear on conditioned emotional reactions and encoding of traumatic memories. 

According to emotional processing theory as applied 

to PTSD,51 impaired “emotional processing” of traumatic experiences can result in creation of memories 

of the trauma (“pathological fear structures”) that are 

disruptively intense, contain unrealistic elements (in 

which harmless stimuli are associated with escape or 

avoidance responses), and include erroneous evaluations or interpretations (eg, “anxiety will persist until 

escape” or “fear will cause harm”). The Ehlers and 

Clark52 Cognitive Theory of PTSD is similar to emotionprocessing theory in drawing attention to the nature of 

trauma memories (and their links to other memories), 

to appraisals of the trauma and its sequelae, and to the 

behavioral and cognitive responses that prevent cognitive change and therefore maintain the disorder.52

Foa and Kozak51 suggest that there are two conditions for change in these problematic fear-related 

memories once they have been created: (1) the fear 

structure must be activated, and (2) there must be an 

incorporation of new information into the memory. 

Memory activation alone is insufficient for change. 

In fact, trauma memories are frequently activated by 

nightmares, conversations, or trauma reminders without benefit to the survivor. These experiences often 

increase fear for the person, or prompt maladaptive 

escape or avoidance behaviors. Dual representation 

theory argues that activation of memories can lead 

not only to recovery but also to chronic emotional processing (permanent preoccupation with consequences 

of trauma and intrusive memories), or to premature 

inhibition of processing that results from avoidance 

and is associated with continued phobic avoidance, 

somatization, and vulnerability to reactivation later 

in life.53 When PTSD symptoms become chronic, this 

is thought to reflect a failure to engage in successful 

emotional processing of the traumatic experience, because avoidance limits activation of the memory and 

access to new, corrective information.54 

Following this thinking, it is the job of the treating provider to encourage conditions for change and 

reduce emotional avoidance. Deliberate therapeutic 

activation of traumatic memories is most directly 

attempted in exposure therapies that require the individual to repetitively talk about the trauma in detail 

and approach previously avoided trauma-related 

stimuli. During effective treatment, therefore, avoidance is limited and new information of many kinds 

is purposefully incorporated into the memory. The 

individual learns that it is not dangerous to remember the trauma and experience strong emotions, that 

events can be remembered deliberately with a feeling 

of personal control and manageable physical reactions, that the trauma memory may not be completely 

accurate and must be updated, and that some beliefs 

or judgments about the experience can be challenged 

and changed. 

Although most theories of PTSD emphasize the relationship of fear to the development of PTSD, combat 

and other deployment-related traumas often activate 

other intense emotions—including sadness, anger, and 

guilt—that can be connected to the development of 

PTSD and other posttrauma problems. In Operation 

Iraqi Freedom (OIF), for example, substantial percentages of US Army and US Marine Corps personnel reported potentially traumatic experiences that 

included not only events likely to be associated with 

fear (“being attacked or ambushed”), but also those 

related to loss (“knowing someone seriously injured 

or killed”), moral conflict (“being responsible for the 

death of a noncombatant”), horror (“handling or uncovering human remains”), or helplessness (“seeing ill 

or injured women or children whom you were unable 

to help”).44 These types of experiences are associated 

with a range of intense emotions that can continue to 

trouble trauma survivors. Some of these emotions are 

fueled by negative interpretations or appraisals (of 

personal behavior during the trauma, or the effects of 

the trauma); thus it may be important to supplement 

exposure interventions with those explicitly designed 

to modify appraisals. The cognitive theory of PTSD 

emphasizes “idiosyncratic negative appraisals of the 

traumatic event and/or its sequelae that have the 
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common effect of creating a sense of serious current 

threat”52(p320) and thus serve to maintain acute stress 

reactions. 

Generally, cognitive-behavioral psychological theories and treatment of PTSD instruct that the trauma 

memory needs to be actively confronted, elaborated, 

and integrated into the context of the individual’s 

preceding and subsequent experience; problematic 

appraisals that maintain sense of threat and other negative emotions need to be modified; and dysfunctional 

coping strategies that prevent emotional processing of 

the trauma, and thus recovery, need to be reduced. 

TREATMENT OF DEPLOYMENT-RELATED POSTTRAUMATIC STRESS DISORDER

Treatment of PTSD depends upon a careful assessment of the individual. Treatment plan formulation 

should be based on judgments of factors that may have 

caused problems for that particular person, those that 

maintain them, co-occurring problems of the person, 

and priorities for intervention. Regardless of specific 

interventions, treatment of individuals with PTSD can 

be conceptualized as a temporal process that starts 

with client engagement, alliance building, and education about the nature of trauma, posttraumatic stress 

reactions, and the recovery process. This is followed 

by coping skills training or trauma-focused interventions or both—aspects of treatment that require greater 

involvement and commitment by the client. Finally, as 

treatment intensity is decreased, attention is focused 

on relapse prevention and maintenance of treatment 

gains. 

Active Engagement and Alliance Building 

In order for treatment of PTSD to commence, individuals with PTSD must present for care. However, 

many are reluctant to seek mental health treatment. 

Those experiencing higher levels of symptoms may be 

even less likely to seek help and report more barriers to 

help-seeking.55 For example, four US combat infantry 

units were administered an anonymous survey 3 to 4 

months after their return from combat duty in Iraq or 

Afghanistan.44 Only 38% to 45% of the soldiers whose 

responses met criteria for a mental health disorder 

indicated an interest in receiving help, and only 23% 

to 40% reported having received professional help in 

the past year. Those screening positive for disorder 

were twice as likely to report concern about being 

stigmatized, as well as other barriers to seeking mental 

health services. In this study, barriers to seeking help 

included concern about being seen as weak, feelings 

of embarrassment, and concern about reactions from 

leadership. For some, another barrier to seeking treatment for PTSD within a Veterans Healthcare Administration (VHA) or Department of Defense (DoD) setting 

is fear that documentation of PTSD-related problems 

in the medical record might have an adverse effect on 

advancement in a military career or later employment 

in some civilian occupations (eg, police).

Screening programs can increase rates of identification of PTSD and rates of referral.56 These screenings 

should occur at multiple points in time, given that 

soldiers have been found to report more mental health 

concerns 3 to 6 months following return than in the first 

month.57,58 In some screening environments, however, 

there may be significant disincentives to give positive 

responses. Factors that may lead to underreporting of 

early postdeployment distress in military personnel 

include positive mood at the time of return, misattributions about existing symptomatology, and reluctance 

to endorse distress because of perceived stigma.43 Although many who screen positive will not seek care, 

many individuals may nonetheless ask for help—35% 

of Iraq war veterans accessed mental health services 

in the year after returning home.59

Relatively little is known about the determinants 

of help-seeking in those with PTSD. Treatment seeking in Canadian veterans with lifetime PTSD was 

predicted by cumulative lifetime trauma exposure, 

traumatic event type, PTSD symptom interference, 

and comorbid major depressive disorder.21 Those with 

comorbid depressive disorder were 3.75 times more 

likely to have sought treatment than veterans without 

concurrent depression. Multiple deployments are associated with greater levels of PTSD symptoms,38 so 

that soldiers with more than one deployment should 

be monitored. In research with veterans, the failure of 

veterans with PTSD to seek VHA mental healthcare 

was found to be affected by personal obligations that 

prevented clinic attendance, inconvenient clinic hours, 

and current receipt of mental health treatment from a 

non-VHA provider.60 Another study suggested that 

veterans’ pursuit of mental health services appears to 

be driven more by their guilt, and the weakening of 

their religious faith, than by the severity of their PTSD 

symptoms or their deficits in social functioning.61

Outreach interventions can be investigated empirically. In a study of veterans who were service-connected for PTSD but not receiving PTSD treatment, half 

received an outreach intervention, and the other half 

were assigned to a control group.60 The intervention 

group received a mailing that included a brochure 

describing VHA PTSD treatment and a letter telling 

them how to access care. These individuals were also 
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telephoned and encouraged to enroll in treatment. 

Results indicated that those receiving the intervention were significantly more likely to schedule an 

intake appointment, attend the intake, and enroll in 

treatment. 

Initial presentation for help does not necessarily 

result in active involvement in the treatment process. 

The importance of this issue is highlighted by clinical experience with OIF veterans 1 and 2 years after 

their return to the United States. In VHA settings, 

many veterans come to one or two treatment sessions 

but do not begin active participation in counseling 

services. In fact, once an individual presents for help, 

clinicians must take steps to maintain attendance and 

achieve active engagement in the treatment process. 

It is important to assess for obstacles to participation 

and make efforts to ensure that treatment makes sense 

to these individuals and is perceived as relevant to 

their needs. 

Ongoing Assessment and Monitoring of Treatment 

Effectiveness 

Initial engagement in treatment can be expected 

to be affected by the assessment process. Assessment 

provides practitioners with an opportunity to inquire 

about perceived needs and to describe treatment in 

terms that make clear its relevance to those needs. This 

suggests that assessment must include not only attention to symptoms and problems, but also perceived 

areas of importance to the help-seeker (eg, partner and 

family conflict, sexual functioning, work functioning 

and satisfaction, and parenting experiences). The assessment interaction communicates interest in, and 

understanding of, the individual, as well as expertise 

on the part of the provider. 

Assessment of military-related PTSD requires a 

multimethod approach in which multiple measures 

are used to assess different domains of functioning, 

both to improve diagnostic confidence and to identify 

multiple targets for intervention.62 A few key issues can 

be identified. First, it is important for the provider to 

gather information about the individual’s experiences 

during deployment. Use of self-report questionnaires, 

such as the Deployment Risk and Resilience Inventory, 

can make this process more complete and efficient for 

provider and patient.63 Second, findings of high rates 

of lifetime physical and sexual victimization among 

veterans in treatment for chronic PTSD support the 

need for routine assessment of history of trauma exposure.64 Adverse childhood experiences are strongly 

associated with mental health symptoms65 and predict 

the presence of PTSD and depression among active 

duty soldiers seeking mental health services.

66 Third, 

it is important that clinicians engage in ongoing assessment and monitoring of treatment impact. Although 

this is not currently routine practice in many treatment 

settings, it is important to help provider and survivor 

evaluate the effectiveness of their work together, and 

make changes when necessary. The clinical practice 

guideline for PTSD, jointly developed by the VHA 

and the DoD, recommends routine use of validated 

self-administered checklists (and interviews as appropriate) at intake and to monitor follow-up status 

(at least every 3 months).67

Ongoing Interactive Education 

Patient education comprises a basic component of 

most forms of psychotherapy for PTSD, and should be 

introduced early and continued throughout all stages 

of the treatment process. To this end, traumatic stress 

education classes are often included as part of a first 

phase of comprehensive treatment programs. Traumatic stress education includes a number of components: (a) information about how traumatic experiences 

can affect individuals; (b) information about common 

reactions to trauma; (c) “normalization” of reactions; 

(d) emotional support and reassurance; (e) presentation 

of a rationale for, and description of, what happens in 

treatment and what the individual will be asked to 

do; and (f) a description of how recovery can happen. 

Education for the family is also important. Although 

education alone is unlikely to result in remission of 

PTSD, it is important to building commitment to 

treatment participation and helping the survivor more 

clearly understand the traumatic experience and how 

to actively participate in treatment.68

Coping Skills Training 

There is a great difference between knowing what 

to do versus knowing how to do it. Skills training 

methods are designed to help individuals learn and 

practice what to do to cope more effectively with the 

various kinds of situations that challenge them. Skills 

training methods are commonly used to help those 

suffering with PTSD to increase their ability to reduce 

anxiety, communicate with loved ones, manage anger, 

and respond assertively (not aggressively) to conflict 

situations. Through a cycle of instruction, demonstration, rehearsal/practice, feedback/coaching, and more 

practice, survivors learn skills in treatment sessions 

and practice them in the natural environment. They 

keep written records of their attempts to apply the 

skills, which help them learn and provide practitioner 

and survivor with real-world experiences to review. 

Clinical experience indicates that survivors are typi-
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cally attracted to the idea of learning skills (“tools”) 

for coping. The methods of skills training help to 

actively involve the survivor in treatment, provide a 

greater sense of control (and responsibility for active 

participation in treatment), and strengthen the transfer 

of what is learned in treatment to the natural environment of the client. For example, stress inoculation 

training (SIT)69 focuses on teaching the survivor skills 

for managing anxiety symptoms, and includes education, muscular relaxation training, breathing retraining 

(slow abdominal breathing), assertiveness training, 

covert (imaginal) modeling, role playing, thought stopping, and positive thinking and self-talk. SIT has been 

found to significantly reduce PTSD symptoms in some 

treatment research,70 and is “strongly recommended” 

in the VA/DoD clinical practice guideline.

Deliberate, Planned Confrontation of Trauma 

Memories and Reminders 

The core element of PTSD treatment is active discussion and exploration of traumatic experiences and their 

implications. The treatments that focus explicitly on 

traumatic memories and meanings—prolonged exposure (PE),71 cognitive therapy (CT), and eye movement 

desensitization and reprocessing (EMDR)72—have 

received the most empirical support to date, and comprise three of the four “strongly recommended” treatments in the VA/DoD clinical practice guideline. 

Methods of therapeutic exposure, such as PE, involve the most direct confrontation of memories and 

reminders. Imaginal exposure involves a repeated 

retelling of the trauma story with emotional activation. In vivo exposure adds real-world exposure to 

stimuli associated with the trauma via confrontation of 

avoided trauma-related stimuli in the natural environment. These procedures involve multiple repetitions 

achieved by listening to a cassette recording of the 

trauma narrative, writing about the experience, or 

approaching real-world trauma reminders systematically in between-session tasks. A combination of 

imaginal and in vivo exposure is thought to be more 

effective than either procedure alone. According to 

Foa and Jaycox,73 PE treatment assists the individual 

to incorporate new information into the memory by 

reducing cognitive avoidance of trauma-related feelings, demonstrating that remembering the experience 

is not dangerous and that anxiety will diminish via habituation, fostering discrimination between the trauma 

and similar nontraumatic situations, strengthening 

ability to tolerate memories and thereby challenging 

perceptions of personal incompetence, and reviewing 

details of the experience that provide evidence against 

disabling beliefs about danger and incompetence.

Exposure to trauma memories is an element of a 

number of treatments other than PE that are supported 

in the research literature. For example, individuals being treated with cognitive processing therapy (CPT)74

are asked to write out the details of their traumatic 

experience and to read the account on a regular basis. 

EMDR includes an exposure component that involves 

bringing to mind an image of a traumatic event while 

visually tracking a therapist’s finger as it moves back 

and forth in front of the patient’s visual field (or tracking a light moving back and forth, or listening to tones 

alternating from one ear to the other).

Challenging Negative Trauma-Related Thoughts 

CT is a systematic approach that includes education 

about the role of beliefs in causing distress; identification of distressing beliefs held by the individual; 

discussion and a review of evidence for and against 

the beliefs; testing of beliefs; generation of alternative 

beliefs; and rehearsal of new, more adaptive beliefs. 

Thoughts that create significant distress (eg, traumarelated guilt, exaggerated thoughts about danger) 

are replaced with more realistic and self-supportive 

thoughts. For example, if an individual has the thought 

“I will never be safe again, the world is a very dangerous place,” CT might focus on helping the individual 

to consider evidence for and against the belief and 

move toward a more realistic appraisal (eg, “I am safe 

in most situations and the chances of harm coming to 

me are quite small in the civilian world”). It is often 

important that trauma-related guilt be made a formal 

target of PTSD treatment, and some interventions 

with a strong CT component, such as CPT74 and CT 

for guilt,75 target guilt explicitly. Instruments designed 

to assess guilt (eg, Trauma-Related Guilt Inventory76) 

and other trauma-related beliefs (eg, Post-Traumatic 

Cognitions Inventory77) are available. 

Negative thoughts can be challenged through 

direct review of the belief and consideration of 

alternatives, and through encouraging real-world 

experiences that can help to disconfirm them. For 

example, having a successful experience in disclosing personal information to another person can help 

challenge the belief that “other people cannot be 

trusted.” Successful implementation of PE can also 

result in modification of distressing trauma-related 

cognitions by disconfirming beliefs (“anxiety stays 

forever” or “I will go crazy”) and helping the survivor differentiate the trauma from similar but safe 

events (disconfirming “the world is extremely dangerous”). PTSD symptoms themselves may begin to 

be associated with mastery rather than incompetence 

(disconfirming “I am incompetent”).
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Treatment of Deployment-Related Posttraumatic Stress Disorder

Pharmacotherapy 

Medication is an important treatment option that 

should be considered for almost all patients with significant symptoms of PTSD. The use of a medication 

in these patients may be directed at PTSD symptoms 

generally, specific symptoms, common co-occurring 

symptoms, or comorbid conditions (eg, depression). 

Initiating a medication trial may occur at different 

phases in treatment, depending on patient-specific 

factors. As mentioned earlier, those patients with high 

levels of symptoms may be the most reluctant to seek 

psychotherapy care. A medication initiated within the 

primary care setting may reduce symptoms to a level 

such that this reluctance can be overcome. However, 

many military patients may be concerned about the 

potential side effects of a medication or the stigma of 

taking a “psych drug” and will need to build trust with 

their mental health provider before starting a medication can become an option. 

Despite the wide use of a variety of medications 

for the treatment of PTSD, there is a relative lack of 

definitive evidence for their efficacy.78 The most thoroughly investigated agents are the selective serotonin 

reuptake inhibitors (SSRIs). SSRIs have demonstrated 

superiority over placebo in large randomized controlled trials (RCTs) as well as in a number of smaller 

investigations, and they are now considered the firstline pharmacological treatment option for PTSD.79

Sertraline and paroxetine have been subjected to 

large industry-sponsored trials for the acute treatment of symptoms and have received US Food and 

Drug Administration approval for treating PTSD.80–82

Fluoxetine, escitalopram, and citalopram have shown 

efficacy in smaller randomized or open trials.83,84 In 

these trials, SSRIs improved all three clusters of symptoms in PTSD, as well as quality of life and functional 

impairments. They appear effective in preventing the 

relapse of symptoms once a patient has responded to 

treatment.81,85,86 But the data on SSRIs in the treatment 

on PTSD in certain populations, including combat 

veterans, are still limited.78

SSRIs have proven effectiveness for many other anxiety and depressive disorders that are highly comorbid 

with PTSD. PTSD and major depression overlap to a 

considerable degree; both share sleep disturbances, 

social withdrawal and isolation, decreased pleasure 

and enjoyment, and impaired concentration. Major 

depression is the most common comorbid disorder in 

patients with PTSD, with close to 50% of PTSD subjects having a history of major depression.25 Although 

SSRIs improve both PTSD and depression, SSRIs are 

efficacious for both PTSD patients with and without 

depression.82 Panic disorder and generalized anxiety 

are also responsive to SSRI treatment and also often 

co-occur with PTSD.87

As with most other disorders treated with antidepressants, a full therapeutic response to SSRIs in PTSD 

takes 4 to 6 weeks. Although better tolerated than older 

antidepressants, SSRIs are not without side effects 

that can include nausea and gastrointestinal distress, 

insomnia, akathesia, and sexual dysfunction. Many 

of these side effects are time-limited but still result in 

relatively high rates of medication discontinuation.88

Education and support by all members of the treatment 

team are vital to prevent early discontinuation.

Other antidepressants have less empirical support 

for the treatment of PTSD than do SSRIs, but available 

evidence suggests similar efficacy. Therefore, non-SSRI 

antidepressants should be considered as second-line 

medication treatment options for PTSD. Antidepressants with RCT data supporting their use in PTSD 

include venlafaxine,89 mirtazapine,90 and nefazodone.91

Clinically, the choice of an antidepressant is often based 

on comorbid symptoms and conditions. Venlafaxine, 

as well as duloxatine, are efficacious in some chronic 

pain conditions92 and may be useful in PTSD patients 

with diabetic neuropathy, fibromyalgia, or certain 

other pain disorders. Mirtazapine is generally sedating 

and may be useful in targeting insomnia in PTSD, but 

weight gain can be a problem. Although the efficacy 

of bupropion in PTSD is uncertain,93 it is an option for 

patients with PTSD who are also attempting to stop 

smoking.94 There is limited RCT data to support the 

efficacy of tricyclic antidepressants and monoamine 

oxidase inhibitors. Furthermore, their clinical use is 

limited by their higher rate of side effects, from common dry mouth and constipation to more serious 

cardiac conduction delays and a lower safety index in 

overdose. Noradrenergic reuptake inhibiting tricyclic 

antidepressants, such as nortriptyline, are efficacious 

for chronic pain conditions92 and may also be used 

in PTSD patients with these conditions. Trazodone is 

widely used at lower dose as a hypnotic in PTSD due 

to lack of addiction potential. 

If antidepressant treatment fails to produce a sufficient treatment response, other psychopharmacological treatment options are available, but with even less 

empirical support. After antidepressants, the atypical 

antipsychotics have the most RCT data supporting 

their efficacy in the treatment of PTSD. Data support 

their use either as an augmentation therapy to SSRI 

treatment95–98 or as a single agent therapy,99 although 

not all studies have been positive100 and the studies 

conducted to date have been limited in size. In addition to targeting core PTSD symptoms, atypical antipsychotics are often used to treat comorbid psychotic 

symptoms96 or as mood stabilizers to treat symptoms 
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Combat and Operational Behavioral Health

related to bipolar disorder or symptoms associated 

with borderline personality disorder. Another class 

of mood stabilizers, the third-generation anticonvulsants, had shown promising findings in early clinical 

case reports and open-label investigations, but small 

RCT investigations of valproate,101 topiramate102 and 

tiagabine103 have all failed to demonstrate statistically 

significant efficacy in PTSD. Therefore, their use should 

be limited to treating refractory cases or comorbid 

mood disorders. 

Agents targeting noradrenergic neurotransmission 

have been proposed as possible treatments for PTSD, 

based in part on the role noradrenergic neurons play in 

the biological response to stress.104 Due in part to their 

ability to decrease central and peripheral noradrenergic activity, the α-2 adrenergic receptor agonists clonidine and guanfacine had been suggested as treatments 

for PTSD. But RCT investigations of guanfacine have 

failed to demonstrate efficacy in patients with chronic 

PTSD.101,105 Centrally active β-adrenergic receptor 

antagonists, such as propranolol, may influence how 

stressful memories are stored106 and have been efficacious in some,107 but not all,108 preliminary studies in 

preventing the development of PTSD in traumatized 

individuals. There are also limited data indicating 

that the α-1 adrenergic agonist prazosin has efficacy 

in treating nightmares and sleep disturbances in PTSD 

patients.109,110 Both propranolol and prazosin are currently under investigation in larger RCT trials. 

Benzodiazepines are effective in treating timelimited anxiety, but have significant dependence and 

abuse potential and are associated with adverse effects, 

including short-term memory impairment. Small RCTs 

have failed to demonstrate efficacy for benzodiazepines in the treatment of PTSD111,112 or in preventing 

the development of PTSD in trauma survivors.113 If 

benzodiazepines are prescribed, they should be used 

in a time-limited manner and with great caution in 

patients with PTSD due to the high rates of substance 

use disorders.114

A possible problem with prescription of medications (as with nonpharmacological interventions) 

is nonadherence to appropriate use. Indeed, many 

trauma survivors discontinue their medications 

without discussion with their provider. It can often be 

important to explore the meaning of medication for the 

person. When survivors interpret their need for medication as a sign of personal weakness or inability to 

cope, a judgment of failure in psychotherapy, evidence 

of the clinician’s lack of personal interest, or avoidance 

of dealing with the “real” problem, they may be less 

likely to adhere to appropriate use.

In summary, medications, particularly antidepressants, may reduce the overall severity of PTSD symptoms and serve as useful tools in the treatment of PTSD. 

Psychotropic medications may also be used to treat 

associated features or comorbid conditions or both. 

But the practitioner and the patient must be aware that, 

with the exception of antidepressants, their use is off 

label. Drug treatments for PTSD should not be used as 

a routine first-line treatment in preference to a traumafocused psychological therapy. Individuals with PTSD 

should be offered a course of trauma-focused cognitivebehavioral therapy or EMDR, regardless of time since 

trauma.115 If the PTSD sufferer reports little or no 

improvement after one of these psychological treatments, an alternative trauma-focused treatment, and 

then augmentation with pharmacological treatment, 

can be considered. It is important to consider the least 

restrictive or intrusive treatment model and choose efficacious treatments.116 Medications may be warranted, 

particularly when symptoms are significant and daily 

functioning is severely impaired, the person has severe 

insomnia, an additional psychiatric condition (eg, depression) is present, or if significant symptoms are still 

present following psychological treatment. Polypharmacy can occur in patients with PTSD in the absence 

of empirical support117 and should be avoided. 

Maintenance and Relapse Prevention 

Relatively little is known about rates and processes 

of relapse after treatment for PTSD. Studies in the 

civilian sector suggest that improvements resulting 

from use of evidence-based treatments can be maintained for significant periods of time.118 Some evidence 

suggests that patients discharging from residential 

PTSD treatment and referred for outpatient aftercare 

are more likely to make an outpatient visit within 1 

month of discharge if they receive biweekly telephone 

calls after discharge.119 Research also suggests that 

long-term treatment of PTSD with SSRIs maintains 

treatment response and quality-of-life improvements, 

and that discontinuation of SSRI treatment after 12 

weeks results in a greater relapse risk, compared with 

extended treatment.120 

ASSOCIATED PROBLEMS IN POSTTRAUMATIC STRESS DISORDER TREATMENT

As noted above, approximately 80% of those diagnosed with PTSD experience concurrent additional 

mental health disorders.25 They also experience a range 

of problems in living that are often addressed in treatment. PTSD symptoms are associated with reduced 

quality of life before treatment. Evidence suggests that 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

positive change in PTSD is significantly associated 

with positive change in quality of life.121 Most PTSD 

outcomes research has focused on reduction of PTSD 

symptoms; the impact of treatment on the wider range 

of quality of life and functional outcomes is less well 

investigated. Successful treatment should be accompanied not only by a reduction in PTSD symptoms but 

also by an improvement in quality of life.122 To address 

the many problems for which those with PTSD seek 

help, it will often be important to supplement PTSD 

symptom-focused interventions with adjunctive 

treatment components targeted at other clinically significant problems identified in the assessment process, 

especially if these problems do not remit once PTSDfocused interventions have been provided. 

Substance Abuse and Addictive Behaviors 

Co-occurrence of PTSD and substance abuse (SA) 

problems is well documented in populations of civilians and veterans.123,124 For example, Kulka et al13

reported that 73% of Vietnam veterans with PTSD met 

criteria for lifetime alcohol abuse or dependence. It is 

likely that untreated alcohol and drug problems will 

impede treatment of PTSD; continuing PTSD symptoms may make sobriety more difficult to achieve. 

Some research suggests that veterans with PTSD 

who also abuse substances will benefit more from SA 

treatment if they also address PTSD. Patients who received PTSD treatment in the first 3 months following 

discharge from SA treatment were more likely to be 

in remission from substance use disorders at followup than those who did not receive PTSD treatment.123

The interconnectedness of these disorders has generated increased development of integrated PTSD/SA 

treatments.125 However, the widespread organization 

of PTSD and SA care in separate clinics, and the lack 

of cross-training of professionals in these areas, are 

among the impediments to delivery of integrated 

care. 

Evidence also suggests that PTSD is associated 

with increased risk of smoking26 and that unremitted 

PTSD is a risk factor for late-onset smoking among 

individuals who were nonsmokers prior to developing PTSD.126 In an RCT, McFall et al127 demonstrated 

that smoking cessation intervention incorporated into 

routine mental health care for PTSD is more effective 

than treatment delivered separately by a specialized 

smoking-cessation clinic.

Other addictive behaviors may also be associated 

with PTSD. In civilians seeking treatment for pathological gambling, frequency of PTSD symptoms has 

been found to predict greater lifetime gambling severity.128 A study of Australian PTSD treatment-seeking 

veterans found that the veterans were likely to be 

problem gamblers, but that PTSD was unrelated to 

the behavior.129 However, because all subjects had 

PTSD, the study was not optimally designed to detect 

a relationship.

Depression and Suicidality 

PTSD is strongly comorbid with depression.18,23,25,38,130,131 For example, Vietnam veterans with 

PTSD have higher levels of depression than veterans without PTSD.13 In retrospective studies, most 

individuals with both disorders report that PTSD 

developed first.25 A 2-year prospective study of the 

temporal relationship between PTSD and depression 

symptomatology in Gulf War veterans indicated a 

bidirectional relationship in which initial PTSD symptoms predicted increases in depression symptoms and 

initial depression symptoms predicted PTSD, although 

initial PTSD symptoms were more strongly predictive of later depression.132 Breslau et al found greatly 

increased risk for major depression in persons with 

PTSD,23 but not in exposed persons without PTSD, 

suggesting that exposure to traumatic events does not 

increase the risk for major depression independent of 

its effects on PTSD. 

Presence of PTSD is associated with increased risk 

of suicide. Sareen et al used data from the nationally 

representative National Comorbidity Survey to investigate the relationships between anxiety disorders and 

suicidal ideation and attempts.133 PTSD was significantly associated with suicidal ideation and suicide 

attempts; none of the other anxiety disorders showed 

such an association. Generally, PTSD in US Army 

veterans is associated with mortality from external 

causes, including homicide, suicide, drug overdoses, 

and unintended injury.134 Clinicians treating PTSD 

should therefore routinely screen for suicidality and 

remain alert to the need to monitor suicidal ideation 

and provide preventive interventions.

Anxiety 

PTSD, itself classified as an anxiety disorder, is 

highly comorbid with other anxiety disorders, including panic disorder, generalized anxiety disorder, social 

anxiety disorder, obsessive-compulsive disorder, and 

phobias. Among veterans receiving medical care in primary care clinics, those with PTSD have greater rates of 

social anxiety disorder (22%) than those without PTSD 

(1.1%).135 Development of obsessive-compulsive disorder can be precipitated by trauma in combat.136 Little 

research has examined the impact of PTSD treatment 

on co-occurring anxiety problems, but a treatment for 
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individuals with PTSD who also experience panic attacks has been developed.137

Anger and Violence 

Anger and irritability comprise one of the symptoms of PTSD. Intense anger is commonly part of 

the presentation of those with PTSD138 and is more 

significant among those whose traumas were experienced during military service.139 Vietnam veterans 

with PTSD have higher levels of anger than veterans 

without PTSD,13 and high levels of anger have been 

reported among Iraq and Afghanistan War veterans.140

Compared to veterans without PTSD, those with it take 

less time to feel anger, have greater mean heart rate 

and diastolic blood pressure responses during relived 

anger, and report greater anger and anxiety during 

a laboratory task in which they are asked to relive a 

self-chosen anger memory.141

The volatile anger reactions of their patients can 

present treatment providers with challenges in establishing therapeutic relationships and in delivering 

treatment itself. In a study of Australian veterans, anger at intake was the most potent predictor of failure to 

show symptom change.

142 Anger might interfere with 

the confrontation with, and processing of, traumatic 

memories that can be important in recovery from the 

disorder.71 A high level of anger at the beginning of 

PE treatment interferes with response to treatment.143

Anger reduction should often be made an explicit goal 

of treatment; individuals can be taught skills (eg, time 

out/cool down, anger self-monitoring, identifying anger situations, relaxation/breathing, anger discrimination, self-talk, assertion training) to reduce their anger 

or modify its expression. 

Anger problems may also require the provider to 

assist the veteran in reducing risk of violence. Research 

has indicated that veterans receiving inpatient treatment for PTSD are more violent than male psychiatric 

inpatients without PTSD and community Vietnam 

veterans with PTSD not undergoing inpatient treatment.144 Domestic violence may be an accompanying 

problem,145,146 and experiencing PTSD symptoms 

increases risk for perpetrating intimate partner 

violence.147 Moreover, veterans with PTSD often have 

ready access to weapons and engage in potentially 

dangerous firearm-related behaviors.148 Thus, clinicians should routinely address gun storage and safety 

issues as part of the treatment process.

Complicated or Traumatic Bereavement 

Many of those deployed to a war zone will be exposed to significant personal losses, and these deaths 

will often be encountered in traumatic circumstances. 

Traumatic bereavement can lead to anhedonia and 

depression; grief about fallen friends can make social 

interaction and activity seem pointless. Loss of close 

comrades and friends in battle is associated with 

postwar distress and social dysfunction.149,150 Pivar 

and Field found that grief-specific symptoms can be 

distinguished from other war trauma-related symptoms in combat veterans with PTSD. In their sample, 

veterans’ mean scores on grief measures 30 years after 

their losses were higher than those found in studies of 

midlife individuals whose spouses had died within the 

previous 6 months.151 The authors argued that unresolved grief will endure over time for many individuals if not addressed by clinical intervention. Indeed, 

treating symptoms of unresolved grief may be as 

important as treating fear-based symptoms associated 

with PTSD. Unfortunately, treatment for traumatic or 

complicated grief has received relatively little formal 

evaluation. However, most treatments include education about grief, restructuring of cognitive distortions 

about events, restoration of positive memories of the 

deceased, acknowledgment of caring feelings toward 

those lost, retelling the story of the death, and help in 

tolerating painful feelings.152 Elements of treatment 

for PTSD can be adapted for treatment of complicated 

grief.153

Physical Health Problems 

PTSD is associated with poorer perceived health 

status, greater somatic complaints, greater number 

of chronic health problems, and increased levels of 

healthcare utilization.13,18,154–156 Overall, studies suggest 

that PTSD mediates the relationship between war zone 

exposure and physical health for both men and women.155 The majority of veterans seeking PTSD treatment 

do not engage in preventive health behaviors (eg, 

exercise and medical screening) at levels consistent 

with healthcare guidelines.157 These issues should be 

assessed and, if necessary, addressed in treatment.

Attention to management of health problems in 

veterans with PTSD is especially important in light 

of the “graying” of the veteran population. Veterans 

with PTSD report greater increases in psychological 

and physical symptoms during retirement than other 

veterans.158 Some research suggests that the challenges 

of aging may be associated with exacerbation of PTSD 

symptoms.159,160 Davison and colleagues, for example, 

described a phenomenon observed in aging combat 

veterans that they labeled late-onset stress symptomatology, or “LOSS.” For many veterans who experienced 

highly stressful combat events in early adulthood, and 

then managed to function successfully throughout 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

their lives without chronic stress-related disorders, 

the changes of aging are associated with increased 

combat-related thoughts, memories, and symptoms.159

The strong relationships between PTSD and health 

outcomes also extend to OIF returnees.161 For this latter 

population, early severity of physical injury is strongly 

associated with development of later PTSD or depression.162 Such findings support the need for increasing 

integration of mental health screening and services in 

primary care and other medical settings. 

Traumatic Brain Injury 

The high rate of co-occurring traumatic brain injury 

(TBI) and PTSD in those returning from deployment to 

Iraq and Afghanistan poses clinical challenges that are 

ill understood at present. Evidence suggests that PTSD 

can develop following both mild and severe TBI, even 

in individuals who have lost consciousness during the 

event or display posttraumatic amnesia.163 In one study 

of military personnel deployed to Iraq, mild TBI (ie, 

concussion) was found to be strongly correlated with 

PTSD and physical health problems 3 to 4 months 

after return to the United States. The relationship 

between mild TBI and health was largely mediated 

by PTSD and depression.164 Thus, PTSD treatment 

for those with TBI may need to include modifications 

that address difficulties that may be associated with 

injury, including difficulty in retrieving the traumatic 

memory, comprehending and remembering treatment 

recommendations, and reporting on symptoms and 

experience. Bryant et al demonstrated that civilians diagnosed with mild TBI and acute stress disorder could 

be effectively treated with a brief cognitive-behavioral 

therapy protocol designed to prevent development of 

PTSD.165

AREAS OF IMPAIRED FUNCTIONING

Family 

The anger, emotional numbing, and social withdrawal often associated with PTSD can isolate veterans 

from their families. PTSD veterans and their partners 

report more problems in their relationships and more 

difficulties with intimacy (and have taken more steps 

toward separation and divorce) than veterans without 

PTSD and their partners. The degree of relationship 

distress is correlated with the severity of veterans’ 

PTSD symptoms, particularly symptoms of emotional 

numbing.34 Emotional numbing symptoms are also 

correlated with perceived relationship quality with 

children.166 Higher levels of PTSD symptoms (avoidance and emotional numbing symptoms in particular) 

may lower parent–child relationship satisfaction.167

Men reporting combat as their worst trauma are more 

likely to be divorced and physically abusive to their 

spouses than men reporting other traumas as their 

worst experience.168 

Partners of those with PTSD are significantly 

affected by the symptoms of their loved one and 

experience burdens associated with care giving.169

Compared to partners of Dutch peacekeepers without 

PTSD symptoms, partners of peacekeepers with PTSD

symptoms reported more sleep and somatic problems, 

more negative social support, and poorer marital relationships.170 PTSD symptomatology places veterans at 

increased risk for perpetrating relationship aggression 

against their partners.171 Such findings suggest that 

more attention should be paid to supporting partners. 

Treatment goals should include reduction of problems 

for the partner and family. 

A treatment focus on improvement of family functioning would suggest that steps should be taken 

to more systematically involve spouses or partners 

in care.172,173 Significant others can be included in 

the assessment process, in the setting of treatment 

goals, and in treatment itself. Although couples’ 

interventions require systematic development, early 

work suggests that they can reduce survivors’ selfreported levels of anxiety and depression.174 However, 

combining family therapy with exposure is not more 

effective than exposure alone in reducing symptoms 

of PTSD.175

Social Connections 

Military-related PTSD is often associated with 

withdrawal from participation in social activities, 

limited friendships, and reduced emotional intimacy.34,176,177 As noted above, some research suggests 

that veterans with PTSD have greater rates of social 

anxiety disorder. Poor social support predicts development of PTSD and a more chronic course of the 

disorder. Veterans with PTSD who are more involved 

in the community are more likely to show remission 

in PTSD symptoms than those with less community 

involvement7 and adjustment to peacekeeping stressors is significantly related to self-disclosure, especially to supportive significant others.178 Overcoming problems in social functioning and promoting 

social participation may require active, sustained 

intervention. When indicated, improvements in 

social functioning should be established as a formal 

treatment goal.
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Workplace 

Evidence indicates that PTSD impairs work performance and reduces work productivity.179 Savoca and 

Rosenheck found that, on average, veterans with a 

lifetime diagnosis of PTSD were less likely to be currently working than veterans who did not meet diagnostic criteria.180 Among those who were employed, 

veterans with PTSD earned less per hour. Veterans 

with more severe symptoms were more likely to work 

part-time or not at all. Men reporting combat as their 

worst trauma are more likely to be unemployed, or 

fired, compared to men reporting other traumas as 

their worst experience.168 It has been suggested that 

even modest reductions in PTSD symptoms may lead 

to employment gains, even if the overall symptom 

levels remain severe.181

No interventions to date have targeted the workplace functioning of individuals with PTSD. It would, 

however, seem useful for clinicians to assist employed 

patients to apply stress and anger management 

skills on the job. Patients could also be taught to use 

problem-solving skills in difficult situations. These 

strategies would help reduce the impact of traumatic 

stress reactions on this important domain of patient 

functioning.

TREATMENT OUTCOME RESEARCH

Reviews of the impact of PTSD interventions have 

generally concluded that PTSD treatment can be efficacious.182 In their meta-analysis of PTSD outcome studies, Bradley and colleagues183 reported that 40% to 70%

of trauma survivors included in controlled research 

trials showed substantial reduction in symptoms or 

were no longer diagnosablewith PTSD posttreatment. 

To what extent these gains are sustained beyond6 to 12 

months following completion of treatment is relatively 

unknown. Although there is little empirical support 

for group-administered treatments at present,184,185 

research suggests that several kinds of individually 

administered psychological interventions, including 

exposure-based interventions (eg, PE), EMDR, CPT, 

and SIT, are effective in reducing PTSD symptomatology. 

CPT and PE were compared in treating a sample 

of chronically distressed rape victims with PTSD.186

Compared to a group of victims receiving only minimal attention and assessment, both treatments were 

effective in reducing PTSD and depression symptoms. 

CPT was superior to PE in reducing some kinds of guilt 

cognition. Some research has suggested that adding 

CT to PE appears not to improve PTSD outcomes,187,188

but findings are mixed.186,189 It should be noted that 

although CT and exposure have been separated for 

research purposes, they are usually combined in 

clinical practice. For example, PE treatment includes 

extensive processing of trauma memories that assists 

in modification of trauma-related cognition. CPT combines repeated writing about the trauma memory with 

a systematic approach to challenging negative beliefs 

or meanings associated with the trauma.

The few studies that have compared CT and imaginal (not in vivo) exposure have found no significant 

differences between the two approaches at the end of 

treatment.190 However, a long-term, 5-year follow-up of 

patients who had taken part in a randomized clinical 

trial comparing imaginal exposure and CT showed a 

clear superiority of CT,191 although there had been no 

difference at 12 months posttreatment. Those receiving 

CT showed significantly fewer PTSD symptoms and 

were less likely to meet criteria for PTSD. Indeed, no 

patients who received CT were diagnosed with full 

PTSD, compared to 29% of those who received imaginal exposure. These results cannot be generalized 

to exposure treatments, however, because imaginal 

exposure should be combined with in vivo exposure 

for best effects.

There is little research comparing cognitivebehavioral or other psychological interventions to 

medications or examining the combination of these 

approaches for treating PTSD. Individuals with PTSD 

were randomly assigned by van der Kolk et al to eight 

sessions of EMDR, 8 weeks of fluoxetine, or placebo. 

Immediately following treatment, there were no differences among the three groups. At 6-month follow-up, 

the EMDR group was more likely to show reductions 

in PTSD symptom severity and remission and depression symptoms than the other two groups.192 For individuals showing only a partial response to sertraline, 

PE treatment has been found to further reduce PTSD 

severity following 10 weeks of medication treatment.193

More research is needed before recommendations 

regarding the relative and combined effectiveness of 

medications and psychosocial interventions can be 

made with confidence.

Research With Veterans and Active Duty Military 

Personnel 

Several studies have examined various traumafocused interventions with veterans who have combatrelated PTSD. Individually administered imaginal 

(without in vivo) exposure has been associated with 

modest but significantly improved PTSD symptom 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

outcomes compared to other treatment as usual.194–196

Glynn et al found that a combination of imaginal exposure plus cognitive restructuring was more effective 

than a wait-list control condition.175 These studies also 

suggested that in veterans with chronic PTSD, avoidance and emotional numbing symptoms may respond 

less well to treatment than symptoms of reexperiencing 

and hyperarousal. 

Schnurr et al compared two treatments for male 

veterans with chronic PTSD: (1) trauma-focused group 

psychotherapy, and (2) a present-centered comparison treatment that avoided detailed discussion of the 

military trauma.197 Weekly group treatment was provided for 30 weeks (followed by 5 monthly “booster” 

sessions). Follow-up assessments were conducted at 

the end of treatment (7 months) and at the end of the 

booster sessions (12 months). A subset of participants 

was also followed up at 18 and 24 months. Both treatments resulted in modest but significant improvements in PTSD symptoms and other outcomes, but 

no differences between the two interventions were 

observed.

In a trial of CPT, significant improvements were 

reported in PTSD and comorbid symptoms in those receiving CPT compared with a wait-list control group.198

Forty percent of the intention-to-treat sample receiving 

CPT did not meet criteria for a PTSD diagnosis at posttreatment, and 50% had a reliable change in their PTSD 

symptoms.198 The positive effects of CPT extended 

beyond PTSD symptoms to include improvements in 

frequently co-occurring symptoms of depression and 

general anxiety, affective functioning, guilt, and social 

adjustment. This trial provides some of the most encouraging results to date related to treatment of male 

veterans with chronic PTSD. 

Positive results have also been obtained with female 

veterans with chronic PTSD. Schnurr et al compared 

two types of individually administered cognitivebehavioral therapy—PE and present-centered therapy 

(a supportive intervention)—for female veterans 

with PTSD in an RCT. PE treatment was associated 

with greater reduction of PTSD symptoms, decreased 

likelihood of meeting PTSD diagnostic criteria, and 

greater total remission (15.2% vs 6.9%) posttreatment 

and at follow-up.199 This study is especially significant 

in that it demonstrated increased impact of PE when 

compared with a well-designed alternative treatment, 

and when delivered by practitioners in the VHA and 

DoD health care systems.

Studies have also investigated the effectiveness 

of EMDR as a treatment for veterans with PTSD. A 

number of studies have produced positive findings 

with veterans,200,201 but there is some reason for concern 

that changes may not be maintained over time. For 

example, Devilly and colleagues found that Australian veterans treated with EMDR were initially more 

likely to display reliable posttreatment improvement 

in trauma symptomatology than those in a control 

group, but that at 6-month follow-up, reductions in 

symptomatology were not maintained and there were 

no differences between groups.202 A 5-year follow-up 

evaluation of 13 US combat veterans of the Vietnam 

War with chronic PTSD who participated in a study 

of EMDR found that the moderate therapeutic benefits that were obtained immediately were lost at 

5-year follow-up. Furthermore, there was an overall 

worsening of PTSD symptomatology over the 5-year 

follow-up period in both EMDR-treated subjects and 

nontreated control subjects.203

Some research with veterans has targeted the sleep 

disturbance associated with PTSD. In a placebo-controlled, blinded study of veterans of multiple conflicts, 

prazosin was found to be significantly more effective 

than placebo in reducing trauma nightmares, improving sleep quality, and improving the general clinical 

condition of the treated patients.204 Prazosin has also 

been effective with OIF returnees.205 In an uncontrolled 

investigation, Forbes et al offered preliminary evidence 

for the impact of imagery rehearsal therapy in veterans with PTSD.206 The treatment reduced nightmare 

frequency and intensity and overall PTSD, depression, and anxiety symptomatology. Changes were 

maintained at 12-month follow-up. Some research has 

suggested that imagery rehearsal therapy can reduce 

nightmares and improve sleep quality in civilians 

with PTSD.207

In a comprehensive review of PTSD treatment effectiveness, the Institute of Medicine Committee on 

Treatment of Posttraumatic Stress Disorder applied 

conservative methodological criteria and found that 

the research evidence is sufficient to conclude that 

exposure therapies are efficacious in the treatment of 

PTSD.208 The Institute of Medicine found that the evidence for other psychopharmacological treatments and 

psychosocial interventions is inadequate to reach clear 

conclusions. It was also judged that the evidence supporting PE was less consistent for veteran populations, 

especially male veterans with chronic PTSD. Generally, 

treatment outcomes in veteran samples have been less 

robust than those obtained with civilian groups.183

The reasons for this are not well understood, but may 

include a number of factors. Those who seek treatment 

at VHA hospitals may have more severe pathology 

than some civilian samples. Veteran samples have 

typically been characterized by PTSD that has existed 

for many years. Veterans seeking care for chronic 

PTSD may represent a treatment-refractory subgroup 

of the more general PTSD veteran population. Veter-
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Combat and Operational Behavioral Health

ans whose problems were more malleable may have 

already recovered and thus be underrepresented in 

the treatment system. The PTSD disorder commonly 

observed in veterans may also differ in various ways 

from PTSD among other groups. Or, the compensation system for PTSD may cause some veterans to be 

reluctant to report symptom improvement.

Posttraumatic Stress Disorder Program Evaluation 

Some uncontrolled studies have evaluated individual treatment programs for veterans.209,210 Johnson 

et al analyzed the outcome of a 4-month intensive 

inpatient program for combat-related PTSD among

Vietnam veterans.209,210 Comprehensive measures of 

PTSDand psychiatric symptoms, as well as social functioning, were assessed at admission, discharge, and 6, 

12, and 18 months after discharge from the intervention 

program. The study showed an increase in symptoms 

from admission tofollow-up, but a decrease in violent 

actions, thoughts, and legal problems. Family and 

interpersonal relationships and overall morale were

improved at discharge but then returned to pretreatment levels at 18 months. 

Johnson et al conducted a long-term follow-up of 

the program at 18 months and 6 years later because 

previous studies had shown that program impact on 

course of illness had been negligible.211 The sample 

of 51 veterans showed an extremely high mortality 

rate of 17% over 6 years. Nearly three-fourths of the 

sample had experienced an inpatient hospitalization. 

Self-ratings showed significant improvement in all 

areas of functioning except employment, and a positive view of the effects of the program. The majority 

had experienced some improvement in their ability to 

cope with their chronic illness and decreased their use 

of violence and substance abuse. Nevertheless, most 

continued to experience high levels of symptomatology with worsening of hyperarousal symptoms and 

social isolation. 

Bolton et al studied veterans with PTSD who participated in a series of groups focusing on understanding 

PTSD (education), stress management, and anger management.212 Although the impact on PTSD symptoms 

was small, there were moderate impacts on depression 

and overall life satisfaction, and strong declines in 

reports of recent violent behavior and improvements 

in self-reported physical health. Ready et al185 evaluated a VHA specialized PTSD outpatient program 

that delivered a three-phase treatment that included 

group-based exposure therapy. At posttreatment and 

at 6-month follow-up, veteran patients showed significant reductions in PTSD symptoms.185

Findings of evaluations of individual PTSD programs are difficult to generalize to the larger population of treatment programs. However, larger scale 

evaluations of PTSD treatment are available. Creamer 

et al reported on the effectiveness of hospital-based 

programs for Australian veterans with PTSD.213 These 

group-based programs deliver a set of cognitivebehavioral interventions, including psychoeducation 

about PTSD and its treatment; symptom management for anxiety and depression; anger management; 

interpersonal, problem-solving, and communication 

skills training; attention to substance abuse, physical 

health and lifestyle issues; and relapse prevention. 

Trauma focus work (or direct therapeutic exposure) 

is delivered in group or individual formats or both. 

Individual counseling is provided throughout the 

12 weeks, in addition to regular medication reviews. 

Education and support are provided for veterans’ 

partners, often in the form of a weekly group. Overall, individuals in these programs showed significant 

improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. 

Changes occurred most frequently between admission 

and 3 months posttreatment, and were maintained at 

9 months. Patients and partners reported perceived 

improvement and strong satisfaction with treatment. 

Nevertheless, treatment gains were variable and, for 

most veterans, considerable pathology remained following the program. Creamer et al reported 2-year 

follow-up outcomes for 1,508 Australian veterans 

receiving care in the same treatment system. Selfreport measures of PTSD,214 anxiety, depression, anger, 

alcohol use, and general functioning showed significant improvements at 6 months (with smaller gains 

continuing through to the 24-month assessment) for 

PTSD (effect size = 0.8), anxiety (0.5), and depression 

(0.5). These results suggest that specialized treatment 

programs for combat-related PTSD can be effective and 

that improvements are maintained over time.

As noted earlier, existing treatments are often not as 

effective for veterans as they are for civilian populations with PTSD. Studies of individual programs attest 

to the difficulty of treating PTSD in veterans whose 

problems have lasted many years. Veterans themselves 

report greater satisfaction with participation in specialized PTSD programs than nonspecialized psychiatry 

programs215 and high absolute levels of satisfaction.216

National program evaluation in VHA PTSD residential 

rehabilitation programs shows significant decreases 

in PTSD symptoms, alcohol and drug abuse, and violence,216 but the magnitude of changes in PTSD is modest. Increasingly, PTSD is treated in outpatient settings. 

Therefore, future research should compare the impact 

of various forms of intensive outpatient treatment on 

the full range of outcomes related to traumatization. 
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Treatment of Deployment-Related Posttraumatic Stress Disorder

TOWARD IMPROVEMENT OF POSTTRAUMATIC STRESS DISORDER SERVICES

to monitor changes in key indicators throughout 

treatment, to evaluate the impact of intervention, 

and to inform ongoing redesign of treatment. At 

the level of the treatment program, outcomes-based 

program evaluation can assist teams with redesign 

of services to ensure program improvement over 

time. Ongoing administration of validated questionnaires as measures of change has not been standard 

practice in PTSD treatment or in mental health 

treatment generally. With the use of computerized 

self-administration of measures, this situation can be 

expected to change, thereby leading to more rapid 

improvement of treatment. 

In many settings, including the VHA, PTSD treatment is commonly delivered through programs that 

combine delivery of focal PTSD treatment with other 

intervention components designed to address concurrent disorders and difficulties.223 Treatment of PTSD 

in such programs commonly involves participating 

in both individual and group activities that includes 

individual assessment, PTSD education classes, 

problem-targeted groups (eg, anger management 

groups, communication skills groups), trauma-focused 

interventions (eg, PE), case management, and pharmacotherapy. Treatment programs are often delivered in 

phases, with a beginning, middle, and end of active 

treatment, followed by lower-intensity maintenance 

support as needed. Little is known about the best way 

to organize these structures of care. More research into 

the types of services that are being provided and the 

real-world effectiveness of such services is required. 

Establishment of systematic outcome monitoring of 

treatment programs can facilitate research and enable 

comparison of treatment structure. 

In fact, there are many treatments for PTSD and 

co-occurring problems,224 and new treatments are 

being developed at an increasing rate. The increasing complexity of the field means that, especially in 

large-scale treatment systems like the DoD and VHA, 

it will be important to develop more effective ways to 

“manage knowledge” within the field of PTSD.225 It 

will also be important to help providers upgrade their 

information, acquire new skills, and learn new interventions, as well as to assist providers and program 

managers in sharing experiences and learning from 

one another’s efforts. 

Despite the existence of a VHA-DoD clinical practice guideline for PTSD that spells out recommended 

practices derived from clinical consensus and research 

findings (available online at www.QMO.amedd.

army.mil or www.oqp.med.va.gov/cpg/cpg.htm), 

there is wide variation in treatment of deploymentrelated PTSD within VHA217 and DoD healthcare 

systems and in the civilian community. Programs 

vary along many dimensions, including the nature 

of interventions, intensity of treatment, balance of 

group or individual therapy, and relative reliance on 

psychosocial interventions versus medication. This 

variation reflects the fact that there are many ways of 

structuring care for PTSD and many treatment options 

that may in principle be concordant with treatment 

guidelines. However, variation in treatment practices 

illustrates the challenge of ensuring that key elements 

of practice guidelines are implemented in routine care. 

Central to service improvement is the dissemination of 

evidence-based treatments.218 Consistent with reviews 

of the general PTSD treatment outcome literature, the 

VA/DoD clinical practice guideline endorses four 

interventions most strongly: (1) exposure therapy, 

(2) CT, (3) SIT, and (4) EMDR. In the past, empirically supported treatments for PTSD have not been 

widely available in most treatment settings, including 

military mental health settings and the VHA.219 Some 

treatments, such as PE, have occasionally been seen 

as difficult or risky to administer, despite the fact that 

the evidence does not support the validity of these 

perceptions.187,220 In the civilian community, Becker 

et al found that two major barriers to clinician use of 

exposure therapy in treatment of PTSD are (1) lack of 

sufficient training, and (2) concern about the safety of 

exposure therapy.221 Findings from research evaluating 

whether more patients drop out from PE than other 

treatments for PTSD and whether PE causes symptom 

worsening have not supported such concerns.222 Dissemination initiatives are now underway to ensure 

that PE and CPT are accessible to veterans and active 

duty personnel with PTSD.

In addition to implementation of evidencebased interventions, another important way to 

use evidence to enhance treatment delivery is to 

establish routine monitoring of outcomes in PTSD 

services. For the individual clinician, it is important 

SUMMARY

Management of deployment-related PTSD has been 

changing rapidly. Screening for PTSD is widespread, 

returning personnel are informed about the disorder, 

and the VHA and DoD have collaborated to establish 

clinical practice guidelines for responding to the specific needs of those with PTSD. As treatment systems 
312

Combat and Operational Behavioral Health

evolve, it is critical that more and better quality evaluation of treatment effectiveness be undertaken. More 

treatment outcome research is needed, and program 

evaluative outcomes monitoring, if extended routinely 

to active duty and veteran treatment systems, can 

inform all aspects of care and enable more rapid and 

effective improvement of services. Because PTSD is 

associated with a wide array of co-occurring disorders 

and associated problems in living, assessment and 

program evaluation must be expanded beyond PTSD 

symptomatology. And because PTSD and other posttraumatic problems affect the whole family, their needs, 

too, should receive consideration when evaluating and 

providing services. More systematic monitoring of the 

effectiveness of PTSD services, along with increasing 

systemic and public knowledge of PTSD, will inform 

discussions on disability, fitness for military service, 

and, most importantly, what constitutes satisfactory 

support following deployment. As approaches to treatment of deployment-related PTSD continue to develop, 

the authors anticipate that use of evidence-based 

practices will increase, routine evaluation of outcomes 

will become standard practice, and care decisions will 

become increasingly guided by empirical data. 

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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

Chapter 20

the continuum of care for 

new combat veterans and 

their families: A PUBLIC HEALTH

approach

HAROLD KUDLER, MD*; ALFONSO R. BATRES, PhD†; CHARLES M. FLORA, MSW‡; TERRY C. WASHAM, 

MSSA, LISW§

; MARSHALL J. GOBY, PhD¥; and LAURENT S. LEHMANN, MD¶

INTRODUCTION

A BRIEF OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS

Readjustment Counseling Service: The Vet Centers

Seamless Transition, Care Management, and Social Work

SERVICES FOR VETERANS OF AFGHANISTAN AND IRAQ

NEW PROGRAMS FOR COMBAT VETERANS AND THEIR FAMILIES

The Joint Conference on Postdeployment Mental Health

The Public Health Model for Deployment Mental Health

Post-Deployment Health Re-Assessment: A New Level of Service Integration

Battlemind Training

Extending and Strengthening the Continuum of Care

BEYOND THE DEPARTMENT OF DEFENSE/VETERANS AFFAIRS CONTINUUM

State and Community Partnerships

Key Elements Replicable in Every State

Summary

*Associate Clinical Professor, Department of Psychiatry, Duke University Medical Center, Durham North Carolina; Associate Director, Mental Illness 

Research, Education and Clinical Center, Mid-Atlantic Veterans Integrated Service Network (VISN 6), VA Medical Center, 508 Fulton Street, #166A, 

Durham, North Carolina 27705 

†

Chief Officer and Director, Readjustment Counseling Service, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420 

‡

Associate Director, Readjustment Counseling Service, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420

§

Colonel, Medical Service Corps, US Army Reserve; Military Liaison Coordinator, Office of Seamless Transition, Department of Veterans Affairs, VA 

Medical Center, 10000 Brecksville Road, Brecksville, Ohio 44141

¥

Colonel, US Army (Retired); Team Leader/Supervisory Psychologist, Veterans Affairs Readjustment Counseling Service, Palm Beach Veterans Center, 

2311 10th Avenue North, #13, Lake Worth, Florida 33461; formerly, Reserve Psychology Consultant, Office of The Surgeon General, US Army, Falls 

Church, Virginia

¶

Associate Chief Consultant in Mental Health, Office of Mental Health Services, Department of Veterans Affairs, 810 Vermont Avenue NW, Room 966, 

Washington, DC 20420
326

Combat and Operational Behavioral Health

INTRODUCTION

On October 16, 2003, the US House of Representatives Committee on Veterans’ Affairs held a hearing 

on healthcare for veterans, later published as Handoff 

or Fumble? Do DoD and VA Provide Seamless Health Care 

Coverage to Transitioning Veterans?1 Testimony summarized developments to that date, including the push 

for systematic, standardized posttraumatic stress disorder (PTSD) screening and triage for all patients seen 

in Department of Defense (DoD) and Department of 

Veterans Affairs (VA) primary care and mental health 

settings; the release of the DoD/VA Clinical Practice 

Guideline for Management of Post-Traumatic Stress2; 

the placement of VA liaisons in major military medical 

treatment facilities (MTFs); the importance of coordination between medical personnel and chaplains 

in identifying and reaching out to veterans and their 

families; and the need for new information technologies capable of integrating best practices into DoD and 

VA computerized medical record systems. 

A key observation made in this hearing was that 

the VA is the world leader in the care of post-traumatic stress disorder, but its clinical and research programs have primarily been directed towards veterans 

who suffer from chronic PTSD from Vietnam, Korea, 

and World War II. Starting with the first Gulf War and 

gaining momentum with [the attacks of] September 

11 [2001 and] the conflicts in Afghanistan and Iraq, 

the VA is learning to tackle PTSD proactively.2(p40)

Furthermore, it was noted that 

real grunts see post-traumatic stress disorders, not as 

a reaction of a normal person exposed to a very abnormal situation, but rather, as a failure of training, of 

leadership, strength, or, perhaps, character. This is a 

stigma and it’s the single greatest impediment to effective intervention and continuity of care.2(p41)

This observation was subsequently validated by 

Hoge et al in their seminal report, “Combat Duty in 

Iraq and Afghanistan, Mental Health Problems, and 

Barriers to Care,” that appeared in the New England 

Journal of Medicine in July 2004.3 These considerations 

helped set the stage for the ongoing efforts to strengthen and integrate the continuum of care for combat 

veterans and their families across DoD, VA, state, and 

community settings described in this chapter. 

A BRIEF OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS

Although the VA is well known nationally and internationally, it may still be helpful to provide a brief 

description of what the VA is and who it serves. The 

following information is primarily derived from the VA 

Web site, www.va.gov.4

 Established as a cabinet-level 

agency in 1989 succeeding the Veterans Administration, the department is responsible for providing federal benefits to veterans and their families. Its mission 

is inspired by the words of Abraham Lincoln’s second 

inaugural address, delivered in the final days of the 

Civil War: “to care for him who shall have borne the 

battle and for his widow and his orphan.” Headed by 

the Secretary of Veterans Affairs, the VA is the second 

largest of the 15 cabinet departments. The VA operates nationwide programs for healthcare (the Veterans 

Health Administration [VHA]), financial assistance 

(the Veterans Benefits Administration [VBA]), and 

burial benefits (the National Cemetery Administration). In fiscal year 2007, the VA’s spending totaled 

over $80 billion, including $34.9 billion for healthcare 

and $41.5 billion for benefits. 

Of the 24 million American veterans currently 

alive, nearly three quarters served during a war or 

an official period of conflict. About a quarter of the 

nation’s population, approximately 74.5 million, 

are potentially eligible for VA benefits and services 

because they are either veterans, family members of 

veterans, or survivors of veterans. The VHA provided 

healthcare to almost 5.5 million people in 2006, a 29% 

increase since 2001. By the end of fiscal year 2006, 78% 

of all disabled and low-income veterans had enrolled 

for VA healthcare, and 65% of these had received care 

from the VA. The VA provides care at over 1,400 sites, 

including 155 VA medical centers, 872 communitybased outpatient clinics, and 209 community-based 

Vet Centers. Expansion plans will bring the number of 

Vet Centers to 232. Facilities are located in all 50 states 

and in the District of Columbia, Puerto Rico, Guam, 

and the Philippines. VA services also extend over time: 

as of December 2007, VA was providing benefits to 

three children of Civil War veterans and 232 children 

and widows of Spanish–American War veterans. The 

VA also provides medical backup to DoD at times of 

national emergency or disaster. 

The VA is the nation’s largest provider of graduate 

medical education and a major contributor to medical 

and scientific research. Each year about 90,000 health 

professionals train in VA medical centers, and more 

than half of the physicians practicing in the United 

States received some part of their professional education through the VA. The quality of VA medical care 

significantly exceeds that of the Medicare fee-forservice program across a wide range of objective 

performance measures.5
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

Readjustment Counseling Service: The Vet Centers

The Readjustment Counseling Service (RCS), also 

known as the Vet Center system, plays a unique and 

pivotal role in the DoD/VA/state/community continuum of care. RCS was established by Congress in 

1979 because of the recognition that many Vietnam 

veterans still struggled with readjustment problems 

years after that war’s end.6 Vet Centers are communitybased and staffed by small multidisciplinary teams 

of dedicated providers, many of whom are combat 

veterans. Services are available to any veteran who 

served in the military in a combat theater or anywhere 

during a period of armed hostilities. Family members 

are also eligible for Vet Center services, such as support 

for the families of veterans coping with deploymentrelated stress and bereavement counseling services to 

surviving parents, spouses, children, and siblings of 

service members (including federally activated reserve 

and National Guard personnel) who die of any cause 

while on active duty.

To better respond to the needs of the newest generation of US combat veterans, Congress authorized RCS 

to hire and train 100 veterans of Operation Enduring 

Freedom (OEF) or Operation Iraqi Freedom (OIF) 

as global war on terror (GWOT) outreach workers. 

These counselors provide briefings on readjustment 

and VA services to active and reserve component service members after deployment and help enroll new 

veterans in RCS and VA programs once they become 

eligible for services. Their shared military experience 

promotes rapport between GWOT outreach workers and their fellow OEF/OIF veterans, which helps 

greatly to reduce the stigma associated with discussing 

postdeployment problems. 

Vet Centers seek to increase the resilience of new 

combat veterans and their families through early 

intervention. The ultimate aim of these efforts is to 

prevent the development of more chronic postwar 

problems including occupational, marital/family, 

social, financial, or psychological problems. There is 

never a fee or co-pay for RCS services, and veterans 

do not have to be enrolled in VA healthcare to access 

them. Following a tradition of providing “help without hassles,” Vet Centers are designed to decrease the 

stigma that veterans and their families often associate 

with talking about deployment-related issues in traditional healthcare settings by providing a veteran- and 

family-centered approach emphasizing access and 

understanding. These characteristics of RCS have 

recently been featured (and sensitively portrayed) in 

Gary Trudeau’s Doonesbury cartoon series, which depicts the readjustment struggles of a newly returned 

OIF veteran as he works with his Vet Center counselor 

(himself a Vietnam veteran).7

In addition to psychological counseling for combatrelated trauma, RCS services include community 

outreach, case management and referral, supportive 

social services, and counseling for veterans who were 

sexually assaulted or harassed while on active duty. 

Vet Centers play an important role in connecting 

veterans with appropriate VA services. Since the first 

Vet Center opened, more than 2 million veterans have 

been served. Each year, RCS serves more than 130,000 

veterans and provides more than 1 million visits to 

veterans and family members.4

 From the beginning 

of the conflicts in Afghanistan and Iraq through the 

second quarter of fiscal year 2007, Vet Centers had 

contact with over 227,000 OEF/OIF veterans (this 

represents over one quarter of discharged OEF/OIF 

veterans to date). Over 54,000 of these new veterans 

presented directly to Vet Centers, and the remainder 

have been contacted at Post-Deployment Health ReAssessment (PDHRA) programs and through outreach 

efforts conducted primarily at active duty and reserve 

component demobilization sites. 

Seamless Transition, Care Management, and Social 

Work

In August 2003, to ensure that returning OEF and 

OIF combat veterans have timely access to VA care 

following discharge from military service, then-VA 

Secretary for Veterans Affairs Anthony Principi and 

Dr Michael J Kussman, deputy chief in the Office for 

Patient Care Services, undertook an unprecedented 

shift in VA policy. Dr Kussman, a retired Army general 

who had previously commanded Walter Reed Army 

Medical Center (WRAMC), arranged for VA social 

workers to work side-by-side with Army medical 

staff to facilitate the seamless transition of wounded 

veterans to VA medical care.8

 From the beginning of 

OIF, the VBA had stationed VA benefits counselors in 

DoD MTFs to inform wounded service members about 

VA services and help them begin the claims process. 

These benefits counselors could not, however, enroll 

service members for VA healthcare or transfer them to 

VA facilities. A new clinical system was needed that 

would involve VHA staff with the clinical experience 

needed to triage new veterans to the right level and 

location of care. In Dr Kussman’s words: “We just cut 

through the paperwork and got this going.”8(p17)

Within a month, a VA social worker from the Washington, DC, VA medical center was detailed to the new 

VA Seamless Transition Office at WRAMC. In rounding 

with the Army treatment teams, she and the VA social 

workers who took up the same efforts at Brooke, Eisenhower, and Madigan Army medical centers overcame 

the lack of a common computer record system (or even 

a shared set of paper forms) to develop innovative 
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Combat and Operational Behavioral Health

ways to help new veterans access needed VA services. 

One of their findings was that when a veteran was to 

be discharged from the MTF into care at a VA facility, it 

was often difficult to identify the person at the receiving facility responsible for ensuring follow-up. Within 

weeks, VA established a list of seamless transition 

points of contact for administrative issues and seamless transition care managers (usually social workers) 

for clinical issues at every VA medical facility and VBA 

regional office nationwide. Seamless transition workers 

at each VA medical center subsequently enlarged their 

scope of service to become the point of contact for all 

new combat veterans presenting to the VA. The success 

and value of this effort led the VA to develop what is intended to stand as a permanent policy8(p19) on DoD/VA 

care coordination. In January 2005, the VA established 

the Office of Seamless Transition to assist in working 

with the DoD on strengthening transition efforts. 

These transition efforts have continued to expand. 

The VA now has social workers and benefits counselors 

attached to 11 MTFs and the newly created “Center 

for the Intrepid” rehabilitation facility in San Antonio, 

Texas. The US Army surgeon general assigned an 

Army Medical Department soldier to each of the four 

VA polytrauma rehabilitation centers in March 2005 to 

assist all active duty service members and their families with transition issues. The VA has posted Army 

Wounded Warrior (AW2) soldier–family management 

specialists to VA medical centers across the nation. The 

VA also detailed a certified rehabilitation registered 

nurse to WRAMC to assist in the transition of soldiers 

to VA care. In 2006 the VA established a polytrauma 

call center operating 24 hours a day, 7 days a week, 

to help seriously injured service members and their 

families connect with needed care and benefits. The 

VA has formed a partnership with the National Guard 

Bureau that provides for 54 transition assistance advisors, one stationed in each state and territory, to assist 

with transition issues among National Guard members. The VA is working with the Army Manpower 

and Reserve Affairs program on the Army Physical 

Disability Evaluation System improvement initiative. 

These and other efforts, including a 2007 VA conference, “Evolving Paradigms: Providing Health Care to 

Transitioning Combat Veterans,” attended by 250 DoD 

and 1,000 VA participants, have further extended the 

integration of healthcare services and benefits provided by the DoD and VA. 

In March 2007, the Secretary of Veterans Affairs 

authorized a number of additional positions at VA 

medical centers and outpatient clinics to provide 

expanded support for OEF/OIF veterans and their 

families. Each VA medical center has a full-time nurse 

or social worker who serves as an OEF/OIF program 

manager. These program managers are the primary 

coordinators for VA liaisons stationed at MTFs. They 

work with, and manage the activities of, the VA facility 

case managers and points of contact to assure seamless transition for all OEF/OIF service members and 

veterans. Program managers oversee facility outreach 

efforts including PDHRA events to OEF/OIF veterans 

including National Guard and reserve members. They 

work closely with VBA regional offices to track claims, 

and they also assign case managers for all severely 

injured or ill OEF/OIF veterans and others who may 

need or want case management. 

Additionally, 100 transition patient advocates have 

been strategically distributed throughout the 21 veteran integrated service networks to function as ombudsmen for severely injured or ill OEF/OIF veterans 

and their families as they exit the military and enter 

the VA. The transition patient advocate, assigned to 

these service members while they are still at the MTF, 

arranges for the patients and their families to meet 

(virtually) with the treatment team at the receiving 

VA medical center and assists them with transition to 

the new medical center (escorting them when needed) 

and into the VA benefits system.9

 These programs are 

now organized under VA’s Care Management and 

Social Work Service.

Much of the success of this integration is built upon 

VHA Directive 2002-049.10 Enacted September 11, 

2002, it ensured that hospital care, medical services, 

and nursing-home care were made available to recent 

combat veterans for 2 years beginning on the date of 

the veteran’s discharge from military service. In January 2008, the period of service was extended to 5 years. 

During this 5-year period, these veterans are accorded 

high priority for VA care and are never charged a fee or 

co-pay for treatment of any illness that, in the clinician’s 

opinion, is attributable to military service. Veterans are 

encouraged to begin the application process for any 

appropriate service connection so that military-related 

medical problems can be identified and rated for VA 

care to continue after the initial 5 years have elapsed. 

The provisions of VHA Directive 2002-049 ensure that 

recently discharged service members have expedited 

and unambiguous access to VA services. 

In October 2007, the VA and DoD partnered to establish the Joint VA/DoD Federal Recovery Coordination 

Program to further integrate medical and nonmedical 

care and services. This program will focus on recovery, 

rehabilitation, and community reintegration to extend 

the close care coordination between the DoD and VA 

and across the lifetime continuum of care for severely 

injured service members, veterans, and their families. 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

SERVICES FOR VETERANS OF AFGHANISTAN AND IRAQ

As of February 2008, the DoD reported that 837,458 

OEF/OIF veterans had become eligible for VA services. 

The VA tracks their care through its Environmental 

Epidemiology Service.11 Of these new veterans, 39% 

(324,846) have already registered with the VHA for 

medical services (notably, the total number of OEF/

OIF veterans who have presented for VA healthcare 

at the time of this writing represents only about 6% of 

the VA’s current caseload).

Among the OEF/OIF veterans who have presented to VA medical facilities, the three most 

common health problems are (1) musculoskeletal 

injuries (including serious wounds and injuries 

but primarily joint and back problems commonly 

associated with deployment to the rocky terrains of 

Afghanistan and Iraq); (2) mental health problems; 

and (3) symptoms, signs, and ill-defined conditions. 

This third category is a diagnostic placeholder 

that designates a condition still in the process of 

evaluation. 

Mental health issues reported by OEF/OIF veterans 

who have so far presented for VA care are represented 

in Table 20-1 (note that these numbers reflect only 

OEF/OIF veterans who have presented to VA medical centers and registered for care through the VHA). 

Over 11,000 other OEF/OIF veterans with a possible 

diagnosis of PTSD have presented to Vet Centers but 

not to VA medical facilities. It must be emphasized that 

the table lists provisional diagnoses. In many cases, 

the categories simply represent the results of positive 

screens for mental health diagnoses. Although positive 

screens are strongly suggestive of a diagnosis, they are 

not the same as a diagnosis. The VA has developed a 

“pop-up” clinical reminder within its computerized 

medical record12 that prompts clinicians to screen 

OEF/OIF veterans for a number of mental health 

problems including PTSD, major depression, alcohol 

abuse or dependence, and traumatic brain injury. The 

range and number of mental health diagnoses can 

be expected to shift over time as clinical evaluations 

progress. 

Diagnoses may also shift as some health issues 

improve and others develop. The Walter Reed Army 

Institute of Research (WRAIR) has reported that the 

majority of soldiers diagnosed with PTSD or depression at 7 months postdeployment did not meet criteria 

for either condition during the first month after deployment.13 Given the stigma associated with mental 

health problems in general, and with postdeployment 

mental health problems in particular,3 veterans with 

such problems may be hesitant to discuss them when 

they first present for care. Over time, as a clinician–

patient trust develops and family or social pressure to 

seek help mounts, veterans and their family members 

may become more willing to report such problems. 

Kang and Hyams14 have shown that although the rate 

at which medical problems are reported among OEF/

OIF veterans in the VA is fairly constant, the rate at 

which mental health problems are reported increases 

with time. 

The VA findings summarized in Table 20-1 demonstrate the broad range of mental health diagnoses 

to consider, including about as many cases of mood 

disorder and substance abuse or dependence as of 

PTSD. A similar ratio was observed in New York 

City in the wake of the September 11, 2001, attack 

on the World Trade Center.15 Hoge et al3

 noted a 

significant increase in major depression and generalized anxiety disorder, as well as in PTSD, among 

recently deployed soldiers and marines. Postdeployment mental health cannot be about just 

PTSD anymore.

TABLE 20-1 

PROVISIONAL MENTAL HEALTH DIAGNOSES

AMONG OEF/OIF VETERANS PRESENTING 

FOR VA MEDICAL CARE

Diagnosis Number

Posttraumatic stress disorder 67,525* 

Acute reaction to stress 4,070

Nondependent abuse of drugs† 54,415

Depressive disorder 45,155

Affective psychoses 25,399

Neurotic disorders‡ 35,605

Alcohol dependence 11,245

Drug dependence 5,062

*21% of total

†

Excessive tobacco use accounts for a large portion of those identified 

as involved in nondependent abuse of drugs.

‡

This category includes a number of anxiety disorders such as generalized anxiety disorder and panic disorder.

OEF: Operation Enduring Freedom

OIF: Operation Iraqi Freedom

VA: Department of Veterans Affairs
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Combat and Operational Behavioral Health

NEW PROGRAMS FOR COMBAT VETERANS AND THEIR FAMILIES

As noted above, Hoge and colleagues at WRAIR 

demonstrated that the stigma associated with reporting postdeployment mental health problems may be 

the single greatest obstacle to accessing care.3

 Their 

2004 study reported findings from over 3,600 active 

duty soldiers and marines 3 to 4 months after their return from service in Afghanistan or Iraq. For example, 

they found that when asked whether they had concerns about their decision to receive mental healthcare, 

65% of these combat veterans were concerned that “I 

would be seen as weak,” 63% were concerned that “my 

leadership might treat me differently,” and 59% were 

concerned that “members of my unit might have less 

confidence in me.”3

The Joint Conference on Postdeployment Mental 

Health

Hoge and colleagues’ 2004 findings3 and strong 

interagency desire to optimize mental healthcare 

across the DoD/VA continuum inspired plans for a 

joint DoD/VA conference on postdeployment mental 

health. Held in Alexandria, Virginia, on March 8–10, 

2005, this conference was cochaired by Colonel Elspeth 

Ritchie, psychiatry consultant to the Army surgeon 

general, and Harold Kudler, MD, then cochair of the 

VA Under Secretary for Health’s Special Committee 

on PTSD. Among the over 50 participants were the 

assistant secretary of defense for health affairs; the 

deputy secretary for veterans affairs; the surgeons 

general of the Army, Navy, and Air Force; mental 

health experts from across the DoD and VA; other representatives of Army, Navy, Marine Corps, Air Force, 

Coast Guard, National Guard, and reserve forces; 

and leading researchers and health systems planners 

from across the DoD and VA. Given the composition 

of its membership and the agenda set, the meeting 

might have been expected to result in the definition 

of a medical model for assessing and treating PTSD, 

depression, substance abuse, and other mental health 

diagnoses. Instead, the participants concluded this 

historic conference by defining a public health model 

for deployment mental health that has set the tone for 

DoD/VA efforts ever since. 

The Public Health Model for Deployment Mental 

Health

The public health model sprang from the observation that most warfighters or veterans will not develop 

a mental illness, but that all warfighters or veterans 

and their families face important readjustment issues. 

These problems in living may be painful and at times 

disabling, but they are, nonetheless, normal responses 

to extreme stress rather than medical illnesses. Within 

the public health model, the focus is less on making 

diagnoses than on helping individuals and families 

retain or regain a healthy balance despite the multiple 

stressors associated with the deployment cycle. This 

approach incorporates the recovery model and other 

principles of the President’s New Freedom Commission on Mental Health,16 including the importance of 

fostering resiliency and independence. 

The term “recovery” is generally associated with the 

reduction or remission of symptoms and signs specific 

to a given disease. Recovery also refers to the process 

by which people become progressively more able to 

live, learn, work, love, and fulfill a valuable and satisfying role within their families and their communities 

despite an ongoing medical problem. Thus, “recovery” 

may not be the same thing as “cure.” As Parsons has 

shown,17 disease is a biomedical process, but illness 

is largely a social process in which a person who has 

a disease accepts the sick role and its implicit and explicit limitations. Not everyone who has a disease lives 

within the sick role; there is a difference between having a significant problem (even a significant medical 

problem) and being disabled. Even when the signs and 

symptoms of disease are clearly disabling, recovery 

can be understood as the ability to live a fulfilling and 

productive life despite medical limitations. Recovery 

might also be understood as a life in which hope succeeds in sustaining the individual and the family even 

when medical efforts have failed.

“Resilience” refers to the qualities of an individual, 

a family, or a community that enable it to cope and 

rebound despite extreme stress. Resilience likely has 

psychological, biological, and social underpinnings 

with a different configuration in every person, family, 

and society. Resilient people retain or regain a sense of 

mastery, competence, and hope in response to adversity. Jerome Frank, who served as an Army psychiatrist during World War II, and went on to study how 

people cope with and recover from illness and stress 

in diverse cultures,18 suggested that the restoration 

of morale was the common element in all successful 

forms of therapy.19

A public health model, while medically informed, 

is quite different than a traditional medical model. It 

coordinates the efforts of traditional medical programs 

but also extends into nonmedical settings. In a public 

health model based on recovery and resilience, the 

question is less “How do you feel?” than “How are 

you doing?” New combat veterans usually experience 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

the first question as insensitive and difficult to answer. 

The latter question places the focus on function and 

readjustment and will, therefore, engage the veteran 

in a more useful conversation.20

Hoge et als’ findings,3 and the VA utilization statistics provided above, demonstrate that it is not sufficient 

to announce that effective mental health treatment 

exists within the DoD and VA. Although many will 

appreciate the offer of care, only a minority will access 

it; the stigma associated with needing help is simply 

too powerful. The public health model circumvents 

the stigma associated with traditional mental health 

services by reaching directly into primary care settings 

and into the larger community. The primary care clinic 

is the de facto mental health system for a significant 

portion of the population. In times of trouble, people 

trust their primary care providers more than any other 

authority in their community.21 Web sites and public 

service announcements help get the word out, but for 

the message to take hold and access to be maximized, 

it is necessary to partner with allies in the greater 

community. Among the most important of these is 

the veteran’s family, because family members often 

decide when and where the veteran will seek help. Furthermore, resilient, supportive families significantly 

increase the resiliency of their members.22,23

Other allies include DoD and VA chaplains, DoD’s 

family support programs for active and reserve component members, military medical boards, VBA, local 

health providers (including TRICARE providers), 

community mental health centers, public schools, 

local colleges (where many new combat veterans 

study), employers, local congregations, military unit 

associations, and veterans’ service organizations. Military OneSource, a telephone and Web-based service 

available free of charge to service members and their 

families through a contract with DoD,24 is a confidential and highly accessible outreach tool, but its service 

is most effective in coordination with the full range of 

public health resources available to veterans. 

The highly successful Vet Center program was 

founded on public health principles and serves as a 

model for current efforts. RCS was specifically engineered to meet the needs of those Vietnam veterans 

who had reservations about seeking care at VA medical centers. RCS Vet Centers are neither hospitals nor 

mental health centers; they are community-based 

“storefront” operations. As its name clearly implies, 

RCS is about readjustment, not about mental illness. 

RCS freely involves family members and encourages 

them to share their concerns and express their own 

needs. RCS has proven effective in overcoming the 

stigma that kept many combat veterans from presenting to military or VA medical centers. Current public 

health efforts to reach a new generation of combat 

veterans and their families build upon the success of 

the RCS model. 

Because the needs of OEF/OIF veterans and their 

families change over time (as does their access to different services), the public health approach requires a 

progressively engaging, phase-appropriate integration 

of services across the DoD/VA continuum. This program must (a) be driven by the needs of the veterans 

and their families rather than by existing organizational structures and processes; (b) meet prospective 

users where they live rather than wait for them to find 

their way to the right mix of services; and (c) better 

articulate the transition between DoD and VA. Shared 

computerized medical record systems, and standardized, longitudinal follow-up of mutually agreed upon 

baseline assessment measures may in time significantly strengthen the DoD/VA continuum of care. There is 

also an opportunity to optimize the interplay between 

the DoD medical board and the VBA service connection processes to accelerate the rate at which new 

veterans and their families can access the constellation 

of services designed to meet their needs.

Post-Deployment Health Re-Assessment: A New 

Level of Service Integration

In recognition that physical health, mental health, or 

other readjustment problems may not be immediately 

apparent or may take time to develop,3

 DoD developed 

the PDHRA as a follow-up to the postdeployment 

health assessment performed at the time of return from 

a contingency operation. PDHRA is performed 3 to 6 

months postdeployment to ensure timely outreach, 

education, training, screening, assessment, triage, 

treatment, and follow-up. This intervention incorporates a nonpathologizing public health approach 

framed within a global health initiative. 

Screening utilizes a standardized tool, the DD 

Form 2900. Service members fill out the self-report 

section of the form within the context of a special 

education and training session, focused on common 

deployment-related health concerns, that provides 

information on the range of responses and benefits 

available to meet their needs. Each service member’s 

responses are reviewed with a healthcare provider to 

clarify issues, gather any needed clinical information, 

and ensure appropriate connection to services ranging 

from community-based support and preclinical counseling to referral for treatment in primary care, mental 

healthcare, other specialty care, or rehabilitative care 

as appropriate. 

PDHRA is medically informed to effectively identify 

clinical problems and facilitate access to care, but, in 
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Combat and Operational Behavioral Health

line with the public health model, the intervention 

emphasizes readjustment opportunities rather than 

pathology and disability. Vet Center and VA Seamless 

Transition staff and veterans’ benefits counselors are 

on hand at PDHRA events to assist service members 

entering veteran status. To improve access to mental 

healthcare, military and VA medical systems are both 

in the process of increasing its integration into primary 

care settings. Efforts are underway to allow sharing of 

DD Form 2900 findings between DoD and VA clinicians to assure continuity of care across systems. 

Battlemind Training

Hoge and colleagues3 demonstrated that the stigma 

surrounding postdeployment readjustment stress is a 

significant barrier to new combat veterans receiving 

appropriate care. To get around this stigma, Hoge and 

his team at WRAIR developed and tested a new outreach approach to engage OEF/OIF combat veterans: 

Battlemind training.25 Battlemind training has now 

been incorporated into the PDHRA intervention for 

the Army. (The US Marine Corps’ Warrior Transition 

Program26 addresses similar issues but is adapted to 

meet the unique needs of marines.) 

“Battlemind” is an acronym for:

 Buddies vs withdrawal

 Accountability vs control

 Targeted vs inappropriate aggression

 Tactical awareness vs hypervigilance

 Lethally armed vs unarmed

 Emotional control vs anger or detachment

 Mission and operational security vs secretiveness

 Individual responsibility vs guilt

 Nondefensive (combat) driving vs aggressive 

driving

 Discipline and ordering vs conflict

Each element of Battlemind training speaks to an 

important aspect of postdeployment readjustment, 

and each is illustrated and explained in the video 

presentation (viewable at https://www.battlemind.

army.mil/) that forms the centerpiece of training. 

Consonant with the public health model, Battlemind 

emphasizes resiliency rather than pathology, and engages service members through training rather than 

direct offers of treatment. Further interventions up 

to and including appropriate clinical assessment and 

treatment are more likely to be accepted if this initial 

outreach is accepted. 

Battlemind training is designed to be highly acceptable to new combat veterans. Its key message is that 

combat skills and battle mindset sustained the warfighter’s survival in the war zone. Battlemind is defined as the service member’s inner strength to face fear 

and adversity in combat with courage. If, on returning home, service members find that they still “sleep 

with one eye open,” are constantly on alert for signs of 

danger, and respond reflexively with aggression, this is 

evidence that they have adapted to the war zone. This 

explanation is quite different than telling new combat 

veterans that they may be expressing symptoms of a 

mental disorder such as PTSD. The clear implication 

is a positive one: if you were able to adapt to life in a 

war zone, you should be able to adapt again to life at 

home. In short, Battlemind training tells new combat 

veterans that their responses are the normal responses 

of good warfighters, but it also stresses that Battlemind 

may be hazardous to social and behavioral health on 

the home front if it is not transitioned: in other words, 

“don’t try this at home.” Battlemind training has been 

expanded to include spouse Battlemind training for 

both predeployment and postdeployment use. During 

2006, qualified instructors from WRAIR trained all Vet 

Center staff members in Battlemind principles.

Extending and Strengthening the Continuum of 

Care

As this review demonstrates, DoD and VA have 

worked steadily since the start of operations in Afghanistan and Iraq to mesh the gears of their respective agencies through the development of joint clinical 

practice guidelines, the Joint VA/DoD Federal Recovery Coordination Program, PDHRA, and Battlemind 

training to extend and enhance the continuum of care 

for OEF/OIF veterans and their families. These steps 

can be understood as practical applications of a public 

health model particularly suited to this newest generation of combat veterans. 

In 2005 the VA implemented a new program founded on these same principles, which was subsequently 

named Services for Returning Veterans-Mental Health 

(SeRV-MH). Rather than diagnosing specific disorders 

or limiting services to highly specialized interventions 

for PTSD, depression, or substance abuse, the goals of 

SeRV-MH are engagement, health promotion, recovery, and rehabilitation. Triage to primary care, general 

mental health services, and subspecialty services are 

available through SeRV-MH teams. SeRV-MH teams 

actively engage other VHA, VBA, and Vet Center 

programs; DoD active duty and reserve components; 

and other federal, state, and community agencies and 

programs in support of new combat veterans and their 

families. 

Although outreach was initially identified as a core 
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The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

SeRV-MH function, that role is, as noted above, the purview of Vet Centers, so SeRV-MH outreach is carried 

out in collaboration with Vet Center initiatives. SeRVMH teams are distinguished by their unique “in-reach” 

function, which includes services in primary care settings designed to enhance access to behavioral health 

services while reducing the stigma that veterans and 

their families often associate with formal mental health 

settings. SeRV-MH staff members also support facility 

polytrauma services, including those for veterans with 

traumatic brain injury. Service delivery innovations to 

meet the needs of returning veterans who go to work 

or school include the establishment of weekend and 

evening SeRV-MH clinic hours. 

SeRV-MH teams are agents of change within the 

various programs, promoting a view of mental health 

as an essential part of overall health and function. They 

help other VA clinical, administrative, and support 

staff to become aware of the special characteristics of 

OEF/OIF veterans and their families and develop new 

methods of intervention. They embody and disseminate the public health model. More than 80 SeRV-MH 

teams are now distributed across the nation (at least 

one per state), and nationally coordinated training 

(developed by a multidisciplinary DoD/VA team) is 

being rolled out. This training includes information on 

the Army Battlemind approach and education on topics not addressed in more traditional curricula on war 

stress disorders, such as improving closeness among 

family members and addressing traumatic grief. 

The VA has also launched a Mental Illness Research, 

Education, and Clinic Center (MIRECC) dedicated to 

postdeployment mental health.27 MIRECCs were established by Congress in 1997 as translational research 

centers. Ten MIRECCs exist nationwide and each is 

dedicated to a specific area of mental illness, such as 

schizophrenia, substance abuse, or dementia. Their 

stated mission is 

to generate new knowledge about the causes and 

treatments of mental disorders, apply new findings 

to model clinical programs, and widely disseminate 

new findings through education to improve the quality of veterans’ lives and their daily functioning in 

their recovering from mental illness.28

The postdeployment MIRECC works with clinicians 

and researchers across the DoD/VA continuum to 

identify, develop, and disseminate best clinical practices in the service of new combat veterans and their 

families. Some of this work stems from MIRECC laboratory, health services, and epidemiological research, 

while other efforts apply and test new clinical models 

and educate other health workers, the general public, 

and OEF/OIF veterans and their families. 

BEYOND THE DEPARTMENT OF DEFENSE/VETERANS AFFAIRS CONTINUUM

Ideally, the postdeployment readjustment and mental health problems of OEF/OIF veterans would be 

identified and addressed somewhere within the DoD/

VA continuum of care, but this may not be a realistic 

expectation. Hoge et al29 conducted a population-based 

descriptive study of all soldiers and marines who returned from deployment to OEF (n = 16,318), OIF (n = 

222,620), and other locations (n = 64,967) between May 

1, 2003, and April 30, 2004. They found that the prevalence of reporting a mental health problemwas 19.1% 

among service members returning from Iraq, 11.3% 

after returning from Afghanistan, and 8.5% (close to 

the base rate in the military) after returningfrom other 

locations (P < 0.001). Although 35% ofall OIF veterans 

accessed mental health services at least once within a 

yearafter their return home, 60% of those who screened 

positive for PTSD, major depression, or generalized 

anxiety (substance abuse was not addressed in this 

study) failed to present for any mental health service. 

These DoD findings closely parallel those in the VA 

that (as noted above) show that, as of February 2008, 

only 39% of all OEF/OIF veterans eligible for VA care 

have come to the VA for health services. Where are the 

other 61% of OEF/OIF veterans, and what are their 

mental health needs?

Another parallel exists between this information 

and the findings of the National Vietnam Veterans Readjustment Study,30 which found that only 20% of Vietnam veterans who fulfilled diagnostic criteria for PTSD 

at the time of the study (conducted in the late 1980s) 

had ever gone to the VA for mental healthcare.30(p228)

The same study found that 62% of all Vietnam veterans 

with PTSD had sought mental healthcare somewhere 

at some point in time. In other words, among Vietnam 

veterans with PTSD at the time of the study who ever 

sought mental healthcare, only 32% came to the VA for 

that care, while 68% went elsewhere for care. 

These findings suggest that a “silent majority” of 

OEF/OIF veterans with postdeployment readjustment 

or mental health issues may not seek help within the 

DoD/VA continuum of care. Stigma may be the key 

reason for this. But if a silent majority does exist, several important questions face DoD and VA planners 

and clinicians: 

• Who among these veterans should be 

reached?

• What are the best ways to reach them?
334

Combat and Operational Behavioral Health

• At what point should they be reached?

• What interventions would be most appropriate once they have been reached?

• What about their families?

Work with the families is particularly important 

because the level of postdeployment social support 

received by combat veterans strongly predicts their 

resilience.22,23 In addition, if new combat veterans are 

going to get needed help, family members will likely 

be instrumental in their getting it. Finally, families have 

needs of their own that, if left unmet, could have serious consequences for the families and their communities. To reach new combat veterans and their families, 

it is necessary for the DoD and VA to look beyond their 

own continuum of care towards partnerships at the 

state and community levels.

State and Community Partnerships

The DoD and VA realize a number of advantages 

in partnering at the state and community levels. Such 

partnerships enhance access for service members, 

veterans, and family members who are concerned 

about seeking help within the DoD/VA continuum. 

Partnerships may also enhance the quality of services 

new combat veterans and their family members receive 

in the community through joint training and improved 

interagency cooperation. 

Because National Guard programs are organized 

at the state level, it makes sense for DoD and VA to 

develop state-level partnerships. Furthermore, each 

state has its own veterans’ service program. Veterans’ 

service officers in each county or region of the state 

work with veterans and their families to connect 

them with federal, state, and local programs that significantly improve their access to care, benefits, and 

reliable information. Finally, partnerships among the 

DoD, VA, states, and local communities help build new 

systems of interagency communication and coordination that may serve well at times of local or regional 

disaster. A number of DoD, VA, state, and community 

partnerships already exist in areas such as upstate New 

York, Washington state, Ohio, North Carolina, Virginia, 

Alabama, Vermont, and Rhode Island. Because each 

state has a different array of military bases, reserve 

units, VA facilities, and veteran populations, each faces 

unique challenges and opportunities.

One recent example of the DoD, VA, state, and 

community partnership was introduced on February 

12, 2007, when the VA announced a national roll out 

of a partnership with state veterans’ service officers 

through the National Association of State Directors 

of Veterans Affairs. This program links VA staff based 

at 10 DoD MTFs around the country with state veterans’ service officers in all 50 states. The program 

helps identify injured military members who are being 

transferred to VA care so that state veterans’ officers 

can more efficiently identify, locate, and link them and 

their family members to appropriate state benefits and 

services.31

Partnerships can and should extend well beyond the 

traditional scope of mental health and substance abuse 

services to include local primary care providers, pediatricians, ministers and congregations, teachers and 

school guidance counselors, campus-based veterans’ 

benefits specialists, veterans’ service organizations, 

mental health associations and advocacy organizations, employers and supervisors, law enforcement 

agents, judges, and others in order to make diverse 

members of the community more aware of the problems faced by OEF/OIF veterans and their families 

and of the resources available to assist them. 

These partnerships often begin with a state-level 

summit meeting of potential partners including 

state-based DoD and VA elements. These conferences 

generally open with a presentation of the “boots on 

the ground” experiences of new combat veterans and 

the deployment cycle experiences of their families. The 

presence of top leadership, including the governor, 

the state secretary for health and human services, the 

adjutant general of the state National Guard, senior 

leadership from state-based DoD military programs 

and medical facilities, and VA network leadership, 

provides a strong and positive message to participants 

about the importance of the effort and the will of each 

respective partner to pursue it. 

Representatives to the summit meeting exchange 

key information about their respective agencies’ assets 

and goals to identify strategic partnerships in service 

for new combat veterans and their families. Attendees 

work to articulate an integrated continuum of care that 

emphasizes access, quality, effectiveness, efficiency, 

and compassion. Services are centered on service 

members or veterans and their families. Principles of 

resilience, prevention, and recovery are emphasized. 

Attendees agree to work together to optimize access 

to information, support, and, when necessary, clinical 

services across systems as part of a balanced public 

health approach. The product envisioned is a network 

of informational, supportive, clinical, and administrative services through which citizens of the state will 

have ready access to postdeployment readjustment 

assistance. The DoD, VA, state, and community partnership may begin with a single high-profile meeting 

as described above, but if the process is to be successful, 

it must be sustained. This calls for ongoing meetings 

of working subgroups, continued support within 
335

The Continuum of Care for New Combat Veterans and Their Families: A Public Health Approach

each partnering entity, and a clear and practical joint 

plan with scheduled deliverables and clear lines of 

responsibility. 

Key Elements Replicable in Every State

Some states are home to major military bases embedded within strong military-friendly communities. 

In such settings, postdeployment issues are often well 

recognized by local leaders, health professionals, teachers, guidance counselors, school principals, and local 

clergy. Many community support mechanisms may 

already be in place. Other states have few, if any, major 

bases, but have large numbers of reserve or National 

Guard members. Because these citizen soldiers tend 

to be scattered across communities (and relatively 

invisible within them), local leaders, health professionals, school personnel, and religious leaders may 

be less aware of deployment-related issues and less 

knowledgeable about how to access resources once a 

need is identified. Nonetheless, there are certain core 

elements of the DoD, VA, state, and community partnerships that can be successfully replicated in every 

community and state.

The first element is effective outreach. One basic 

mechanism is development of a governor’s letter to 

new combat veterans and their families. Because each 

state director of veterans’ services receives a list of 

the names and mailing addresses of every OEF/OIF 

veteran living within the state, it is possible for the governor’s office to reach out to every affected household. 

The North Carolina Governor’s Focus on Returning 

Combat Veterans and Their Families recommended in 

its final report32 that such a letter be sent to all service 

members and their families, thanking them on behalf 

of the entire state. The letter also invites recipients to 

make use of local resources as they readjust. In North 

Carolina, the letter provides a toll-free telephone number that combat veterans or family members can call for 

information and guidance to appropriate resources. As 

a key step toward enhancing resilience, the governor 

can conclude the letter by recognizing the strength, 

skills, and willingness to sacrifice demonstrated by 

veterans and their families. 

The toll-free number used in North Carolina is an 

application of a preexisting “care line” system established by the state Department of Health and Human 

Services. It is staffed by information-and-referral 

specialists trained about a wide variety of human 

service programs across the state.33 Care line services 

are provided in English and in Spanish and as a TTY 

(text telephone) service for the hearing-impaired (an 

important consideration among combat veterans). 

Until recently, these specialists did not routinely 

inquire whether a caller was a service member, a veteran, or someone calling about a service member or 

a veteran or in relation to postdeployment issues. 

These specialists have now undergone training on 

deployment mental health issues and have begun applying a simple algorithm when fielding calls. They 

ask about the caller’s service in Iraq or Afghanistan, 

military branch, current military status (active duty 

or reserve component), date separated from service, 

date of return from last deployment, and zip code or 

county of residence. 

With this information in hand, a range of services 

can quickly be identified and located in proximity 

to the caller’s residence. The list of potential access 

points resides on an electronic database of over 10,000 

agencies and programs across the state. The referral 

specialist can identify the caller’s local Vet Center 

(and its GWOT outreach worker if one exists); the 

county veterans’ services officer; the seamless transition case manager at the local VA medical center; 

any service-appropriate family program (such as the 

Guard Family Readiness Group); and the nearest regional VBA. The specialist can also put the caller in 

touch with Military OneSource or TRICARE services 

as appropriate to the caller’s needs. This information 

can also be obtained at the care line Web site (http://

www.nccareline.org). 

Joint training efforts are required to build strong 

bridges between the DoD, VA, state, and community 

programs. These should include leaders and clinicians working in local mental health, primary care, 

and family support programs, as well as professional 

organizations and other state and community groups. 

Area Health Education Centers (AHECs), developed 

by Congress in 1971 to recruit, train, and retain a health 

professions workforce committed to underserved 

populations,34 exist in almost every state. AHECs can 

play an important role in disseminating best practices 

and developing a common language and approach 

among federal, state, and community systems. 

One strategy that can be employed with relative 

ease is to develop an AHEC educational program 

based on Battlemind training. Trainers can be recruited 

from local DoD and VA sites. Battlemind training 

videos and supporting materials are available in the 

public domain. Although Battlemind is an Army program and the Warrior Transition Program is a Marine 

Corps program, both incorporate principles that speak 

to universal issues of the deployment cycle and can 

be adapted to different audiences while still respecting distinct cultural differences among the military 

branches. 

Local PDHRA events also offer important opportunities for the DoD, VA, state, and community cooperation. DoD and VA staffs routinely meet with local 

military units (and often with their family members) 
336

Combat and Operational Behavioral Health

during PDHRA. State and community representatives 

could be invited to attend to help reinforce transition 

back to the community and inform service members 

and their families about readjustment resources such 

as medical, vocational, and benefits programs. At the 

same time, participating state and community representatives have the opportunity to learn more about 

the challenges faced by new combat veterans and their 

families, which can then inform further efforts on their 

behalf. Partnerships should coordinate DoD, VA, state, 

and community efforts with those of local providers 

who contract with TRICARE and Military OneSource 

to assure full and ready access to well-trained clinicians 

for service members, new veterans, and their families. 

AHECs can disseminate needed clinical training and 

can also provide information about working with TRICARE (which could lead to more providers choosing 

to become TRICARE providers).

Many service members, veterans, and family members prefer to bring readjustment issues to their chaplain or local religious leader rather than to a medical 

provider. DoD, VA, state, and community partnerships 

offer a unique opportunity for interchange between 

military and VA chaplains and local clergy and their 

faith communities. These partnerships can substantially increase social support for returning combat 

veterans and their families. Clinical pastoral education programs are ideally suited to develop outreach 

and educational activities that promote readjustment, 

resilience, and recovery. Again, Army Battlemind training and the Marine Corps Warrior Transition Program 

can provide core content for instruction that can be 

adapted for specific faith communities. The strategies 

and tactics presented here are not meant to serve as 

an exhaustive list but rather as a jumping-off point for 

new ideas. It is essential that each community explore 

and develop partnerships specific to its own unique 

needs and assets. 

SUMMARY

The VA has long-standing readjustment services 

stemming from Vietnam-era initiatives such as the 

Vet Center program; however, new programs have 

arisen in response to studies finding these efforts 

inadequate. The DoD and VA have established joint 

efforts built on a public health model, including partnerships with state and community resources. These 

partnerships are designed to enhance support and 

outreach, improve referral systems, reduce stigma, 

and promote better health outcomes for new combat 

veterans and their families. The goals of all these 

programs are to provide a seamless continuum of 

care that will support increased resilience, decreased 

military attrition, and decreased disability, as well as 

increased satisfaction among consumers and providers. Experience to date indicates that these ambitious 

goals are attainable. The ultimate goal is to transform 

the postdeployment health system: there should be 

no wrong door to which OEF/OIF veterans or their 

families can come for help. The DoD and VA have 

made significant progress in providing seamless 

healthcare coverage to transitioning veterans and 

their families since the start of military operations in 

Afghanistan and Iraq. The public health model and 

the DoD, VA, state, and community partnerships help 

mark the path for future progress. 

Acknowledgment

The authors gratefully acknowledge the careful review and suggestions made by Dr Kristy Straits-Tröster 

of the VA Mid-Atlantic Health Care Network’s Mental Illness Research, Education, and Clinical Center in 

the course of developing this chapter.

REFERENCES

1. Handoff or Fumble? Do DoD and VA Provide Seamless Health Care Coverage to Transitioning Veterans? Hearing before the 

Committee on Veterans’ Affairs, House of Representatives, One Hundred Eighth Congress, First Session, October 16, 2003.

Washington, DC: US Government Printing Office; 2004: No. 108-26.

2. VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans Health Administration, Department of Veterans Affairs and Health Affairs, 

Department of Defense; December 2003. Office of Quality and Performance publication 10Q-CPG/PTSD-04. Available 

at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5187. Accessed December 16, 2009.
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3. 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;351:13–22.

4. US Department of Veterans Affairs. Fact Sheet: Facts About the Department of Veterans Affairs. Washington, DC: VA; 2009. 

Available at: http://www1.va.gov/opa/fact/docs/vafacts.doc. Accessed December 16, 2009.

5. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on 

the quality of care. N Engl J Med. 2003;348:2218–2227.

6. US Department of Veterans Affairs. Vet Center: Who we are. VA Web site. Available at: http://www.vetcenter.va.gov/

About_US.asp. Accessed December 16, 2009.

7. Trudeau GB. The War Within. Kansas City, Mo: Andrews McMeel Publishing, LLC; 2006.

8. Bristol M. Mission status: not business as usual. Vanguard. 2004;L:16–19.

9. US Department of Veterans Affairs. Transition Assistance and Case Management of Operation Enduring Freedom (OEF) and 

Operation Iraqi Freedom (OIF) Veterans. Washington, DC: VA; 2007. VHA Handbook 1010.01.

10. US Department of Veterans Affairs. Combat Veterans Are Eligible for Medical Services for 2 Years After Separation From 

Military Service Notwithstanding Lack of Evidence for Service Connection. Washington, DC: VA; 2002. VHA Directive 2002-

049. Available at: http://www1.va.gov/environagents/docs/VHADirective2002-049_Sept_11_2002.pdf. Accessed 

December 16, 2009.

11. US Department of Veterans Affairs. Environmental Epidemiology Service. VA Web site. Available at: http://www.

vethealth.cio.med.va.gov/Epidemiology.htm. Accessed December 16, 2009.

12. US Department of Veterans Affairs. Iraq & Afghan Post-Deployment Screen Reminder Setup Guide. Washington, DC: VA; 

2004. Available at: http://www.va.gov/vdl/documents/Clinical/CPRS-Clinical_Reminders/pxrm_1_5_21_setup.

pdf. Accessed December 16, 2009.

13. Grieger TA, Cozza, SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers. Am J 

Psychiatry. 2006;163:1777–1783.

14. Kang HK, Hyams KC. Mental health care needs among recent war veterans. N Engl J Med. 2005;352:1280–1289.

15. Adams RE, Boscarino JA, Galea S. Alcohol use, mental health status and psychological well-being 2 years after the 

World Trade Center attacks in New York City. Am J Drug Alcohol Abuse. 2006;32:203–224.

16. President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in 

America. Final Report. Rockville, Md: President’s New Freedom Commission on Mental Health; 2003. DHHS Pub. 

No. SMA-03-3832. Available at: http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html. Accessed 

December 16, 2009.

17. Parsons T. The Social System. London; England: Routledge and Kegan Paul Ltd; 1951.

18. Frank JD, Frank JB. Persuasion and Healing: A Comparative Study of Psychotherapy. Baltimore, Md: Johns Hopkins University Press; 1991.

19. Frank JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974;131:271–274.

20. US Department of Veterans Affairs. 2005 Report of the Under Secretary’s Special Committee on PTSD. Washington, DC: 

VA; 2005.

21. Heldring M, Kudler H. The primary health care system as a core resource in the response to terrorism. J Aggression 

Maltreatment Trauma. 2005;10:541–552.
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22. King LA, King DW, Fairbank JA, Keane TM, Adams GA. Resilience-recovery factors in post-traumatic stress disorder 

among female and male Vietnam veterans: hardiness, postwar social support, and additional stressful life events. J 

Pers Soc Psychol. 1998;74:420–434.

23. Vogt DVS, Tanner LR. Risk and resilience factors for posttraumatic stress symptomatology in Gulf War I veterans. J 

Trauma Stress. 2007;20:27–38.

24. US Department of Defense, Ceridian Corporation. Military OneSource Web site. Available at: http://www.militaryonesource.com. Accessed December 16, 2009.

25. US Army Battlemind soldier support Web site. Available at: https://www.battlemind.army.mil/. Accessed December 

16, 2009.

26. US Marine Corps. Marine Corps combat operational control (COSC) program Web site. Available at: http://www.

marines.mil/news/messages/Pages/2007/MARINE%20CORPS%20COMBAT%20OPERATIONAL%20STRESS%20

%20CONTROL%20(COSC)%20PROGRAM.aspx. Accessed December 16, 2009.

27. US Department of Veterans Affairs. MIRECC centers home. VA Web site. Available at: http://www.mirecc.va.gov/. 

Accessed December 16, 2009.

28. US Department of Veterans Affairs. MIRECC centers: MIRECC program overview. VA Web site. Available at: http://

www.mirecc.va.gov/national-mirecc-overview.asp. Accessed December 16, 2009.

29. 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;295:1023–1032.

30. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings From the National 

Vietnam Veterans Readjustment Study. New York, NY: Brunner/Mazel; 1990.

31. VA partnering with states to help injured veterans [press release]. Washington, DC: US Department of Veterans Affairs; February 12, 2007. Available at: www1.va.gov/opa/pressrel/docs/State_Outreach.doc. Accessed December 16, 

2009.

32. The governor’s focus on returning combat veterans and their families: substance abuse and mental health services. 

North Carolina Governor’s Focus on Returning Combat Veterans and Their Families Web site. Available at: http://

veteransfocus.org/. Accessed December 16, 2009.

33. North Caroline Department of Health and Human Services. Care-line Web site. Available at: www.dhhs.state.nc.us/

ocs/careline.htm. Accessed December 16, 2009.

34. National Area Health Education Center Organization Web site. Available at: http://www.nationalahec.org/About/

AboutUs.asp. Accessed December 16, 2009.
339

Pain Management

Chapter 21

pain management

FREDERICK J. STODDARD, Jr, MD*; ROBERT L. SHERIDAN, MD†; JEEVENDRA MARTYN, MD‡; JAMES E. 

CZARNIK, MD§; and VIRGIL T. DEAL, MD¥

INTRODUCTION

ANATOMY OF INJURY-RELATED PAIN

BIOLOGY OF PAIN

PRINCIPLES OF PAIN THERAPY

ADVERSE EFFECTS OF PAIN

GENETICS

METHODS OF PAIN ASSESSMENT

METHODS OF PAIN MANAGEMENT: OVERVIEW

PHARMACOLOGICAL MANAGEMENT OF ACUTE PAIN

PSYCHOLOGICAL management of pain and grief

SPECIAL PROBLEMS

Ventilated Patient

Burns and Multiple Traumas

Amputation Pain

Weaning

Pediatric Pain

Psychiatric Risk Factors

Pain Management and the Issue of Addiction

THE ETHICS OF PAIN CONTROL

SUMMARY

*Associate Clinical Professor, Department of Psychiatry, Harvard Medical School at the Massachusetts General Hospital; and Chief of Psychiatry, Shriners 

Burn Hospital, 51 Blossom Street, Boston, Massachusetts 02114; Formerly, Senior Surgeon, US Public Health Service

†

Associate Professor, Department of Surgery, Harvard Medical School at the Massachusetts General Hospital; and Assistant Chief of Staff, Shriners Burn 

Hospital, 51 Blossom Street, Boston, Massachusetts 02114; formerly, Lieutenant Colonel, Medical Corps, US Army; US Army Institute of Surgical 

Research, Brooke Army Medical Center, San Antonio, Texas

‡

Professor/Chief, Department of Anesthesiology and Critical Care, Harvard Medical School/Shriners Hospital for Children, 51 Blossom Street, Room 

206, Boston, Massachusetts 02114

§

Colonel, Medical Corps, US Army; Command Surgeon, Joint Special Operations Command, PO Box 70239, Fort Bragg, North Carolina 28307-5000; 

formerly, Deputy Command Surgeon, US Army Special Operations Command, Fort Bragg, North Carolina

¥

Colonel, Medical Corps, US Army; United States Special Operations Command, 7701 Tampa Point Boulevard, MacDill Air Force Base, Florida 33621-

5323; formerly, Commander, Walter Reed Health Care System, Washington, DC
340

Combat and Operational Behavioral Health

INTRODUCTION

How should acute or chronic pain from combat 

and noncombat wounds and injuries be managed? 

What are the psychiatric implications of the control 

or elimination of the pain of injuries?1

 Which wounds 

cause the worst pain? Do the manifestations of pain in 

(or treatment strategies for) civilians differ from those 

for soldiers? Which emerging treatments can help? 

Are analgesic requirements met, or are they underestimated as in the past?2,3 Is drug-seeking behavior 

a contraindication to use of analgesics, or not? It is 

important to differentiate, with the patient’s help, pain 

resulting from injury, surgery, dressings, amputation, 

and physical therapy, as well as other types of pain 

associated with injury, illness, and emotional suffering. Pain caused by combat wounds and noncombat 

injuries in military personnel and in affected civilians 

are significant in the current context and may cause 

subsequent psychopathology.4–7 Consistent with the 

medical team approach, collaboration of surgeons, 

psychiatrists, anesthesiologists, and allied personnel 

is key to optimal management of pain due to wounds 

and injuries.

A primary task of medical personnel caring for the 

wounded, second only to assuring the safety of the 

patient and staff, is to relieve pain. Prompt, accurate 

diagnosis of mental disorders is key to the effective and 

safe relief of pain. Diagnosis of delirium,8 preexisting 

brain injury, substance abuse, psychosis, posttraumatic 

stress disorder (PTSD), Axis II disorder, or depression 

will affect measurement of pain, diagnostic procedures, precautions, and choice of analgesia. Failure to 

observe the lack of a pain response in a patient with 

a history of serious past trauma, or in a chemically 

paralyzed patient with the inability to communicate 

a pain response, or not diagnosing delirium, risk of 

violence, or high alcohol or drug levels, may cause 

preventable suffering or even death. 

Finding solutions to managing pain leads to central 

clinical and research questions in the care of injuries to 

patients of all ages. The answers have been modified 

or discovered in the last 25 years. Previous publications by the authors of this chapter have addressed 

posttraumatic psychological and neurobiological aspects of injury pain at different stages in the life cycle, 

and different stages postinjury.9–12 Pain is an essential 

focus of the requirements of the Joint Commission 

(formerly the Joint Commission on Accreditation of 

Healthcare Organizations), practice guidelines, treatment protocols, and continuing education. Prevention 

and relief of acute or chronic pain is more achievable 

as a result of treatment initiated at the scene of injury 

and continued throughout care. Pain relief for adults 

and children has a primary place in life-saving surgical care. Furthermore, it is important from a metabolic 

point of view because it decreases the stress response 

that activates the release of the catabolic hormones, 

catecholamines, and cortisol. Treatment to control 

metabolic and stress responses in burns, for example, 

has been tested to confirm a reduction in subsequent 

stress as outlined below.

Which wounds cause the worst pain? The patient 

is the judge of this, and will answer with self-report 

if asked, but may not volunteer this information, 

especially if stoical in temperament. Orthopaedic 

injuries including amputation may cause patients to 

rate pain “25” on a 0-to-10 scale, and the pain may 

rapidly recur with a delay in administering a dose of 

morphine. Burn patients frequently report their most 

severe pain being caused by dressing changes or from 

the donor sites for skin grafts. Although any bodily 

location—including internal organs—can be the site of 

severe pain, areas that are highly innervated, and thus 

most likely to be painful after wounds, are common 

locations of the most severe pain. These include parts 

of the face, scalp and neck, arms and hands, genitals 

and perianal area, and legs. Unexplained behavioral 

symptoms including confusion, combativeness, anger, 

emotional withdrawal, or anxiety may be secondary 

to an unrecognized wound, or a wound causing unrecognized pain.

There is growing evidence to indicate that successful 

pain relief appears to lessen posttraumatic stress, anxiety, and depression, although in one study, the N-methyl-d-aspartic acid (NMDA) antagonist ketamine, which 

is widely used in burn care, was shown to increase 

PTSD symptoms while protecting against posttraumatic reduction of hippocampal volume.13 That study 

is of 30 burned adults, 15 with and 15 without PTSD, 

and provides “evidence that smaller hippocampal size 

in trauma-exposed individuals is a result of traumatic 

stress.”13(p2194) Pain continues to be the subject of extensive research, and in hospital settings ongoing pain 

monitoring and team consultations for complex cases 

is the standard of care. Such teams include nurses, 

surgeons, anesthesiologists, psychiatrists, neurologists, 

pharmacists, physical therapists, ethicists, and others. 

Pain in those with injuries is the subject of great clinical 

attention, systematic evaluation, focused research, and 

a broad and growing range of pharmacological and 

psychological treatment options. Converging research 

in both genomics and neurobiology promises to offer 

new options to improve pain management for the 

injured patient in the future.

There is a well-established knowledge base with 
341

Pain Management

which to design plans to manage and eliminate pain 

in injured children and adults.14,15 Making appropriate 

use of this knowledge is important for everyone caring for those in pain. The evaluation of children’s pain 

requires understanding their ways of communicating, stage of development, their mental impairments, 

and the emotional, as well as physical, effects of pain 

in selecting the appropriate treatments. Similarly, 

evaluation of adults’ pain requires listening to their 

complaints of pain and recognizing the unique needs 

of special populations, such as intensive care patients, 

those with mental or physical disability, substance 

abusers, and the elderly. 

Although psychological elements of treatment, 

such as preparation for painful procedures and hypnosis, are less likely to be covered by protocols than 

pharmacological approaches, they enable patients to 

lessen their own pain and are effective components 

of care.1,16–18 Psychological methods of pain relief do 

not have the risks of drug side effects, toxicity, or 

dependence but may be less effective than drugs. 

Systematic pharmacological research with severely 

injured patients has established the benefits of acute 

management with high-dose morphine and possibly 

benzodiazepines (although some literature indicates 

lorazepam may worsen outcomes),19 other analgesics, 

and adjuvants, utilizing intravenous and other routes 

of administration, mainly in ventilated patients. 

Further advances in management of injury pain are 

continuing. 

A large contribution to pain control for military 

wounded has been in the field of regional pain control. 

It is now possible for casualties of bullet or blast injuries to have at least one extremity rendered pain free 

by the ultrasound-guided placement of a nerve-block 

catheter and administration of appropriate anesthetic. 

These catheters may be maintained in place and connected to infusion pumps. This may allow the casualty 

to remain pain free during the first surgical interventions in theater, through the evacuation to Europe, 

and through washout and further debridement at 

Landstuhl Army Regional Hospital in Germany and 

across the Atlantic to military hospitals in the United 

States. It is anticipated that this will prove to be another 

contribution to a lower incidence of narcotic addiction 

and complex regional pain syndromes in casualties of 

the global war on terror. 

The two temporal components of pain due to acute 

injuries include acute and chronic pain, which are 

further classified. Acute pain, the principal subject of 

this chapter, includes both background pain and procedural pain. Acute pain may be worsened by anxiety, 

depression, sleep deprivation, and “regeneration of 

nerve endings (possible neuroma formation, known 

as postburn neuralgia).”20(p319) Chronic pain is usually 

present for months to years and may not be easily relieved. It may result from scarring, contractures, and 

injury to a bone or joint; from bone formation in soft 

tissues (heterotopic ossification)21,22; or injury to the 

peripheral nerves (neuropathic pain). Although this 

chapter is not comprehensive, it provides scientific 

background, case illustrations, clinical approaches, 

and pertinent references to assist in developing an 

optimal multidisciplinary plan for pain management 

of patients suffering from combat and noncombat 

injuries.

ANATOMY OF INJURY-RELATED PAIN

The anatomic location of pain is a sign of tissue 

injury, underlying infection, or systemic illness. The 

sensory detection of pain (nociception) and pain 

are not the same. Nociception is, according to Sherrington,23 the sensory detection of a noxious event of 

potentially harmful environmental stimulus. Pain, in 

contrast, involves sensory and cognitive components, 

and is defined by the International Association for the 

Study of Pain as “an unpleasant sensory and emotional 

experience associated with actual or potential tissue 

damage.”24 The anatomy of pain involves both central 

and peripheral nervous systems.25 Patients with larger 

injuries generally suffer more pain. Due to the involvement of both central and peripheral nervous systems, 

and afferent and efferent pathways, approaches to 

pain management are needed to address both central 

brain and spinal cord receptors and peripheral nerve 

receptors.

Injury-Related Pain Cases

Case Study 21-1: A 26-year-old Afghani civilian male 

was injured by enemy rocket fire, sustaining a gaping penetrating injury to his left knee. The patient was dragged by 

his comrades to an austere casualty collection point inside 

a secure bunker. He presented screaming and clutching his 

left knee. Primary survey revealed normal mentation and 

respiratory status. A rapid secondary survey revealed no 

other injuries.

The patient was clearly stirred by the visual appearance 

of his knee. He was given an 800-μg fentanyl transmucosal 

lozenge to suck on while his knee was rapidly immobilized 

and dressed and he was comforted by one of his battle 

buddies. By the time intravenous access was obtained (less 

than 5 min), his pain response had significantly improved. 

The simple act of immobilizing and dressing (and thereby 

concealing) his injury was the essential treatment for his 

pain. Thirty minutes after his initial assessment, he was 

titrated with small boluses of intravenous ketamine (0.25 mg/
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Combat and Operational Behavioral Health

kg) to a comfortably dissociated state, whereupon a gross 

decontamination of his wound with copious irrigation could 

be performed.

The patient’s pain was subsequently controlled with immobilization and intermittent use of self-administered transmucosal fentanyl during the next 8 hours until transport could be 

arranged. The profound effect of covering and immobilizing 

his wound significantly decreased his pain response.

Case Study 21-2: A 55-year-old Iraqi male sustained 

direct-fire injury to his left foot, ankle, and tibia. He was 

treated with a tourniquet for hemorrhage control in the field 

and was rapidly transported to a surgical element. He was 

otherwise uninjured and remained alert through his transport. 

The associated direct-fire injury to several key nerves limited 

his immediate pain response; pain control was achieved 

initially through immobilization and intermittent small doses 

of intravenous morphine.

The surgeon’s assessment was that the patient’s best option for a functional recovery in the current environment was 

through a below-the-knee amputation allowing for maximum 

stump length. As the patient was counseled (through an interpreter) as to the surgical options of either attempts at limb 

salvage (with tremendous potential for follow-up infection, 

difficult rehabilitation, and fusion with limited range of motion) 

or amputation, the patient’s “pain” became acutely worse. 

After confirming that there had been no change in the 

status of his injured extremity to account for the surprising 

increase in pain, the interpreter was asked to inquire from the 

patient what would alleviate his new increase in “pain.” Upon 

questioning, he made clear the overwhelming angst he felt 

at the recommendation to amputate his leg. His answer routinely was “Insha’Allah” (English translation “God willing” or 

“If it is God’s will”). The surgeon required a decision from the 

patient, but the patient was unable to make the decision. 

It became apparent that to treat the patient’s pain and to 

continue with any treatment regimen, the patient’s psychological pain needed to be addressed. Through the continued 

verbal analgesic work and religious discourse of the Muslim 

interpreter, the patient eventually became much less distraught and his pain improved markedly. The patient was 

subsequently able to make a decision.

This case demonstrates the multifactorial components 

of pain generation, even in relatively acute traumatic denervation, and how these factors can precipitate a clinically 

severe pain syndrome, which may be relieved by a culturally 

appropriate intervention in the patient’s own language.

Case Study 21-3: A 4-year-old girl was caught in a burning house, sustaining a 55% full-thickness flame burn and an 

inhalation injury. Immediately after rescue, she was intubated 

at the scene by responding medics because of respiratory distress. To facilitate intubation and ventilation during transport, 

she was chemically paralyzed with cisatracurium and sedated 

with approximately 0.05 mg/kg of midazolam and 0.05 mg/kg 

of morphine sulfate as single bolus doses. As a result of witnessing her injuries, her parents were severely traumatized, 

but reassured that she was receiving optimal care.

On arrival to the burn unit she was placed on continuous 

infusions of these same drugs, at 0.05 mg/kg/h each, and 

muscle relaxation was stopped to allow a more accurate assessment of comfort. Assessment after spontaneous reversal 

of neuromuscular blockade revealed a grimacing, writhing 

child in need of further analgesia and sedation. The morphine 

sulfate and midazolam infusions were increased, titrating to a 

Richmond Agitation-Sedation Score of -2.3 Over the following 

2 weeks, until she was extubated, background infusions of 

these agents were gradually increased, as tolerance developed, in response to continuous monitoring of the status 

of her comfort. During this time she needed several skin 

grafting operations, which are associated with substantial 

postoperative pain. At maximum, doses required to maintain 

appropriate comfort were 0.50 mg/kg/h of morphine sulfate 

and 0.40 mg/kg/h of midazolam.

Procedural pain and anticipatory anxiety were important 

issues for her because she required at least daily bedside 

procedures during this period of intubation. Sedation for these 

interventions (dressing changes, intravenous line placement, wound debridement) was provided by the addition of 

ketamine intravenous boluses at 1 mg/kg, repeated every 20 

minutes as needed. When she was awake, the continuous 

presence of her parents, their verbal explanations and reassurance, and their touching her also facilitated her coping 

with pain, fear, and hospitalization.

Donor site and skin graft healing were complete by 2 

weeks, coincident in improvement of the child’s inhalation 

injury. After extubation, the need for sedation was lessened 

by removal of the endotracheal tube and for analgesia by 

healing of wounds. Intravenous background infusions were 

reduced by 10% per day, alternating drug reductions every 

12 hours (eg, 0600 hours reduction in morphine and 1800 

hours reduction in midazolam). During this period, as her 

pain and anxiety lessened, her parents became less stressed 

and more effective in supporting her and participating in 

dressing changes.26

Case Study 21-4: An 18-year-old man was involved in a 

high-speed truck accident and trapped in the wreck, which 

then caught fire. He suffered fractures and deep burns to 

both legs, a 65% mixed second- and third-degree surface 

area burn, and a comminuted closed fracture of the right humerus. After extrication and transport, he was intubated and 

mechanically ventilated for 4 weeks. His comfort management plan included escalating infusions of morphine sulfate 

and midazolam, supplemented by intravenous boluses of 

propofol (2–3 mg/kg) for procedures. At day 10 he underwent 

tracheotomy, which reduced his requirement for intravenous sedation. He underwent excision and grafting of his 

wounds, but required bilateral below-the-knee amputations. 

On weaning his sedation he was transiently delirious, and 

then manifested intrusive recall of the accident contributing 

to flashbacks and insomnia, which were relieved by lorazepam. He was initially depressed in response to his massive 

injuries, but this lessened with supportive psychotherapy, 

acceptance by his friends, and messages of family support. 

In his recovery phase, he developed severe neuropathic 

phantom leg pain that interfered with his rehabilitation. This 

improved with gabapentin, allowing him to be successfully 

fitted with prosthetics. After 6 months he was able to discontinue the gabapentin.27
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Pain Management

BIOLOGY OF PAIN

the modification of pain transmission via inhibitory 

interneurons.

There are multiple projections from thalamic 

nuclei to the cortex, primarily somatic sensory and 

association cortex. Although at least two classes of 

somatosensory cortical neurons can be identified with 

respect to their receptive fields and source of thalamic 

input, nociceptive inputs do not map to the cortex as 

do tactile inputs. Further, lesions to the somatosensory cortex do not result in loss of pain, suggesting 

that parallel or distributed processing of nociception 

in the cortex is likely.28,29 Studies examining cortical 

activation following painful stimuli highlight the 

multiplicity of regions involved, including the contralateral prefrontal cortex, as well as the middle and 

inferior frontal gyrus (Brodmann areas 6, 8, 9, 44, and 

45).30,31

The intense barrage of incoming pain stimuli associated with a trauma results in a decrease in thresholds 

for subsequent excitation of spinal neurons, as well 

as a greater response to subsequent stimuli and an 

expansion of receptive fields.32All of these adaptive 

changes likely underlie the increased pain sensitivity, 

or hyperalgesia, that typically follows a significant 

burn or multiple traumas. Hyperalgesia has long been 

characterized as “primary” if limited to the area of 

injury or “secondary” if it extends to areas adjacent 

to the site of damage.33 Primary hyperalgesia appears 

to require sensitization of both peripheral nociceptors 

and spinal neurons, whereas secondary hyperalgesia 

seems to depend on sensitization of spinal neurons 

alone.34,35 Both types of increased pain sensitivity can 

occur immediately following injury, but secondary 

hyperalgesia may take hours before reaching its peak 

and is likely to resolve before primary hyperalgesia.30

Interestingly, experimental data suggest that chemosensitive nociceptors can be recruited to become 

mechanosensitive receptors following injury.31 This 

ability to recruit otherwise “silent” nociceptors may 

play a role in primary hyperalgesia following injury 

or inflammation.

Any form of major trauma, including burn injury, 

results in a local and systemic response that includes 

fever, anorexia, and pain in the injured (primary 

hyperalgesia) and uninjured areas. Until recently, as 

indicated in the previous paragraph, this sensation was 

thought to occur by transmission of nerve impulses 

from the injured region to the spinal cord and the 

brain.36 Other mechanisms, in addition to nerves, may 

play a role.37 Drugs that silence sensory nerves work 

well to relieve acute pain. When inflammation occurs, 

drugs for acute pain are less effective. Local inflammaThere are several important concepts relevant to 

pain mechanisms to consider: (a) pain receptors in the 

skin (nociceptors), (b) the opioid system, (c) increased 

pain sensitivity (hyperalgesia), and (d) the emerging 

role of the nonopiate pain adjuncts including inhibitors of the enzyme cyclooxygenase-2 (COX-2) and 

gabapentin. 

Pain associated with trauma including burn or 

other tissue injury is transmitted by peripheral nociceptors—the peripheral endings of primary sensory 

neurons whose cell bodies are in the dorsal root of 

the spinal cord and trigeminal ganglia. Unlike other 

sensory receptors in the skin, nociceptors are without 

specialized transducing structures and essentially 

exist as free nerve endings. Different classes of nociceptive fibers can be involved in the experience 

of pain. Thermal or mechanical nociceptors convey 

stimuli rapidly (up to 30 m/sec) via thinly myelinated, small-diameter fibers classified as “A” or “A 

delta.” Polymodal nociceptors are also activated by 

hot stimuli, but transmit impulses more slowly (up 

to 2 m/sec) along small-diameter unmyelinated “C” 

fibers. Both A delta and C fibers are widely distributed 

in skin and in deep tissues.12 Nociceptive fibers, both 

A and C, enter the dorsal horn of the spinal cord and 

split into ascending and descending branches. The 

fibers terminate primarily in lamina I and in lamina 

II, although some A-fiber afferents may terminate 

more deeply in lamina V. Within lamina I, different 

projection neurons process the incoming stimuli. 

“Nociceptive-specific” neurons are only excited by 

nociceptors, but “wide-dynamic-range” neurons 

receive their input from both nociceptors and other 

mechanoreceptors.

Several ascending pathways convey afferent stimuli to the brain. The spinothalamic tract originates in 

lamina I and laminae V–VII and is the major ascending pathway for nociceptive input. The nociceptivespecific and wide-dynamic-range projection neurons 

in this tract terminate in the contralateral thalamus, 

particularly ventrobasal and posterior thalamic nuclei. The spinoreticular tract originates in laminae VII 

and VIII and sends both ipsilateral and contralateral 

projections to the reticular formation and thalamus. 

The spinomesencephalic tract originates in laminae 

I and V, where it projects to the contralateral mesencephalic reticular formation, the periaqueductal gray, 

and other sites within the midbrain. The spinocervical 

tract, and even the dorsal column of the spinal cord, 

also can convey nociceptive stimuli. In addition, in 

the dorsal horn, A-B fibers conveying sensations 

such as vibration and light touch are involved in 
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Combat and Operational Behavioral Health

tion at the site of injury (eg, burn) causes a rapid and 

long-lasting increase in the proinflammatory-signaling 

molecule in the brain, especially interleukin-1β in the 

cerebral spinal fluid. Blockers of interleukin 1β (eg, 

COX-2 inhibitors) strongly inhibit the hypersensitivity to pain.36,37 Increased levels of interleukin-1β cause 

increased expression of COX-2 and prostaglandin E 

synthase, with a resultant increase in prostaglandin E2. 

Thus the use of COX-2 inhibitors currently available 

will not only have antiinflammatory and antipyretic 

effects but also have antihyperalgesic effects by acting at local and central sites. Among those available 

are celecoxib (Celebrex [Pfizer Inc, New York, NY), 

nimesulide (Mesulid [various manufacturers], and 

meloxicam (Mobic [Abbott Laboratories, Abbott Park, 

Ill]). Additionally, trauma/inflammation-induced upregulation of protein kinase Cδ (PKCδ) and NMDA in 

the spinal neurons may also play a role in the hyperalgesia and mechanical allodynic.38 A growing body of 

evidence supports the notion that the upregulation of 

protein kinase Cα (PKCα) and NMDA are implicated 

in the mechanisms of chronic nociception.38 Hence the 

rationale for use of drugs such as ketamine, an NMDA 

antagonist.

PRINCIPLES OF PAIN THERAPY

Laboratory research is clarifying the synthetic 

and degradative pathways by which the levels of 

endogenous opioids are maintained in the body.39,40

In addition to the clarification of the dynorphin gene, 

the neural systems involved in pain and anxiety have 

been located. The three classes of endogenous opioid 

peptides are: (1) endorphin, (2) met-leu-enkephalin, 

and (3) dynorphin. Additional transmitters modulating pain include the monoamine (dopamine, norepinephrine, and serotonin) systems, substance P, and 

the g-aminobutyric acid system—each with its own 

specific brain receptor sites. Clinically, opioids are 

the first-line drug used to treat pain associated with 

injury. Selection of analgesics such as nonsteroidal 

antiinflammatory drugs (NSAIDs), COX-2 inhibitors, 

benzodiazepines, anticonvulsants, and adjuvants 

(eg, stimulants, tricyclic or serotonergic antidepressants, neuroleptics) may be made to modulate and 

potentiate the effects of narcotics. However, the analgesic effects of opioids are unpredictable, particularly 

under chronic pain conditions. This is partly due 

to downregulation of opioid receptors,37 and to the 

development of a condition called opioid-induced 

hyperalgesia (OIH).

Recent observations suggest that chronic administration of opioids leads to OIH. Thus, treatment 

with opioids is a double-edged sword; the treatment 

of pain may lead to a hyperalgesic state. OIH can 

occur during maintenance therapy, withdrawal, or 

both. OIH has been studied in three different clinical 

settings: (1) in former opioid addicts on methadone 

therapy, (2) in patients treated with opioids, and 

(3) in human volunteers. OIH can occur following 

both low-dose and high-dose opiate therapy.41–43

Mechanisms involved in OIH include sensitization 

of peripheral nerve endings, enhanced facilitation of 

the nociceptive signal transduction, altered kinetics of 

nociceptive transmitters, and increased sensitization 

of the second-order neurons to neurotransmitters.41,43

Excitatory amino acids (glutamate), NMDA receptors, 

and PKC seem to play a role in the development of 

OIH. The greater the opioid therapy, the greater the 

OIH will be. 

Tolerance to opioids can also occur acutely44; this 

emphasizes the importance of alternative or adjunct 

therapy with opioids for treatment of pain. Strategies 

to treat tolerance and OIH can include rotation from 

phenanthrene (morphine) to a piperidine (fentanyl) 

opioid derivative. The administration of NMDA 

antagonists (ketamine) prevents opioid-induced 

hyperalgesia and also overcomes tolerance.45 Dexmedetomidine, an α2

 agonist more potent than clonidine, 

has analgesic/sedative effects, particularly in combination with other drugs, and may reduce the incidence 

of delirium and other complications of withdrawal 

from opiates.46–49

Experience gained from treating other pain-associated conditions such as cancer, herpes, diabetic 

neuropathy, and degenerative diseases can also be 

applied to posttraumatic pain syndromes.50 The 

available therapies shown to be effective include 

anticonvulsant drugs, tricyclic and other antidepressants (duloxetine, venlafaxine), topical lidocaine, 

and tramadol. Of great recent interest is gabapentin. 

The mechanism of its action is unclear, but its effects 

on the α2δ calcium-channel subunit may result in 

decreased release of the neurotransmitter and suppression of central sensitization.51 The combination 

therapy of gabapentin with morphine resulted in 

greater reduction of pain than did either drug alone 

or placebo. The combination also had beneficial effects on pain-related interference with daily activities, 

mood, and quality of life.51 Combination therapies 

have the potential to simultaneously alleviate pain, 

insomnia, and mood instability or depression. Tolerance will most likely develop to this combination 

based on previous reports on receptor behavior and 

neuroplasticity.
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Pain Management

ADVERSE EFFECTS OF PAIN

Many factors contribute adverse physiological, behavioral, and psychological effects to the experience 

of pain and injuries.52 It is often difficult to differentiate the specific contribution of pain to the range of 

psychological problems that develop following injury. 

The injury itself may or may not be unexpected and 

normally initiates an ongoing experience of severe 

pain. Shortly after the injury, these patients often find 

themselves in an emergency setting where they may 

undergo application of wound dressings and possibly 

extensive surgery. Hospitalization involves separation 

from the military component and friends, who themselves may have been injured or killed. Treatment usually includes painful dressing changes and support for 

adjustment to permanent and emotionally traumatic 

changes in their bodies’ appearance and function. The 

traumatic nature of severe injuries is compounded by 

the fact that some are inflicted in battle, while others 

are due to mistakes, accidents, or intoxication, or are 

intentionally inflicted or self-inflicted. Injured patients 

frequently manifest severe psychological reactions 

such as nightmares, flashbacks, acute sadness and 

grief, irritability or anger, and behavioral regression.11,53

For example, the psychological intensity of burn trauma, and particularly the relentless stress of extended 

hospital treatment for a burn, has been compared to 

“inescapable shock” or “learned helplessness,”54 both 

of which are models for PTSD.55,56

About one third to one half of injured people eventually develop PTSD,and over half display significant posttraumatic stress symptoms.57 PTSD and posttraumatic 

stress symptoms are reactions to diverse traumatic events 

related to combat and civilian injuries, assaults, witnessing 

violence, disasters, medical illness, physical and sexual 

abuse, and other psychological traumas not involving 

injury.58,59 Symptoms of this disorder include increased 

intrusive recollections, numbing and avoidance, and 

hyperarousal.60 The manifestation of these symptoms is 

triggered by environmental factors, such as exposure to 

objects, people, or situations reminiscent of the trauma. 

PTSD occurs when symptoms are experienced for most 

days and interfere in either a social or occupational setting. 

PTSD causes significant difficulties for a person’s social, 

educational, occupational, biological, and life-cycle development. Children with PTSD are often so preoccupied 

with intrusive recollections or are so hyperaroused that 

they have difficulty processing social information.61,62

The intrusion of trauma-related memories and extreme levels of arousal that traumatized individuals 

experience interfere with job performance and learning at school. Traumatized people often avoid social 

situations secondary to fear and anxiety that memories 

will reoccur. Patients with injuries also develop mood 

(especially depressive), anxiety, sleep, sexual, behavioral, elimination, and attentional problems. PTSD 

symptoms cause tremendous morbidity and may 

persist for many years. Evidence indicates that once 

posttraumatic symptoms become persistent, they are 

refractory to treatment.63 Accordingly, it is important 

in each case of a person sustaining an injury to seek 

interventions that may prevent or ameliorate the 

development of PTSD. Evidence is slowly accumulating suggesting that the early postinjury preventive 

or therapeutic administration of cognitive behavior 

therapy, or of drugs (eg, morphine, propranolol, serotonin reuptake inhibitors, or tricyclic antidepressants) 

can block the emergence of PTSD symptoms in some 

cases, including combat injuries.64–68 

GENETICS

This section briefly outlines the genetics of pain, the 

genetics of opiate drug responses, and the important 

genetic determinants of racial differences in response 

to pain or its treatment. The human genome project 

has revealed data on genomic variations that may 

influence pathologic states, and are certain to influence treatment advances in the future. Nevertheless, 

the molecular biology and genetics of pain has lagged 

behind the research in diseases such as hereditary, 

cardiovascular, and oncologic disorders. Reports 

continue to emanate, however, on the genetic factors 

influencing nociceptive sensitivity and responses to 

drugs. Genes involved in pain perception, pain processing, and pain management include opioid receptors, transporters, NMDA receptors, α2A adrenoceptors, 

and more recently discovered, guanine triphosphate 

cyclohydrolase—the rate-limiting enzyme for tetrahydrobiopterin synthesis, a key modulator of peripheral 

neuropathic and inflammatory pain.69,70

Pain is a complex trait with interaction of multiple 

genes, each with varying effect, that together with 

environmental and cultural factors, play a role in 

sensation of pain. Altered sensitivity to pain can be 

due to hereditary disorders; usually these are due to 

homozygous disorders. For example, a mutation in 

nerve growth factor has been found and in this instance 

there was complete absence of pain.71 Recently, a “pain 

protective haplotype,” the guanine triphosphate gene, 

has been identified with allelic frequency of 15%.72 This 

haplotype was associated with decreased pain sensitiv-
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ity in low-back-pain patients following herniated disc 

surgery and in volunteers undergoing experimental 

pain.70 The degree of activity or inactivity of enzymes 

that metabolize drugs may also influence drug efficacy. 

It is well established that polymorphisms of the cytochrome P-450 (CYP2D6) enzymes influence analgesic 

efficacy of codeine, tramadol, and tricyclic antidepressants.69 Similarly, blood levels of some NSAIDS are 

dependent on CYP2C9 activity.

Catechol-o-methyltransferase is a key regulator 

of pain perception, cognitive function, and affective 

mood. Polymorphisms in this enzyme and μ-opioid 

receptors are known modulators of pain sensitivity and 

opioid efficacy.73,74 In addition to endogenous factors 

that alter pain sensitivity, exogenously administered 

small molecules (peptides) that can alter gene activity 

have been shown to influence pain response. Progress 

in molecular biology has enabled gene expression 

modulation (in animal models) using “knock outs” 

or antisense ribonucleic acid (RNAi) and small RNA 

molecules (sRNA). Gene therapy for patients with 

chronic pain shows encouraging results. Additional 

studies that have been performed on candidate genes 

transmitting pain include opioid receptors, transporters, and other targets of pharmacotherapy. Future 

studies should also elucidate the side-effect profiles 

of these gene manipulations. The challenge is to deliver this RNAi or sRNAs to target tissues such as the 

central nervous system. Genes can also affect signaling pathways related to pain sensitivity and clinical 

response.7,74 Future studies could characterize the roles 

of different genes and metabolizing enzymes along 

with demographic and clinical variables that may 

influence treatment of pain both in acute and chronic 

situations.75 

Few studies of pain in humans have described the 

ethnic or racial background of their subjects. In spite of 

this limitation, findings from any given study are then 

generalized to other ethnic and social groups, although 

there is no evidence base for such generalization of the 

results of these studies. Therefore, genetic studies of 

varying ethnic and social groups are indicated. The importance of genetic factors controlling drug disposition 

and response has received increased attention.76 For example, the variability of a single drug, midazolam, was 

11-fold.77 Selective sequencing of CYP3A4 and CYP3A5 

genes revealed 18 single-nucleotide polymorphisms 

(SNPs), including eight novel CYP3A4 SNPs. These 

differences may or may not account for such variability. Thus, the so-called standard doses of a drug may 

have toxic effects in some but fail to produce expected 

effect in others. Racial and ethnic differences have been 

described for a range of drugs and reflect genetic, environmental (cultural and dietary), and pathogenetic 

causes. Polymorphism of drug-metabolizing enzymes 

(eg, CYP2D6 of the cytochrome P-450 system) is well 

recognized and can affect drug therapy, such that lower 

or higher drug doses should be used. Thus, differences 

in response to pain treatment can be due to pharmacokinetic, pharmacodynamic, or pharmacogenetic factors. 

The identification of such genetic differences will result 

in better therapeutics. The role of pharmacogenetics 

can also be confounded by injury-induced alterations 

in drug metabolism.78

METHODS OF PAIN ASSESSMENT

The perception of pain is subjective and poses 

unique challenges for its objective assessment. The 

measurement of pain has developed to assess both 

the self-report of pain experience and behavioral 

observations. Behavioral measurements can lead to 

data correlating behaviors to subjective reports of 

pain. Self-report measures are used for patients over 

4 years of age, and require sufficient cognitive and 

language abilities. Psychiatric disorders may indicate 

an increased requirement for analgesia. For example, 

a severely injured woman with borderline personality disorder who complained constantly of pain was 

later shown to have had negligible levels of endorphins. Alternatively, patients with Axis II psychiatric 

disorders may exaggerate their needs for analgesia 

and need psychiatric or substance abuse evaluation, 

especially in later stages of care when their wounds are 

largely healed. Other patients, such as those suffering 

depression or bipolar disorder, once treated with antidepressants or mood stabilizers may have significantly 

reduced pain. Patients with factitious disorders may 

use pain or self-inflicted injuries to obtain opiates. 

Patients with a brain injury, delirium, or limited cognitive and language skills may not be able to accurately 

complete self-report measures of pain. 

Various methods assess pain in children.79 Surveys 

of pediatric anesthesiologists have reported that the 

infant’s respiratory rate is commonly used as an indicator of pain.80 Other useful behavioral indices in young 

children include facial expression,81 body movement 

(particularly limb withdrawal to painful signals82),

and crying. Psychophysiological indices include blood 

pressure, pulse, respiratory rate, and neurochemical 

activity.82 There are combined behavioral and psychophysiological indices (eg, the COMFORT scale,83

which is composed of six behavioral dimensions 

[alertness, calmness, muscle tone, movement, facial 

tension, and respiratory response] and two physiologi-
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Pain Management

cal dimensions [heart rate and mean arterial pressure]) 

to assess postoperative pain. Using this scale, it was 

found that the most accurate variables for measuring 

pain were behavioral activity, mean arterial pressure, and heart rate.84 Methods in older patients take 

advantage of the ability to self-report symptoms and 

experiences. The Poker Chip Tool85 allows children 

ages 4 to 8 to describe their pain as “pieces of hurt,” 

using one to four poker chips. The Faces Scale86 asks 

children to choose a picture of a face with expressions 

of various gradations of pain, rated 0 to 5, from “no 

pain” to “the worst pain.”

The most practical and standard pain assessment 

tools in adolescents and adults are verbal or visual (or 

both) analogue scales, asking patients to rate their pain 

on a continuum of intensity along a line using numerical anchors, commonly from 0 to 10, from “no pain” 

to “the worst pain.”87 Visual analogue scales, the most 

commonly used instruments, have good psychometric 

properties and are easily administered. The numerical 

anchors have been enhanced in the visual analogue 

instruments by adding colors to the intensity ratings.75

Pain diaries are also useful, and require the repeated 

numerical rating of pain over the course of time along 

with other relevant information such as activities, 

stressors, or alleviation with medications. 

Comfort management will have different priorities 

depending on the locale of care: prehospital, inpatient, 

and outpatient. In the prehospital setting, the priority 

must be safe and efficient care. The airway must be 

secured. The patient must cooperate with evaluation 

and transport. Medication policies should be simple 

and follow trained protocols. These protocols generally rely on intravenous opiate and benzodiazepine 

dosing, and may include drugs to facilitate endotracheal intubation, including neuromuscular blocking 

agents.88

In the inpatient setting, the focus is on continuous 

evaluation and titration of sedatives and analgesics. Inpatient protocols may be more complex, and 

importantly include regular objective evaluations 

of pain and anxiety using one or more of several 

available scales.89,90 Inpatients may also benefit from 

patient-controlled analgesia devices, which have been 

shown to be associated with reduced total opiate requirements.91 Peripheral nerve blocks92 or continuous 

epidural anesthesia are an excellent adjunct in some 

patients, particularly in the management of short-term 

or postoperative lower body pain.93

In the outpatient setting, where monitoring is less 

feasible, patient safety is an added important consideration. A differentiation should be made between neuropathic pain (eg, phantom pain) and more standard pain 

(eg, open wounds). The former is ideally addressed 

with nonopiate medication or alternative therapies to 

avoid the specter of opiate dependence.94 

METHODS OF PAIN MANAGEMENT: OVERVIEW

Until 20 years ago, pain management for acutely injured patients was relatively neglected due to concerns 

about respiratory depression and its effect on survival. 

Pain became recognized as critically undertreated, 

increasing physiological stress and adversely affecting 

outcomes. Improved pain relief became a priority and 

was successfully addressed by increased use of opiates, 

benzodiazepines, other analgesics, and anxiolytics. 

Today, in managing the pain of severely injured patients with intractable pain and anxiety, combinations 

of agents are commonly used, with close monitoring 

of vital signs and symptoms. Among these agents are 

high-dose opiates and benzodiazepines, NSAIDs, and 

the judicious use of both atypical and typical antipsychotics, antiepileptic drugs, and antidepressants. 

Signs of physiological dependence such as increased 

pulse, blood pressure, or insomnia are common upon 

tapering sedatives after prolonged administration but 

do not indicate psychological addiction; these signs are 

managed by adjusting the weaning regimen. 

Pharmacological approaches are the first-line treatment in management of pain due to combat or noncombat injuries. In addition, psychological methods 

are essential in conjunction with drugs, and their effectiveness is also well established. These include psychoeducation, psychological preparation for procedures, 

relaxation techniques, hypnosis and self-hypnosis, 

guided imagery, and therapeutic touch. Psychological 

approaches enhance trust and communication with the 

patient, facilitating hope, positive coping, and optimal 

recovery despite potentially stigmatizing disfigurement and functional losses. 

PHARMACOLOGICAL MANAGEMENT OF ACUTE PAIN

Two key principles in acute management of pain 

include frequent reassessment and dose titration. It is 

not possible to predict with accuracy the medication requirements of an individual patient. These will vary with 

pain intensity, anxiety state, personality characteristics, 

and distractions. Frequent reassessment of the efficacy of 

pain and anxiety control is essential. Ideally, these findings are documented so that pain and anxiety control can 
348

Combat and Operational Behavioral Health

smoothly transition between shifts of caregivers. There 

are several acceptable scales that are validated for this 

purpose.95 Analgesic and anxiolytic doses will need to be 

titrated to the findings from these reassessments. 

Ideally, every patient care unit will have specific 

written guidelines describing the preferred methods of 

pharmacological pain management. These guidelines 

should have a limited formulary to facilitate development of a working knowledge of drugs used by all 

staff, and allow for bedside dose-ranging depending 

on the findings at regular reassessment. 

There are a limited number of drug classes used 

in acute comfort management. The cornerstones are 

opiates and benzodiazepines. Opiates are potent analgesics with some sedative properties. Although they 

are very effective, side effects are common and include 

respiratory depression and ileus. Benzodiazepines 

are potent anxiolytics. The synergy between these 

two classes of drugs is strong.96 Other drugs useful in 

this setting are propofol (a short-acting intravenous 

anesthetic), ketamine (an intravenous dissociative 

agent), haloperidol (an intravenous antipsychotic), 

and dexmedetomidine (a centrally acting α2 agonist). 

A complete program of pain and anxiety management 

in the intensive care unit is beyond the scope of this 

chapter, but the reader is referred to many excellent 

reviews.97 The important point is that acute pain and 

anxiety management will have an important effect 

on subsequent incidence and severity of acute and 

posttraumatic stress symptoms.65 Frequent pain and 

anxiety assessment should be a regular part of care of 

all acutely injured patients.

PSYCHOLOGICAL MANAGEMENT OF PAIN AND GRIEF

Psychological strategies are quite effective for 

pain1 and for associated anxiety and grief. Reassurance, supportive interventions, increasing structure, 

and a variety of psychosocial interventions geared to 

the patient’s interests can be extraordinarily helpful 

in relieving pain, anxiety, and the sense of helplessness. Videos, television, hypnosis,18 guided imagery, 

relaxation, virtual-reality methods, and therapeutic 

touch may also effectively relieve pain and discomfort. They should be individualized, because some 

methods are more acceptable for one individual than 

for another; they are well established as key interventions for pain relief, with a very low risk of adverse or 

toxic effects. Psychological management of the patient 

and interventions also include assessment for safety, 

empathic listening, modifying cognitive distortions 

through cognitive behavior therapy, providing hope, 

and facilitating a positive long-term attitude toward 

recovery. 

Regarding pain-associated sadness and grief, 

psychotherapeutic approaches should respond to 

the phase of grief (including grieving their injury) 

the patients are in, and their phase of recovery from 

injury. Such grief exacerbates pain, and may be triggered by loss of a close buddy, seeing children die, 

mass casualties, or terrorist attacks. Some bereaved 

patients will have prolonged grief disorder, newly 

proposed for DSM-V.98 Prolonged grief disorder is 

distinguished from bereavement by causing impairment for at least 6 months with one of these three 

symptoms in criterion B, which is called “separation 

distress”:

1. intrusive thoughts related to the deceased, 

2. intense pangs of separation distress, and 

3. distressingly strong yearnings for that which 

was lost. 

These symptoms must occur daily or to an intense 

or disruptive degree. In addition, five of the following 

nine symptoms of criterion C, “cognitive, emotional, 

and behavioral symptoms,” must be present daily or 

to an intense or disruptive degree: 

1. confusion about one’s role in life or diminished sense of self; 

2. difficulty accepting the loss; 

3. avoidance of reminders of the reality of the 

loss;

4. inability to trust others since the loss; 

5. bitterness or anger related to the loss; 

6. difficulty moving on with life; 

7. numbness (absence of emotion) since the loss;

8. feeling that life is unfulfilling, empty, and 

meaningless since the loss; and 

9. feeling stunned, dazed or shocked by the 

loss.

The duration must be at least 6 months from the 

onset of separation distress; it must cause clinically 

significant distress or impairment in social, occupational or other important areas of functioning; and 

lastly, it cannot be due to a substance, general medical 

condition, or other disorder. When present, family support is key to relieving pain, anxiety, and grief. Family 

understanding, coping, resilience, and capacity to 

support need to be assessed and reinforced. Provision 

of supports, including counseling and psychotropic 

medications where indicated, facilitates the capacity 

to care for the patient. 
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Pain Management

SPECIAL PROBLEMS

Ventilated Patient

Analgesia and sedation in the mechanically ventilated patient has the added factor of maintaining 

airway security and patient safety. The agitated patient will not only suffer emotionally, but may die if 

the endotracheal tube or vascular access devices are 

dislodged.99 A “lightly asleep but arousable” state, or 

a Richmond Agitation-Sedation Score of -2, is a common objective when caring for intubated patients in 

the intensive care unit.

Burns and Multiple Traumas

Patients with burns and multiple traumas will have 

very large amounts of noxious stimulation associated 

with wounds and their management. The level of 

analgesic required can have adverse effects on respiratory and hemodynamic status. At times, these adverse 

effects must be accepted and managed (via mechanical 

ventilatory or vasopressor support or both) to ensure 

adequate patient comfort and safety. It is important 

that other potential causes of these problems (most 

commonly sepsis) be excluded.

Amputation Pain

Amputated limbs are a common cause of acute and 

chronic pain syndromes. It is important to distinguish 

acute surgical pain (eg, bone and soft-tissue pain) 

from neuropathic pain (eg, phantom pain), as pharmacological and nonpharmacological management 

strategies differ.100

Weaning

Most pain and anxiety medications stimulate receptor changes that mandate weaning if consequences 

of abrupt withdrawal are to be avoided.101 Opiate 

withdrawal will cause tremulousness, autonomic 

hyperactivity, diarrhea, and emesis. Benzodiazepine 

withdrawal can result in seizures. Gradual weaning is 

well tolerated, with low rates of withdrawal symptoms 

or drug dependence, even when very high drug doses 

are used acutely.102

Pediatric Pain 

Pain in children is treated according to similar principles to those outlined in this chapter, but with specific 

changes adapted to the pediatric population for body 

weight, any pediatric illnesses, developmental status, 

and dependency on parents and family.10 Dosages 

are calculated on a milligram per kilogram basis, and 

treatment is modified if there is concomitant pediatric 

illness. The developmental status of the child—infant, 

toddler, school age, and adolescent—requires adaptation to the physical, mental, emotional, and relationship characteristics of those stages. 

Psychiatric Risk Factors

The principal risk factors for pain complications 

include inadequate analgesia, delirium, unrecognized 

infection or injury, sleep disorders, preexisting psychopathology, self-inflicted injuries, prior addiction, PTSD 

or other anxiety disorder, emergent depression, somatoform disorders, and factitious disorder. Diagnosis 

and specific treatment of these conditions or disorders 

is essential to effectively manage the associated pain. 

Not all apparently psychological contributions to pain 

are that, and further diagnostic investigation is often 

warranted.

Pain Management and the Issue of Addiction

Prior addiction to or abuse of alcohol or other 

substances is very commonly associated with noncombat injuries, as is withdrawal from the drug of 

abuse, especially alcohol, during acute treatment of 

the injuries. As a result, treatment of all injuries should 

include a careful history of substance abuse, toxicology 

screening, ongoing evaluation of possible withdrawal, 

treatment of withdrawal symptoms, and interventions 

to reduce the risk of continuing addictive behavior 

posttreatment.103

The Ethics of Pain Control

Pain control may become complicated. As noted 

above, inadequate relief of pain results in increased 

risk for adverse psychiatric sequelae and poorer 

outcomes. There is therefore an ethical obligation to 

relieve pain to reduce the likelihood of harm. Acutely, 

treatment of serious pain is occasionally complicated 

by excess sedation, respiratory depression, or hypotension. Over the longer term with chronic pain 

management, drug dependency can occur, particularly 

in patients who have been substance abusers. If, in the 

management of chronic pain, overuse of pain medication occurs or is perceived, serious medical com-
350

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plications may arise and could result in challenging 

medicolegal consequences. It is an ethical imperative 

that such risks, as well as those of undertreatment, 

are acknowledged, considered, and appropriately 

managed in formulating a sound treatment plan for 

the injured patient.104–106 

SUMMARY

The objective of this chapter is to aid in improving 

management of acute or chronic pain from combat 

and noncombat wounds. It addresses the psychiatric implications of the control or elimination of 

injury pain, the wounds causing the worst pain, and 

differences in treating soldiers from civilians. Four 

case examples (of patients aged 4, 18, 26, and 55) 

that were presented with combat and noncombat 

injuries provide practical illustrations of the range 

of approaches to pain problems needing evaluation 

and treatment. Biological factors are presented that 

affect pain, including anatomic, genetic, and pharmacological considerations. A range of established 

and emerging treatments is described, and ways to 

assess whether or not analgesic requirements are 

met, underestimated, or exceeded are detailed. The 

problem of addictive behavior in the military must be 

considered both acutely, and later in care, but is not 

a contraindication to providing adequate pain relief. 

Approaches to pain from injury, surgery, dressings, 

amputation, and emotional causes are discussed. 

Pain caused by wounds and other injuries in military 

personnel and civilians is significant, and may trigger 

subsequent PTSD, depression, or behaviors associated 

with disability, especially in vulnerable individuals. 

Consistent with the medical team approach, as well 

as the authorship of this chapter, multidisciplinary 

collaboration of psychiatrists, surgeons, anesthesiologists, and allied personnel is key to optimal pain 

management.

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92. Grossi P, Urmey WF. Peripheral nerve blocks for anaesthesia and postoperative analgesia. Curr Opin Anaesthesiol. 

2003;16(5):493–501.

93. Schug SA, Saunders D, Kurowski I, Paech MJ. Neuraxial drug administration: a review of treatment options for anaesthesia and analgesia. CNS Drugs. 2006;20(11):917–933.

94. Roganovic Z, Mandic-Gajic G. Pain syndromes after missile-caused peripheral nerve lesions: part 2—treatment. Neurosurgery. 2006;59(6):1238–1249.

95. Kwekkeboom KL, Herr K. Assessment of pain in the critically ill. Crit Care Nurs Clin North Am. 2001;13(2):181–194.

96. Hogarth DK, Hall J. Management of sedation in mechanically ventilated patients. Curr Opin Crit Care. 2004;10(1):40–

46.

97. Adam C, Rosser D, Manji M. Impact of introducing a sedation management guideline in intensive care. Anaesthesia.

2006;61(3):260–263.

98. Zhang B, El-Jawahri A, Prigerson HG. Update on bereavement research: evidence-based guidelines of the diagnosis 

and treatment of complicated bereavement. J Palliat Med. 2006;9(5):1188–1203.

99. Krinsley JS, Barone JE. The drive to survive: unplanned extubation in the ICU. Chest. 2005;128(2):560–566.

100. Bosmans JC, Suurmeijer TP, Hulsink M, van der Schans CP, Geertzen JH, Dijkstra PU. Amputation, phantom pain and 

subjective well-being: a qualitative study. Int J Rehabil Res. 2007;30(1):1–8.

101. Cammarano WB, Pittet JF, Weitz S, Schlobohm RM, Marks JD. Acute withdrawal syndrome related to the administration of analgesic and sedative medications in adult intensive care unit patients. Crit Care Med. 1998;26(4):676–684.

102. Zapantis A, Leung S. Tolerance and withdrawal issues with sedation. Crit Care Nurs Clin North Am. 2005;17(3):211–

223.

103. Findley JK, Park L. Psychiatric issues in trauma. In: Sheridan RL, ed. The Trauma Handbook of the Massachusetts General 

Hospital. Philadelphia, Penn: Lippincott Williams & Wilkins; 2004: 662–681.

104. Ballantyne JC. Opioids for chronic nonterminal pain. South Med J. 2006;99(11):1245–1255. 

105. Magnusson RS. The devil’s choice: re-thinking law, ethics, and symptom relief in palliative care. J Law Med Ethics.

2006;34(3):559–569, 481.

106. Green C, Todd KH, Lebovits A, Francis M. American Academy of Pain Medicine Council on Ethics. Disparities in pain: 

ethical issues. Pain Med. 2006;7(6):530–533.
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US Army Occupational Therapy: Promoting Optimal Performance

Chapter 22

US ARMY OCCUPATIONAL THERAPY: 

PROMOTING OPTIMAL PERFORMANCE

MARY W. ERICKSON, MAOL, OTR/L*; TERESA L.BRININGER, PhD, CHT, OTR/L†; SHARON M. NEWTON, OTR/L, MHS‡

; AMY M. MATTILA, MS, MBA§; and JAMES P. BURNS, OTR/L, MOT¥

INTRODUCTION

OCCUPATIONAL THERAPY IN WORLD WAR II

ARMY OCCUPATIONAL THERAPY IN THE 21ST CENTURY

Army Occupational Therapy Credentials and Training

Role of Occupational Therapy Assistants

Overview of Occupational Therapy Services in Combat and Operational Stress 

Control 

AN INTEGRATED ARMY RESERVE REGIONAL COMBAT AND OPERATIONAL 

STRESS CONTROL PROGRAM 

OCCUPATIONAL THERAPY IN SUPPORT OF OPERATION IRAQI FREEDOM 

DETAINEE HEALTHCARE

PEAK PERFORMANCE TRAINING IN OCCUPATIONAL THERAPY

OCCUPATIONAL THERAPY IN THE WARRIOR TRANSITION UNIT

The Comprehensive Transition Plan

Work Reintegration Programs

Occupational Therapy’s Focus in Work Reintegration

OCCUPATIONAL THERAPY ON THE HOME FRONT

SUMMARY

*Colonel, Individual Mobilization Augmentee, US Army Reserve; Chief, Occupational Therapy, Reintegration Branch Chief for the Proponency Office 

for Rehabilitation and Reintegration, Office of The Surgeon General, Falls Church, Virginia

†

Lieutenant Colonel, Medical Specialist Corps, US Army ; Deputy for Rehabilitation and Reintegration, Telemedicine and Advanced Technology Research 

Center, Medical Research and Materiel Command, 504 Scott Street, Building 722, Room 30, Fort Detrick, Maryland 21702

‡

Lieutenant Colonel, Medical Specialist Corps, US Army; Command Inspector General, 30th Medical Command, CMR 442, APO AE 09042; formerly 

Theater Consultant for Combat and Operational Stress Control, Iraq

§

Captain, Medical Specialist Corps, US Army; Chief, Department of Occupational Therapy, Reynolds Army Community Hospital, 4301 Wilson Street, 

Fort Sill, Oklahoma 73503; formerly, Chief, Occupational Therapy, 254th Medical Detachment (Combat Operational Stress Control), Germany

¥

Major, Medical Specialist Corps, US Army; Occupational Therapist, Department of Orthopaedics and Rehabilitation, Building 2, Room 3J04, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5001; formerly, Chief Occupational Therapist, Department of Surgery, 

Fort Jackson, South Carolina
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Combat and Operational Behavioral Health

INTRODUCTION

Occupational therapy (OT) utilizes engagement in 

meaningful occupation (purposeful everyday tasks 

and activities that “occupy” one’s time) to facilitate 

function and achieve a healthy and balanced lifestyle.1,2

Early history records the use of activity, music, and 

games to assist with the recovery of mental health. 

In 172 ce, Galan wrote: “Employment is nature’s best 

physician and is essential to human happiness.”3 The 

profession grew out of the moral treatment movement of the early 19th century, with a focus on compassion and occupation using manual labor such as 

agriculture, sewing, and tailoring to treat the insane.4

The founders of OT in the United States came from a 

variety of backgrounds including psychiatry, social 

work, and architecture. Adolf Meyer, a psychiatrist, 

observed human behavior and habit in relation to the 

environment, writing 

the whole of human organization has its shape in a 

kind of rhythm...work and play and rest and sleep, 

which our organism must be able to balance even under difficulty. The only way to attain actual balance in 

all of this is actual doing, actual practice, a program 

of wholesome living as the basis of wholesome feeling and thinking and fancy of interests.5

During the 20th century, OT became closely aligned 

with treating wounded soldiers and sailors in response 

to the two world wars.6(p158),7 Then, as now, the profession’s foundation is the belief that occupation, or 

purposeful activity, is vital to regaining or maintaining 

the health of the entire person. This purposeful activity 

is graded according to the individual’s ability. Furthermore, the philosophies of OT and treating service 

members with combat or operational stress reactions 

go hand-in-hand.6

The use of OT in the US military dates to World 

War I, when the US Civil Service Commission (precursor to the Office of Personnel Management) called 

for individuals trained in OT and other professions 

such as teachers and artists to serve as reconstruction 

aides in military hospitals. Early in 1918, the Surgeon 

General’s Office began recruiting reconstruction 

aides to work with and treat service members who 

were wounded or suffered from battle neurosis to 

return to the battlefield. In February of that year, 

the Army’s first trial of OT, occurring at Walter 

Reed Hospital, demonstrated its value in treating 

both the mind and the body of the wounded service 

member using occupation in the form of treatment: 

physically, to improve upper extremity function; 

and psychologically, to help prevent depression, 

control attention, and calm the wounded.3(pp159–160)

By June 1918 the first OTs arrived at Base Hospital 

117 in France, serving as civilians in the American 

Expeditionary Forces.3

During World War I, OT was established in Army 

hospitals for the reconditioning of convalescent 

soldiers by the Division of Physical Reconstruction 

within the Office of The Surgeon General, established 

in January 1918. Its intent was “through the use of 

mental and manual work, to restore to complete or 

maximum possible function, any military person 

disabled in line of duty.”7(p70) The overall goal of the 

reconditioning program was to return soldiers to military duty in the highest state of physical and mental 

fitness in the shortest possible time. If disqualified for 

further military service, the aim of reconditioning was 

to return the soldier to civilian life in the best possible 

physical condition, “well oriented in the responsibilities of citizenship and prepared to adjust successfully 

to social and vocational pursuits.”8(p329) The mission 

was accomplished by a coordinated program of educational reconditioning, physical reconditioning, and 

occupational therapy.

OCCUPATIONAL THERAPY IN WORLD WAR II

During World War II, OT grew in breadth and 

scope of practice in both physical medicine and 

neuropsychiatry. Programs developed to treat the 

physical and psychological injuries incorporated 

educational reconditioning, activity-based workshops, 

industrial therapy, and recreational therapy. OT 

carried out within physical medicine addressed “the 

restoration of physical function to impaired joints and 

muscles...seeking (1) improvement of the general 

physical condition, (2) the development of work 

tolerance through graded activity, and (3) stimulation 

of mental acuity through interesting occupation.”8(p344)

Occupational therapists’ observations of behavior, 

attitude, and reactions of patients were extremely 

valuable to the medical team and were reported during 

interdisciplinary staff conferences. These regularly 

scheduled meetings helped staff to plan and adjust 

the overall treatment program as needed.

OT in the neuropsychiatric section was placed under the immediate direction of the psychiatrist. The 

goals of OT within neuropsychiatry were “(1) to guide 

mental attitudes into healthy channels, (2) to promote 

a desire to get well, (3) to restore self-confidence and 

a sense of security, (4) to substitute encouragement 
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US Army Occupational Therapy: Promoting Optimal Performance

for discouragement, (5) to establish and maintain 

good work habits and (6) to afford opportunity for 

socialization.”8(p348) General treatment principles used 

with neuropsychiatric patients included (a) quiet, 

soothing work to help calm patients; (b) noisy, active 

work to discharge tension; (c) responsible work to 

promote self-confidence; (d) simple, easily completed 

tasks for encouragement; (e) interesting, colorful 

work for stimulation; (f) absorbing, detailed tasks 

for improving concentration; and (g) group work for 

socialization.

OT’s role in educational reconditioning included 

identifying the service members’ goals and interests 

and providing valuable information for the establishment of individualized treatment programs. Essential 

components of the educational reconditioning program included OT laboratory shops that provided 

practical experience for patients following the completion of academic courses sponsored by the educational 

reconditioning program in fields such as photography, 

radio, electricity, and motor mechanics. The “noisy” 

shop was used for patients who needed to discharge 

tensions through work. Activities in the noisy shop 

included carpentry, metalworking, work with plastics, 

and printing. The “quiet” shop was used for patients 

who were easily distracted or disturbed by noise and 

included activities such as weaving, leatherworking, 

ceramics, and art. Patients confined to the ward participated in OT through the use of small handicrafts 

carried out under close supervision. 

An industrial therapy program also emerged during 

World War II, in which occupational therapists organized therapeutic “industrial” assignments involving 

hospital maintenance. The program included identifying available job assignments by gathering information 

on each job title, duties required, physical and mental 

requirements, and work standards. The program 

successfully provided participants a balanced work 

program, helped maintenance personnel complete 

daily tasks, and provided therapeutic activity for a 

large number of patients while requiring few trained 

supervisors. It was designed as a transitional program 

to meet the work requirements of patients who had 

progressed beyond the need for specific therapy but 

could not yet return to full duty. The work activities 

improved 

general physical ability including muscle tone, 

strength, and joint motion, to combat the effects of 

prolonged hospitalization, to increase work tolerance, to re-establish work habits counteracting the 

effect of periods of mental and physical idleness and 

to stimulate mental alertness.8(p352)

Job task analysis was an essential component in the 

World War II reconditioning program. Occupational 

therapists analyzed jobs from both a physical and a 

psychological perspective, and subsequently identified 

a variety of job opportunities. Work areas utilized for 

reconditioning included the utility shop, motor pool, 

warehouse, post office, laundry, mess hall, supply 

department, administrative office, medical laboratory, 

photographic laboratory, orthopaedic shop, messenger 

service, drafting, landscaping, and gardening. The 

patients’ clinical appointments and medical consultations took precedence over industrial work assignments, and high standards were maintained: work 

projects were not allowed to deteriorate into a source 

of “cheap labor,” and the therapists ensured that the 

job task was appropriate for the soldiers’ physical and 

mental capabilities.

Another OT effort was a recreational (or “diversional”) program used “to divert the patient’s mind 

from thinking of himself constantly, to provide for 

the constructive use of leisure time, to furnish opportunity for self-expression, to stimulate interests and 

sustain morale, to conserve initiative and maintain 

good work habits, to promote socialization by group 

activities and to improve general physical fitness by 

stimulating the appetite and the circulation.”8(pp353–354)

The Arts and Skills Corps, composed of craftspeople 

recruited and organized by the Red Cross; the “Gray 

Ladies,” a group of volunteers assigned to hospital 

OT departments; and Women’s Army Corps assistants 

expanded the reach of OT to include minor crafts 

such as model making, art, wood and soap carving, 

plastics, leatherwork, ceramics, fly-tying, and weaving. Shop programs included photography, radio 

and electrical work, motor mechanics, and the use of 

power equipment.8(p355) In 1947, the Army established 

the Women’s Medical Specialist Corps under Public Law 36, 80th Congress, giving OTs a permanent 

military status. In 1955 the name was changed to the 

Army Medical Specialists Corps under Public Law 

294, 84th Congress, reflecting the inclusion of men 

in the corps.7(pp5,402) Current Army OT policies and 

practices are built on the foundations established in 

World War II.

ARMY OCCUPATIONAL THERAPY IN THE 21ST CENTURY

Serving throughout the world in times of war and 

peace, Army occupational therapists (OTs, military 

occupational specialty [MOS] 65A) and military occupational therapy assistants (OTAs, MOS 68WN3) 
360

Combat and Operational Behavioral Health

currently number over 200 in strength. The mission 

of OT in today’s Army is to promote soldier readiness, healthy living, and optimal performance among 

all Department of Defense (DoD) beneficiaries using 

OT principles and practices (Exhibit 22-1). Army OTs 

incorporate best clinical practices and strive to deliver 

them in a timely and cost-efficient manner.9

Today, Army OT practitioners function as human 

performance experts whose innovative programs and 

services help to optimize soldier performance and 

readiness in both field and garrison settings. OTs treat a 

wide range of conditions with many soldiers impacted 

by both physical and psychological injuries. In addition to the behavioral health role of OT in combat and 

operational stress control (COSC) efforts, OTs provide 

neuromusculoskeletal evaluation and rehabilitation 

with an emphasis on the upper extremity; inpatient 

and outpatient rehabilitation, including specialty 

areas such as cognitive rehabilitation, community 

reintegration, driving rehabilitation, and burn care; 

neurology and orthopaedics; ergonomics, including 

the development of strategies to prevent injuries and 

decrease human and economic costs of injuries in 

the DoD; peak performance training; use of assistive 

EXHIBIT 22-1

US ARMY OCCUPATIONAL THERAPY SCOPE OF PRACTICE

The unique role of occupational therapy (OT) emphasizes the enhancing of each individual’s performance in his or 

her various life roles (ie, soldier, worker, parent, student, and retiree). Occupational therapy’s services are designed 

to respond to soldier, patient, family, and military organizational needs and expectations. Army OT helps prevent 

dysfunction, promotes and develops healthy lifestyles, and facilitates adaptation and recovery. Army OT helps the 

wounded, injured, or ill adapt daily occupations and routines in the areas of self-care, home management, community participation, education, work, and/or leisure activities. New Army OT initiatives include standardization of 

a military-specific Functional Capacity Evaluation, driving rehabilitation including the use of driving simulation, 

animal-assisted therapy, warrior goal-setting training, and use of a toolkit to evaluate and treat concussion/mild 

traumatic brain injury. 

Occupational therapy’s scope in the provision of services encompasses the following:

• Military readiness. All services provided to the soldier population target optimized effective performance, 

prevention, and expeditious return to duty following medical or psychological conditions.

• Priority of care is directed to the soldier to assist in maintaining his or her highest level of performance and 

ensure fitness to fight.

• Prevention and wellness. Includes screening and health promotion interventions to maintain and promote 

effective performance of soldiers and Department of Defense beneficiaries.

• Combat stress prevention and intervention in the combat environment and in stability and support operations.

• Unit consultation to promote psychosocial well-being, including ergonomic evaluation, training, and worksite analysis; identification of and ergonomic intervention for conditions where the etiology is physical or 

stress-related.

• Support of humanitarian missions in the primary care role for upper extremity neuromuscular screening 

or stress prevention and intervention.

• Direct patient care may include but is not limited to basic and advanced self-care (activities of daily living) 

evaluation and training. Training emphasizes regaining and sustaining functional performance while developing and improving diverse, complex skills including problem-solving and decision-making capabilities.

• Psychosocial treatment with emphasis on functional performance in various life roles through insight development, skill acquisition, education, and treatment programs.

• Work reintegration, including ergonomic analysis, fit-for-duty programs, and injury prevention and training 

that keep workers on the job, reduce costs, and improve productivity. Programs that promote work behaviors for improved physical and psychological performance include stress, coping, and life skills education 

programs.

• Evaluation and treatment of upper extremity conditions, including upper extremity neuromusculoskeletal 

evaluations in support of the orthopaedic physician.

• Orthotic (splint) fabrication. Adaptive technology evaluation and recommendations for, or fabrication of, 

equipment.

• Developmental pediatric evaluation and treatment (at specified treatment facilities).
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US Army Occupational Therapy: Promoting Optimal Performance

technology; and work reintegration programs within 

warrior transition units (WTUs). Recognizing the psychological as well as functional value of early return 

to wearing the uniform following injury, OTs helped 

develop the Army’s Wounded Warrior Clothing Support Program in 2008, which authorizes the wear of 

uniforms with adaptations/modifications prescribed 

by OTs or other rehabilitation specialists. Additionally, 

Army OTs serve in dedicated research positions as well 

as academic appointments. 

Emerging OT practice areas include pilot programs 

in brigade combat teams to treat individuals with 

traumatic brain injury, animal-assisted therapy and 

animal-assisted activities in COSC units, and servicedog training programs. Creative partnerships with 

501(c)(3) (nonprofit) organizations have produced 

successful service-dog training programs. For instance, 

initial service-dog training may be conducted within 

a civilian prison with specialized service-dog skills 

training conducted as part of a WTU work therapy 

program to prepare future service dogs to meet the 

unique needs of wounded soldiers. OTs are involved 

in a growing use of therapeutic riding programs as 

well. An integrated process team consisting of OTs, 

veterinarians, and behavioral health specialists is 

addressing principles and standards, and updating 

policies related to the human-animal bond.

Army Occupational Therapy Credentials and 

Training

Army OT practitioners, who serve in command 

and executive positions throughout the Army Medical 

Department, must be versatile, competent leaders to 

successfully operate and manage clinic operations in 

both deployed and garrison environments. Army OTs 

are credentialed healthcare providers and, as commissioned officers, they require National Board for Certification in Occupational Therapy (NBCOT) registration 

and a current, active, valid, and unrestricted OT license 

from a US state or jurisdiction. Currently, OT recruits 

entering the Army with a master’s degree in OT will 

be able to earn a doctorate of science in occupational 

therapy (DSCOT). The DSCOT program and the enlisted 68WN3 OTA program are taught at the Army 

Medical Department Center and School at Fort Sam 

Houston in San Antonio, Texas. As of 2010, Army OTAs 

are required to obtain NBCOT national certification 

and state licensure. Civilian OTs working within a military setting must be registered by NBCOT and licensed 

according to the regulatory requirements of the state in 

which they are practicing.9

 Civilian OTAs are required 

to take the NBCOT examination and be credentialed as 

a certified occupational therapy assistant (COTA) with 

licensure according to the regulatory requirements of 

the state in which they are practicing. 

Role of Occupational Therapy Assistants

OTAs are specialists who bring the perspective 

of the enlisted soldier to the therapeutic process by 

assisting the supervising OT in evaluating a service 

member’s occupational performance; conducting initial occupational performance history interviews and 

mental status evaluations; using observation to gather 

data as part of task-performance skill assessments; and 

implementing OT interventions under the supervision 

of a credentialed OT. OTAs coordinate, set up, and 

oversee work hardening sites; lead OT groups; and 

monitor, facilitate, and supervise therapeutic activities. 

The OTA supervises combat and operational stress 

reaction casualties, provides status updates for these 

casualties, and conducts classes on selected stressrelated topics. OTAs assist in all COSC functional areas 

including unit needs assessments and traumatic event 

management in the deployed environment. 

Overview of Occupational Therapy Services in 

Combat and Operational Stress Control 

The role of the OT practitioner in Army COSC is to 

evaluate occupational performance and implement 

interventions to enhance that performance.6

 OT’s 

unique core skills are aimed at keeping soldiers able 

to perform their mission and include

• analysis of jobs and job tasks for underlying 

requisites (required subtasks, performance 

standards, equipment used, the social and 

physical work environment, occupational 

hazards);

• assessment of occupational performance 

(functional abilities) relating to specific tasks 

and jobs;

• configuration of a therapeutic, structured environment in which skills can be developed;

• analysis, selection, and application of occupations (activities) as therapeutic media; and

• the ability to match the individual to tasks he 

or she can successfully perform.2(p22),6,7

Army OTs evaluate soldier performance across the 

spectrum of occupational areas including activities 

of daily living, work, education, leisure, and social 

participation. The OT, or a COSC team member under 

the guidance of the OT, selects therapeutic occupations 

(purposeful activities) based on the soldier’s current 

functional ability that support maintaining the sol-
362

Combat and Operational Behavioral Health

dier’s military identity, enhances the soldier’s sense 

of competence, and restores confidence. OTs perform 

task analysis and functional assessments, structure a 

therapeutic environment, provide occupation-based 

treatment, and match soldiers’ abilities to the tasks or 

jobs they can perform. OTs also identify and evaluate mental and physical stressors, stress reactions, 

and cognitive function. They subsequently develop 

a treatment plan, which often includes teaching prevention, adaptive coping, and psychosocial skills. 

Additionally, they utilize therapeutic media and 

therapeutic use of self within individual and group 

settings to enhance environmental adaptation and 

maximize treatment.10(pp3–8) Army OTs integrate their 

diverse training in upper extremity orthopaedics, 

rehabilitation, ergonomics, and COSC techniques to 

identify areas of need for both individual soldiers 

and organizational units. Functional assessments 

include analysis of skills required by the soldier’s 

MOS, identification of tasks the soldier can perform, 

and synthesis of therapeutic occupations. Interventions such as “work hardening for Warriors” involve 

occupation-based treatment that matches the soldier’s 

functional ability with therapeutic occupations that he 

or she can perform. 

OT groups engage in work activities, cognitive and 

sensorimotor activities, activities that parallel taskperformance skills, cooperative activities, expressive 

arts, and exercise. Psychoeducational training may 

include selected common and collective soldier tasks 

or life skills such as stress management, relaxation 

skills, sleep hygiene, anger management, communication skills, problem solving, assertiveness training, 

and time management. Therapeutic activities of daily 

living may include personal hygiene and uniform 

maintenance; work/productive activities may include military-relevant tasks such as vehicle or site 

maintenance; and social and leisure activities may 

include cooperative or competitive sports, games, 

ceremonies, or celebrations. Therapeutic occupations 

are graded to offer challenges that are “just right” for 

each individual, leading to successful performance that 

instills competence and confidence. The soldier then 

gradually improves his or her functional capacity and 

ability to return to duty.10(pp10–12)

OT personnel also provide services as members of 

fitness teams and preventive teams in the delivery of 

behavioral health services in a deployed setting. The 

OT’s role in a preventive team is the same as the other 

team members: providing outreach services through 

establishing rapport with supported units and leaders, assessing unit needs, and making regular contacts 

with supported units. An OT approaches these tasks 

from a unique perspective of assessing and addressing 

functional performance. The OT evaluates a soldier’s 

current level of functional performance in a deployed 

environment. OTs also assess how psychological and 

cognitive function impacts task performance. They 

draw from a battery of standardized assessments that 

can help identify the presence of a combat and operational stress reaction, behavioral health problem, or 

traumatic brain injury. Collaborating with the rest of 

the team, the OT assimilates this information in determining the appropriate interventions, referrals, or 

other necessary action. For example, the OT may find 

that the best intervention is to restructure the soldier’s 

job or environment to ensure successful completion of 

a task. Interventions often involve educating both the 

soldiers and their leaders. 

Observation is one of the tools the OT uses to assess function. Observation can be especially valuable 

while conducting outreach visits. While performing 

“walk-abouts” within the area of operation, OTs work 

alongside soldiers and use their expertise to help them 

retain the functional ability to perform their mission. 

By working alongside soldiers, OTs can observe how 

each soldier is functioning and assess the mental or 

physical demands required to complete a particular 

job. Using this knowledge, the OT can begin to identify 

potential problems in task performance and intervene before problems escalate. For example, during 

Operation Iraqi Freedom (OIF) I (2003), an OT on the 

preventive team helped prepare and serve a meal in 

a mobile kitchen trailer. The OT talked casually with 

soldiers preparing the meal, getting a better idea of 

how they were dealing with the stress of operations. 

Additional stressors quickly presented themselves: 

working in a hot, crowded kitchen and dealing with 

large numbers of flies. Even the manner in which the 

food on the serving line was placed created physical stress. The OT provided suggestions for a more 

efficient and safer order of food trays, and adjusted 

the height of a work surface for one of the soldiers so 

she could more easily reach it. An added bonus was 

getting a glimpse into the basic cognitive function and 

general mood of hundreds of soldiers as they filed 

past the serving line. 

The OT’s observation skills are helpful when performing a unit needs assessment through evaluating 

the occupational performance needs of individuals 

in the unit. OTs identify component factors that are 

essential to successful performance. They may also 

assess the behavioral health training needs of soldiers, 

leaders, the unit ministry team, and other medical 

personnel within the unit. This may lead to additional 

interventions to enhance occupational performance 

and the development of plans to meet the future COSC 

needs of soldiers and units based on prevention and 
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US Army Occupational Therapy: Promoting Optimal Performance

early intervention. 

To enhance the provision of COSC services, 

Army OT practitioners utilize their background 

and training in upper extremity orthopaedics, rehabilitation, and ergonomics in both garrison and 

theater. Since the early 1980s, OTs have proposed 

and participated in programs designed to promote 

the soldier’s job performance in garrison.6(p56) Occupational therapists have been included in missions 

to Bosnia-Herzegovina, Peru, and Russia, to name a 

few. The global war on terror continues to provide 

opportunities for OTs to utilize their unique skills to 

promote the health and welfare of service members. 

OTs have deployed to Afghanistan and Guantanamo 

Bay in support of Operation Enduring Freedom. In 

the Iraq and Afghanistan theaters of operations, they 

offer OT services to US and Coalition military members, national security forces and civilians, and the 

detainee population. OT practitioners within WTUs 

help meet the needs of injured, ill, and wounded 

soldiers through a focus on life skills training and 

work reintegration. OT personnel were also involved 

in the development of regional Army Reserve COSC 

programs on the home front.

An Integrated Army Reserve Regional Combat and Operational Stress

 Control Program

Identifying the need for home-front support as large 

numbers of Army Reserve soldiers began to deploy in 

2003, the commanding general from the 88th Regional 

Readiness Command (RRC) initiated a COSC program 

for Army Reserve soldiers and their families within 

a six-state region in the upper Midwest (Minnesota, 

Wisconsin, Ohio, Michigan, Indiana, and Illinois). 

Two COSC officers from the 785th Medical Company 

(Combat Stress Control) were mobilized (an OT and 

a social work officer) to initiate a deployment cycle 

support program. From the inception of the program, 

the team used an interdisciplinary psychoeducational 

approach to help build resiliency and coping skills in 

soldiers and their families (Figure 22-1; Table 22-1). 

When available, Reserve component behavioral health 

specialists within the region augmented the team to 

provide local support. In 2005, a psychiatric nurse was 

mobilized to enhance the capabilities of the 88th RRC 

COSC team.

The COSC team established a strong working relationship with the other RRC elements that had direct 

roles in preparing and supporting deploying soldiers 

and their families. Program staff brought together 

representatives from family readiness groups; the 

chaplain’s, public affairs, and casualty affairs offices; 

and the RRC leadership to establish an integrated approach to meet the comprehensive needs of soldiers 

and families. A multilevel needs assessment was conducted to identify capabilities, needs, and resources for 

soldiers, leaders, and families throughout the region. 

The implementation of an integrated operational stress 

management program was seen as an essential element in producing secure and resilient soldiers with 

families prepared to withstand the rigors of military 

separation, combat operations, and the more routine 

stressors common to the military lifestyle. The COSC 

team explained to unit leaders that its mission is to 

keep their soldiers with them, doing their jobs through 

Military Joint Service Civilian

2003 2004 2005 2006

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Figure 22-1. 88th Regional Readiness Command educational 

stress briefings, numbers of participants, 2003–2007.

programs designed to promote resiliency in the workplace, the family, and the community. 

Through a series of meetings and site visits a plan 

of operation emerged. The plan included the provision of information to leaders, soldiers, and family 

members as well as other regional military and civilian 

organizations. The team’s goal was rapid response: to 

provide soldiers and their families with educational, 

spiritual, and psychological resources to strengthen the 

basic bonds essential to high morale and good order. 

The expected outcomes included mission-capable soldiers and self-reliant families who were stress resilient, 

confident, secure, supported, and healthy (physically, 
364

Combat and Operational Behavioral Health

TABLE 22-1

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL PROGRAM: 

ACTIVITY SUMMARY, APRIL 2003–DECEMBER 2006

COSC Briefings* Individual Counseling

Mobilization (soldiers/families) 13,398 Soldier/family and stress/PTSD issues 2,363

Midcycle (families) 4,826 Bereavement support (ie, funeral, follow-up, etc) 496

Homecoming (families/friends) 13,839 Well-being (acupuncture and therapeutic massage) 1,901

Reconstitution support (first postdeployment drill) 8,541 PREP couples’ support† 934

SRP training 28,247 Marriage/relationship‡ 228

Educational stress briefings

Community groups 6,045

Military groups 7,548

Other military (NG, Navy, etc) 2,258

*Number of participants

†

Marriage retreat. No program participation in 2006

‡

Single soldier retreat

COSC: combat and operational stress control

NG: National Guard

PREP: Prevention and Relationship Enhancement Program 

PTSD: posttraumatic stress disorder

SRP: Soldier Readiness Program

emotionally, psychologically, and spiritually). Soldiers 

departing for extended missions would have confidence that their families were prepared and supported, 

and would be more likely to resist the debilitating 

effects of long-term operational stress. Families who 

knew their soldiers had a solid base of preparation and 

training would feel more secure sending them out to 

serve and would be more likely to support a soldier’s 

decision to make the Army a career. Outcome measures 

were based on assessments of physical, social, and environmental factors with direct and indirect feedback 

from soldiers, family members, and leaders. Metrics 

included the number of training sessions conducted, 

attendees at each, individual consultations and followup referrals, and requests for further information and 

training sessions, as well as feedback on the effectiveness of the educational material including handouts, 

presentations, and resources provided.

Training (including informational briefings), command consultation and support, and referral were core 

features of the program. Crisis intervention, sexual 

assault prevention and advocacy programs, suicide 

prevention training and briefings, and grief-counseling 

support were also incorporated. Family stress support 

services included community outreach programs and 

collaborative programs with other branches of the 

military. For instance, Army Reserve family readiness 

groups (FRGs) “adopted” family members of service 

members from other components of the military who 

were living within their local area. 

Training for leaders and soldiers included prevention, identification, and management of combat and 

high-intensity training stressors and battle-fatigue–

related injuries (Exhibit 22-2). The training covered 

stress reduction techniques, predeployment “hardening,” anger management, suicide prevention, sexual 

assault prevention training, first responder (unit level) 

training in combat stress control, and buddy aid. 

The team provided briefings for soldiers and family 

members, addressing predeployment stressors and 

coping techniques, midcycle issues related to rest and 

recuperation visits by soldiers halfway through their 

deployment, redeployment (reunification) stressors 

and coping techniques, and reconstitution issues including reestablishing family roles and relationships, 

anger management, operational stress reactions, traumatic brain injury, and posttraumatic stress disorder. 

Family stress support services included direct and 

indirect (consultation support) services to help families 

develop stress coping skills, address couple dynamics, 

deal with children’s issues, and prepare for reunification. The team worked closely with FRGs following the 

loss or severe injury of unit members. Linking FRGs 

with Reserve combat stress control assets and other 

military, veteran, and community-based resources was 

a significant part of the COSC team’s role.

A well-being program was established at the RRC 

Headquarters to provide a variety of self-care services 

teaching leaders, soldiers, and contract personnel ways 

to build personal coping skills and resiliency. Inte-
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EXHIBIT 22-2

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL 

TEAM FIRST RESPONDER TRAINING

1. MISSION. The Combat Operational Stress Control Team (COSC) of the 88th Regional Readiness Command 

Surgeon’s office will conduct Operational Stress Control First Responder Training for Command-designated 

representatives from subordinate units in support of Department of Defense Directive 6490.5 (Combat Stress 

Control [CSC] Programs) JP-1-02, Force Protection.

2. EXECUTION.

 a. Intent: Prepare Soldiers/leaders within the USAR in basic principles of Combat Operational Stress Control 

to enhance force protection and improve Soldier readiness in support of Contingency Operations. Embedding 

Soldiers and FRG representatives knowledgeable in COSC into each unit will enhance early recognition, intervention/referral with stress issues that often result in problems that may affect unit efficiency and degrade 

the quality of life of soldiers and their families. It is assumed that this trained group of first responders will 

maintain contact with a COSC team and their commands on a regular and as-needed basis.

 b. Concept of Training. Conduct 21⁄2-day course with training consisting of Power Point slide presentations, 

video, handouts and role-playing to familiarize non-medical Soldiers with concepts of operational stress 

and battle fatigue. A team consisting of operational stress control personnel and chaplains will conduct the 

training. Both a pre- and a post-test will be administered in order to evaluate the effectiveness of the training. 

(Training Annex W)

3. CONCEPT OF OPERATIONS. To train the participants in the following topics.

 a. Basic combat operational stress principles

 b. Emotional cycles of deployment

 c. Identifying and responding to individuals with suicidal and homicidal behaviors

 d. Recognizing and responding to:

• aggression

• domestic violence

• depression

• posttraumatic stress disorder

• combat stress reactions and battle fatigue

• methods of deescalating potentially dangerous situations

• sexual assault prevention and identifying sexual harassment

 e. Available military, VA, civilian and other resources—how to access and use them

COSC: combat and operational stress control 

USAR: US Army Reserves

VA: Department of Veterans Affairs

Data source: 88th Regional Readiness Command Headquarters, Surgeon’s Office, Fort Snelling, Minnesota. 

grative healthcare providers from the civilian sector 

volunteered their services to provide a variety of selfcare techniques including seated chair massage, acupuncture, guided imagery, healing touch, reflexology, 

Reiki, aroma therapy, and relaxation skills training. 

Information on a variety of stress management topics was provided in the form of brochures, handouts, 

computer disks, and posters. Topics included but were 

not limited to information on stress and anger management, sleep hygiene, communication skills, parenting, 

transitioning, suicide prevention, brain injury, and 

posttraumatic stress, with resources from Military 

OneSource, the Brain Injury Association, Veterans 

Affairs (VA), chaplains, and the Public Health Command (Provisional), formerly the US Army’s Center for 

Health Promotion and Preventive Medicine. Personnel 

who participated in the program reported decreased 

pain and stress levels and increased awareness of stress 

management techniques.

The 88th RRC sustained the highest number of 

Army Reserve soldiers killed in action during the 

early part of the war. The COSC team worked closely 
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Combat and Operational Behavioral Health

with chaplains, public affairs staff, and casualty affairs 

personnel to establish strong support networks for 

grieving families, units, and communities. The team 

addressed the topic of grief and loss at the leadership, 

FRG, and soldier level. Frequently accompanying the 

chaplain, public affairs office, and the funeral honors team, the COSC officer provided support to the 

family, unit leadership, and other unit members and 

their families, as well as the honors team. In specific 

instances, COSC team members met with FRGs to provide bereavement support and education on ways to 

deal with loss. For instance, while five sisters anxiously 

awaited the beginning of their brother’s memorial service, the OT taught them some simple relaxation skills 

for self-calming. The family reported later how much 

those simple techniques helped them get through that 

difficult time. During a funeral, one of the honors team 

members was having a hard time standing still for 

his 20-minute rotation. A few minutes spent helping 

him refocus and practice some simple breathing techniques allowed him to successfully manage the task. 

In another case, the COSC team provided bereavement 

support for family members during an FRG meeting 

following the battlefield death of one of the soldiers. 

They discussed factors involved in grief and loss including the associated fear of having a loved one still 

in harm’s way, taught self-care techniques for adults 

and children, and explained how to locate resources 

for additional support. Following the educational part 

of the meeting, families shared a potluck meal, local 

massage therapists provided “pro bono” seated chair 

massage, and families participated in structured leisure 

activities while socially engaging with one another 

within a safe environment. The COSC team provided 

one-on-one consultation support during this time. 

Throughout the remainder of the unit’s deployment 

the team provided periodic support to the FRG.

Located in a predominately civilian region, outreach 

to civilian organizations within the 88th RRC was vital 

to help the community understand the unique and 

changing culture of the citizen soldier (the next-door 

neighbor, coworker, or church member serving as a 

Reservist). A concerted effort was launched in partnership with the National Guard, VA, and veterans’ 

service organizations to address the reintegration of 

soldiers into the workplace and community following their return home. Briefings were prepared to 

meet the individual needs of employers, community 

groups, and faith-based groups. For instance, OT staff 

developed briefing material to alert leaders, units, and 

care providers about the impact of traumatic brain 

injury, combat stress reactions, and posttraumatic 

stress disorder. 

Community outreach presentations on a regional, 

state, and national level also provided training and 

workshops for civilian healthcare workers. Law enforcement training was provided through interagency 

partnerships. State-based postdeployment healthcare 

collaborations were supported by the COSC teams 

in Wisconsin, Ohio (Ohio Cares), and Minnesota 

(postdeployment collaboration with the VA, DoD, 

and community health professionals). The team provided training for both Minnesota and North Dakota 

county veterans’ service officers, helping the officers 

to understand the changing culture and needs of redeployed soldiers and refer them to the appropriate 

level of services.

College and university presentations focused on the 

needs of returning combat veterans in the classroom, 

the needs of families and friends of a combat veterans, 

and resources available to returning veterans. The state 

of Minnesota allocated funds for the state college and 

university consortium to establish campus-based veterans’ transition centers. Veterans were encouraged to 

utilize the services of these centers to identify “battle 

buddies” as they returned to college living and to focus 

on formation of attitudes and behaviors to promote 

success in their college experience. A county library 

donated thousands of books for deploying troops at 

Soldier Readiness Processing centers as well as their 

families to provide constructive diversion from deployment cycle stress. Exhibit 22-3 describes the types of 

soldier and family briefings provided throughout the 

deployment cycle.

Occupational Therapy in Support of Operation Iraqi Freedom 

Detainee Healthcare

US Army combat support hospitals are responsible 

for providing quality healthcare with dignity and respect to Iraqi civilians as well as detained insurgents. 

Individuals with acute injuries can be admitted day 

and night in an intensive combat environment. Patients on detained status are required to live in the 

theater internment facility while they receive medical 

treatment. A dynamic and multifaceted rehabilitation 

program is necessary not only for the improvement 

of patients’ performance in all areas of occupation, 

but also to enhance their functional outcomes. The 

goal is for the patient to achieve a functional level 

sufficient for discharge in a facility with a rapid 

turnover rate.

Patients admitted to a combat support hospital 

have often sustained polytrauma, which can include 
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US Army Occupational Therapy: Promoting Optimal Performance

EXHIBIT 22-3

88TH REGIONAL READINESS COMMAND COMBAT AND OPERATIONAL STRESS CONTROL 

TEAM DEPLOYMENT CYCLE SUPPORT BRIEFINGS

Deployment cycle support briefings are the single most important mechanism for establishing rapport with soldiers and family members. Through these briefings, soldiers and family members learn about the effects of chronic 

stress on the body and on performance. A significant element in all the presentations is improving communication 

skills: a factual presentation of the negative results of poor communication is given, followed by suggestions for 

developing positive communication skills. Effects of the deployment cycle on children and significant others are 

also presented.

Soldier readiness processing briefings consist of 30-minute slide presentation that alerts soldiers to the need to 

prepare themselves and their families for deployment. Briefings discuss preparation in terms of Preventative Maintenance Checks and Services (PMCS; a routine personal self-care program to maintain mission capability) and stress 

the need to start working on communication skills and problems before the soldier is mobilized.

Premobilization briefings consist of a 45-minute slide presentation describing the ramp-up to deployment and 

the effect this process has on soldiers, their spouses and significant others, and the children. Handouts are used to 

reinforce the briefings.

Mid-cycle briefings are presented to members of a family readiness group. The loosely structured briefings are 

used to answer questions and allay fears that have become burdens to family members and children, and may include one-on-one talks with individuals with specific questions. Most of the issues revolve around communication. 

Handouts are used to reinforce the briefings.

Demobilization briefings are ideally presented to family members and interested others 2 to 4 weeks before the 

soldiers return home; however, they are usually presented the same day the soldiers return. The slide presentations 

used at homecoming try to cover a range of issues from readjustment of roles to intimacy issues. Handouts are used 

to reinforce the material.

Reconstitution briefings are directed sessions of teaching followed by small group and one-on-one discussions on 

issues that have come up since the soldiers’ return. Issues include operational stress reactions, posttraumatic stress 

reactions, and marital and parenting problems. A slide presentation can be used to present issues, but often this briefing takes the form of a more relaxed and unstructured conversation. Handouts are used to reinforce the material.

Data source: 88th Regional Readiness Command Headquarters, Surgeon’s Office, Fort Snelling, Minnesota.

many orthopaedic or neurological deficits. OT staff 

members critically observe and analyze patients to 

determine a baseline performance for motor, cognitive, and communication skills. OTs and OTAs then 

work with patients to reconcile the changes to their 

bodies by empowering them to establish new habits, 

routines, and roles to maximize performance during 

daily activities. The model of human occupation frame 

of reference provides theoretical guidance to OT staff 

working with detainees, aimed at enabling inpatients 

to make order out of the disorder that they are experiencing.11 Active involvement in improving health 

and learned wellness are two key constructs of the 

model that are directly applied to detainee healthcare. 

Detainees may not readily expect to take an active approach in their own recovery process; therefore, adding 

a patient education piece to other aspects of healthcare 

service delivery is an important aspect of recovery. 

Patients must cope with the transition from the status 

of “detained patient” to an ordinary “detainee” upon 

discharge. Detainees are expected to perform the activities of daily living requirements independently in 

the internment facility.

Cultural differences bring particular challenges to 

detainee care. Many detained patients do not speak 

English, necessitating interpreters. In addition, gender 

roles within the Muslim culture are significantly different than Americans are accustomed to; for example, 

the expectation of taking direction from primarily 

female nurses can pose difficulty for male patients 

raised in a male-dominated society. If a detainee is 

having difficulty complying with medical instructions from staff, the OT may become involved. The 

therapist would work with the detainee to facilitate 

understanding of the benefits of inpatient care using 

the listen, learn, and comply approach: the OT explains 
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Combat and Operational Behavioral Health

Peak Performance training in Occupational Therapy

The concept of peak performance, developed 

originally at the US Military Academy’s Center for Enhanced Performance and currently used by Army OTs, 

is derived from “mental toughness training to develop 

the Army pentathlete.”12 It is based on the principle 

that Army leaders must be self-aware, mentally agile, 

and adaptive. Peak performance has been described 

as “sports psychology taken to the battlefield” in that 

the core components rely on human performance and 

behavior, but the thought–performance interaction 

is essential in successfully completing warrior tasks. 

A mental imagery research study found that mental 

imagery (imagining squeezing an immobilized hand 

without performing any movement) might be of benefit in preventing strength loss during immobilization.13

OTs have successfully utilized peak performance training with Operation Iraqi Freedom/Enduring Freedom 

patients, specifically in combat stress casualties or 

those diagnosed with posttraumatic stress disorder. 

Peak performance techniques decrease recovery time 

and prepare individuals for success both physically 

and mentally in returning to their respective areas of 

expertise. The OT uses peak performance concepts 

to help maximize soldiers’ physical, mental, and 

emotional performance during periods of temporary 

or permanent life changes following illness or injury. 

Through their knowledge of human factors, occupational performance, and occupational adaptation, OTs 

help soldiers build their performance capabilities in 

overcoming physical, cognitive, and emotional challenges posed by illness or injury. 

The five core foundations of peak performance are 

(1) a cognitive foundation, (2) attention control, (3) 

goal setting, (4) stress and energy management, and 

(5) visualization and imagery. Improving skills related 

to each of the five components ultimately leads to 

optimizing mental agility and performance. An example of an effective therapeutic intervention derived 

from peak performance training is the use of guided 

imagery and relaxation. Guided imagery involves 

using a series of thoughts or suggestions to direct a 

person’s mental focus toward a more relaxed state. 

Nightingale14 suggested various ways that imagery 

could be used for counseling, such as motivation by 

imagining a positive future, insight through exploration of possibilities, and problem solving. In warrior 

training and rehabilitation programs, OT services are 

conducted by an OT and an OTA. The OTA conducts 

the group program and implements orthopaedic treatments, while the OT completes individual evaluations 

and treatment sessions.

Peak performance training has been implemented 

in the form of group intervention, 1 hour per week for 

6 weeks. The OT staff facilitates a group addressing 

the following six topics: (1) goal setting, (2) stress and 

energy management, (3) visualization and imagery, 

(4) confidence, (5) attention control, and (6) anger 

management. To foster esprit de corps, the soldiers in 

the program develop a unit creed while participating. 

Group interventions focus on enhancing the thought–

performance interaction to maximize performance 

outcomes. For example, one group might focus on 

recognizing physiological changes such as skin temperature, heart rate, and muscle tension while experiencing both physical and mental stressors to allow 

participants to experience physical manifestations of 

stress. Participants would then implement steps to 

enhance performance in this stressful environment. 

Both negative and positive self-fulfilling prophecies 

can ultimately affect performance on any given event, 

not only during the training but also in many settings throughout soldiers’ lives. These core areas are 

essential to enhancing soldier performance and can 

ultimately be applied to either battlefield or garrison 

environments. 

Individual peak performance training augments 

group topics to develop the skills necessary for successful performance. Soldiers can choose goal setting 

and/or stress management for their care plan. During 

goal setting, the soldier develops personal goals ranging from graduating from the Warrior Training and 

Rehabilitation Program (WTRP) to military retirement. 

In the goal-setting session, soldiers identify the reasons 

for participating in any given event, what they want 

to accomplish, and most importantly, how they will 

achieve their goals. The end result is energy, persistence, 

and a prime selection of strategies for achieving each 

person’s goals.12 Ultimately a personalized “goal sheet” 

is developed and kept with participants at all times. The 

stress management option involves the use of Freeze 

Framer, a computerized biofeedback program, or a 

relaxation plan. Individual peak performance intervention can either be self-referred or command-referred if 

the soldier is not adapting well to WTRP.

that it is the patient’s responsibility to listen to directives put forth by the staff to maximize the benefit of 

multidisciplinary healthcare. For patients to take responsibility for the personal management of their own 

health, patient education about the injury or illness is 

imperative. Patient compliance is necessary because 

the staff must meet the needs of the other patients in 

a timely manner. 
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US Army Occupational Therapy: Promoting Optimal Performance

The stress and energy management model in peak 

performance is based on a concept called “grip and 

gravity,”12 based on identifying things individuals 

cannot control (gravity), and redirecting focus to 

things individuals have the ability to control (grip). 

In a setting where many injured soldiers feel out of 

control, future plans, current situations, attitudes, 

and perceptions will always be within their “grip” 

forces. Once the soldier has grasped the concept of 

taking control over his or her own life, biofeedback 

and relaxation techniques can be introduced into the 

treatment plan.

Biofeedback tools are used to teach soldiers how 

to recognize physiological changes (such as heart 

rate and breathing patterns) that occur with stress 

and make the necessary changes to reduce the magnitude of the stress response. By using biofeedback 

instruments, the soldier gains increased awareness 

and sensitivity to internal stress responses. The 

ultimate goal of this treatment is for the soldiers to 

recognize internal cues of stress without the aid of 

the instrument, and implement the steps to regain 

control. This reemphasizes the thought–performance 

interaction concept discussed during the group 

intervention. Equipment required for this program 

includes a computerized biofeedback instrument for 

treatment sessions and a relaxation chamber, which 

allows for optimal relaxation positioning and control 

of environmental stimuli during the intervention. 

The biofeedback equipment has been shown to improve overall physical speed and accuracy, enhance 

problem-focused coping skills, sustain concentration, 

and manage stress and anger.12

Using the peak performance model and its inherent mental agility intervention can improve soldiers’ 

satisfaction with themselves, their careers, and their 

families. With dedicated work and intervention, it can 

facilitate patients’ return to the unit without removal 

from theater or return to garrison duty. When utilized 

in the garrison setting, peak performance training at 

WTRP enabled soldiers’ return to duty earlier when 

compared to programs that do not incorporate peak 

performance concepts. Soldiers also reported increased 

satisfaction in their own outcomes as well as a decrease 

in negative thoughts. Overall, the peak performance 

program integrates psychological, cognitive, and 

physiological concepts to enhance performance and 

promote positive attitudes among soldiers both in 

theater and in garrison. 

Case Study 22-1: SGT JS, an infantryman, was initially 

seen by OT for an upper extremity injury following his return 

from Operation Iraqi Freedom. The therapist noticed that 

JS was having difficulty dealing with issues related to his 

deployment, specifically with anger and depression. He was 

referred to a community mental health social worker and a 

posttraumatic stress disorder group, which met once a week 

for 6 weeks. He decided immediately that his goal was to 

work on anger management, specifically when it came to his 

relationship with his wife. In a group-learning environment, 

he acquired many of the skills of the peak performance 

model, including energy management and goal setting. 

SGT JS also attended OT for one-on-one intervention for 

8 weeks, incorporating a biofeedback heart rate program, 

guided imagery, and progressive muscle relaxation to gain 

control and composure when dealing with stressful situations. SGT JS reported an increase in confidence, increased 

satisfaction with his marriage since his return, and an overall 

increase in well being after attending the group and one-onone sessions.

Occupational Therapy in the Warrior Transition Unit

Since World War I, OT’s philosophy of matching 

interventions to the soldier’s ability has been an 

integral part of the effort to help those wounded in 

combat return to work. It was thought that wounded 

soldiers should be “restored to trades appropriate to 

their abilities, interest, and background.”3(p152) Contributions did not end with direct care. Early OTs 

were also instrumental in setting national policy, 

contributing to the passage of the Soldiers Rehabilitation Act in June 1918.3(p158) Similar involvement 

continues today, with OT personnel instrumental 

in the formation of the Army’s Proponency Office 

for Rehabilitation and Reintegration in May 2007, 

the development of the Comprehensive Transition 

Plan, and the development of the role of OT within 

WTUs. 

The goal of a WTU is to promote soldiers’ abilities to 

return to the force or transition to a productive civilian 

life. OT helps individuals regain, develop, or master 

everyday skills to live independent, productive, and 

satisfying lives.15 Within the WTU, OT’s primary role is 

to address life-skills needs and coordinate work reintegration, thus assisting soldiers to return to productive 

living. Work includes activities needed for engaging 

in paid employment or volunteer activities.16(p341) Occupation refers to the everyday activities of life that are 

named, organized, and given value and meaning by 

individuals and a culture. “Occupation is everything 

people do to occupy themselves including looking 

after themselves, enjoying life and contributing to the 

social and economic fabric of their communities.”17(p34)

Work reintegration is defined as a program that provides a structured environment with participation in 

vocationally related activities. The participant must 
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Combat and Operational Behavioral Health

be medically stable and have a goal of competitive 

employment.18

The Comprehensive Transition Plan

The desired outcome is for each participant to be 

a successful soldier or successful veteran, physically 

and mentally strengthened, vocationally enabled, with 

a life-care plan established, able to maintain relationships, and proud of his or her military service.19 Each 

soldier’s comprehensive transition plan is an individualized, multiphased process with overlapping 

boundaries. The reception phase is generally 1 week in 

duration. Upon arrival at the WTU, soldiers are greeted 

with a unit welcome and orientation that delineates 

the expectation that they will actively participate in 

their own healing process. They are educated on the 

overall mission statement that will be inculcated into 

their daily life within the WTU: 

I am a warrior in transition. My job is to heal as I transition back to duty or continue serving the nation as 

a veteran in my community. This is not a status, but a 

mission. I will succeed in this mission because I AM 

A WARRIOR AND I AM ARMY STRONG. 

The soldier is issued a “Warrior Toolkit” that includes the soldier mission statement, orientation materials, and life-skills material designed to encourage 

self-empowerment in the healing process. 

Next comes the assessment and goal-setting phase, 

which generally lasts a month. During this initial 

period, soldiers undergo assessments for behavioral 

health risk; pain, sleep, and safety (including cognitive awareness, mobility, vision, and hearing tests); 

and requirements for housing assistance, medical 

supplies, family needs, and nutrition management. 

The staff members also appraise the soldier’s level 

of function, vocational goals, skills, abilities, health 

maintenance and lifestyle, and the initiation/sustainment of rehabilitation. At the same time, the 

soldier’s goal-setting phase begins with a focus on 

the development of positive life skills and habits. The 

soldier works with the nurse case manager, primary 

care manager (a physician or physician’s assistant), 

squad leader, OT personnel, social work, and unit 

ministry teams to develop goals for improvement in 

body, mind, and spirit. OTs have a leadership role in 

warrior goal-setting training. Functional independence and mobility goals are established, including 

accessing transportation resources. Vocational, educational, social, leisure, and recreation goals are also 

established during this phase. Intrapersonal goals 

are identified to enhance self-esteem, responsibility 

to self, interpersonal relationships, and community 

responsibility.

Next, during the active rehabilitation phase, the 

soldier works toward attaining specific goals. This 

phase is divided into four tiers based on the soldier’s 

abilities, and a training calendar is established to help 

reset the soldier. Tier assignment levels include tier A 

(medical recovery/rest) for soldiers who are placed 

on quarters. Soldiers in tier A are generally unable to 

participate in any physical, mental, relationship, or 

spiritual strengthening programs. Tier B (basic reset) 

consists of soldiers who spend their training day in rehabilitation basics. These soldiers are actively engaged 

in medical appointments; group or individual therapy 

to improve strength, range of motion, or endurance; 

programs and classes in nutrition or weight management; classes in life skills; or classes and workshops 

on relationships. Tier B includes programs that every 

warrior in transition needs to build basic skills and 

strengths as well as individualized programs to address unique circumstances.

Tier C (advanced reset) follows completion of the 

basic skills program. These soldiers spend part of their 

duty day in vocational or educational activities, but 

still require significant time for activities specifically 

designed to rehabilitate their body, mind, and spirit. 

Tier C generally involves interventions targeted at 

addressing a specific goal. Tier D (life reset) is focused 

on vocational, educational, family, and community 

pursuits. Soldiers in this tier must have completed 

tier B basics. They spend the majority of their duty 

day in vocational or educational activities, but still 

require ongoing medical treatment or rehabilitation. 

Throughout the active rehabilitation phase, a mandatory review of progress and reassessment occurs on a 

regular basis, with the soldier actively participating in 

multidisciplinary team meetings coordinated by the 

nurse case manager.

The final transition preparation phase, which may 

last up to 90 days, occurs once each individual’s disposition decision has been made. During this phase, the 

soldier undergoes final preparation for the expected 

disposition. Details regarding return to home, family, 

and community living as well as ongoing vocational 

or educational pursuits after they leave the WTU 

are addressed and coordinated to assure a smooth 

transition. 

Work Reintegration Programs

The objectives of a work reintegration program involve returning the soldier to the role of worker either 

in a military or civilian capacity. This is done through 

promoting, improving, conserving, and restoring the 
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US Army Occupational Therapy: Promoting Optimal Performance

skills, abilities, and aptitudes of soldiers through both 

vocational and avocational reintegration services. A 

soldier-centered work reintegration program pursues 

these goals for the soldier in transition. The program 

focuses on the behavioral, psychosocial, vocational, 

avocational, and educational needs of the soldier using techniques to facilitate independence and empowerment. The work reintegration program involves 

collaboration with military and civilian communities 

to set up safe work sites that promote quality work 

performance and enhance the quality of the service 

member’s everyday life. The soldier actively participates in the work reintegration program, developing 

an understanding of how the services provided can 

positively impact his or her ability to function in a 

work environment. 

The program also incorporates collaboration with 

appropriate professionals and community members 

to minimize impairment, maximize independent 

function, and enhance the quality of life of the service 

member in transition. Through the use of performance 

indicators, the work reintegration program measures 

the effectiveness of services provided along the continuum of care. OTs assist service members to develop 

and attain realistic short-term and long-term goals that 

reflect their interests in vocational and avocational 

pursuits. Service members benefit from this program 

by increasing the likelihood of attaining their personal 

goals, while the community benefits by reacquiring 

responsible and competent workers.

Occupational Therapy’s Focus in Work 

Reintegration

The director of the work reintegration program is 

a registered and licensed OT who is qualified in both 

OT and work reintegration. Certified OTAs provide 

support in areas including screening, programming, 

life skills training, work-site development and coordination, and networking with internal and external 

resources to assure a well-balanced program aimed at 

returning soldiers to productive living. OT personnel 

work closely with other WTU staff to develop and 

implement the work reintegration program, which 

the OT is then responsible for overseeing. OTs are 

located in proximity to the WTU to facilitate communication with the cadre and increase interactions 

with participants. The OT and COTAs should be allocated appropriate space to develop and conduct a 

successful work reintegration program. Responsibilities of the OT assigned to the WTU include but are 

not limited to:

• working closely with OTs at the medical treatment facility to ensure continuity of care;

• developing and implementing standard operating procedures that support the overall 

goals and objectives of the work reintegration 

program;

• assessing limitations that prevent or delay return to work and providing recommendations 

for modifications and equipment needs;

• working closely with case mangers in coordinating vocational training, job skills training, 

and work placement;

• conducting visits to work sites to ensure job 

appropriateness and verifying that the participant is performing the agreed-upon job 

tasks;

• developing collaborations within the community to determine resources and to prevent 

duplication of services;

• working closely with other WTU staff to ensure continuity of care and accountability;

• establishing specific quantifiable standards 

to measure the work reintegration program 

success; and

• supervising the COTA personnel assigned to 

the WTU.

All soldiers assigned to the WTU undergo a comprehensive evaluation by the OT to determine eligibility 

and placement in the work reintegration program. 

Tools used by the OT may include a vocational interest survey, vocational aptitude assessment, career assessment tests, life skills assessments, cognitive skills 

assessments, occupational performance assessments, 

functional capacity evaluations, a driving evaluation in 

a simulator, and an evaluation of firearm performance 

in a simulator. All soldiers in transition also should be 

evaluated by the OT within 1 to 2 weeks of in-processing to determine if they are eligible to participate in 

the work reintegration program. Soldiers eligible for 

the program will be assigned a meaningful job within 

the limits of their physical profile and commensurate 

with their grade. Work internships are being developed 

in collaboration with the VA and 501(c)(3) (nonprofit) 

organizations to provide work experiences in areas of 

potential career fields. Each work reintegration program should maintain a file on each work site including a job description with work hours, dress code (if 

civilian), point of contact, memorandum of agreement, 

and the physical, cognitive, and psychosocial requirements of the job. 

OTs collaborate with unit training personnel to 

help develop a structured daily schedule for each 

participant consisting of life skills development, work 

preparation, education, training, and structured duty 
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assignments to prepare soldiers for return to functional living. Activities are matched to the individual’s 

needs and abilities and may include (a) stress management, (b) anger management, (c) assertiveness/

communication skills training, (d) functional activities, (e) soldier basic skill training, (f) MOS training, 

(g) problem-solving and goal-setting skills training, 

(h) financial management skills training, (i) time 

management skills training, and (j) work readiness 

skills—work habits, values, interests, skills, and vocational exploration.

The supervisor at each work reintegration site 

provides weekly progress reports to the OT. In addition, the OT conducts at least bimonthly follow-ups 

to reassess each participant for continuance of the 

current work placement. The OT also decides what 

type of follow-up is needed when participants leave 

the unit. By the day of discharge/transition, written 

recommendations are given to providers in the continuum of care and other stakeholders as appropriate. 

Depending on the needs of the soldier, the written 

recommendations address: 

• medical issues relevant to job placement;

• functional issues relevant to job performance;

• psychological issues relevant to job placement;

• significant abilities, relevant aptitude scores; 

• areas for growth;

• identification of additional training if needed; 

and

• available community integration services, including local, regional, provincial, or national 

consumer organizations.

The work reintegration program includes a data collection system for performance indicators—collected 

initially and reevaluated over time—to measure the effectiveness of services provided across the continuum, 

including the number of WTU soldiers who were discharged from the military, who returned to duty, who 

received a permanent job placement, and who enrolled 

in school. Program staff also record satisfaction of the 

job site from the participant and family members. 

Occupational Therapy on the Home Front

The emotional cycle of deployment affects not only 

soldiers, but also their families, employers, coworkers, schools, and the surrounding community.20 The 

role of OT on the home front involves building skills 

to withstand the stress of deployment separation as 

well as focusing on habit training to assist soldiers 

and their families in the reintegration process. Incorporating rituals and traditions that can carry over 

throughout the deployment may provide a sense of 

consistency and order during a chaotic time. A psychoeducational approach using a resiliency model to 

enhance life skills in predeploying soldiers and their 

families may act as a protective measure in preparing them to overcome the hardships of deployment 

separation.

Returning combat troops and their families 

frequently report increased levels of anxiety and 

risk-taking behaviors when the soldier resumes 

driving at home.21 This may be due to the retention of automatic combat driving behaviors that 

were overlearned to help the soldier survive in a 

hostile environment. Although appropriate on the 

battlefield, automatic combat driving behaviors do 

not mesh well with local traffic laws at home. OT 

personnel assess the physical, cognitive, and behavioral components of driving to help soldiers safely 

perform this daily living skill. Awareness training 

and specific interventions are useful in managing 

maladaptive postcombat driving behaviors. Using 

a consultative approach, occupational therapists 

collaborated with Military OneSource to develop 

a handout for service members and their families, 

providing awareness of and tips for managing postcombat driving behaviors. An article published in 

a national newsletter for traffic court judges also 

helped to increase the judges’ awareness of these 

issues when returning soldiers have pending legal 

action in the traffic court system.21,22

A collaborative relationship between an academic 

institution and an Army OT resulted in the development of postdeployment driving reintegration tools. 

Research conducted by OT faculty and students at 

the University of Minnesota described postcombat 

soldier driving responses and identified specific 

interventions that effectively enhance driving safety. 

In consultation with the Proponency Office for Rehabilitation and Reintegration, the student/faculty team 

incorporated survey results, focus groups, and oneto-one interviews to develop informational brochures 

for soldiers and family members. The brochures 

address postcombat driving on the American road 

and include suggestions to help returning soldiers 

drive safely at home. In addition, the OT academic 

researcher developed clinician training for OTs working in military settings to help standardize the use of 

driving simulation.
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US Army Occupational Therapy: Promoting Optimal Performance

SUMMARY

REFERENCES

1. American Occupational Therapy Association. Occupational therapy practice model: domain and process. Am J Occup 

Ther. 2002;56:609–639.

2. Gerardi S, Newton S. The role of the occupational therapist in CSC [combat stress control] operations. US Army Med 

Dep J. 2004;Jul–Sep:20–27. Available at: http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U@&doc=GetTRDoc.

pdf&AD=ADA493056. Accessed October 7, 2010.

3. Quiroga VAM. Occupational Therapy: The First 30 Years, 1900 to 1930. Bethesda, Md: American Occupational Therapy 

Association; 1995.

4. Crepeau EB, Cohn DS, Shell BB, eds. Willard and Spackman’s Occupational Therapy. 11th ed. Philadelphia, Penn: LippincottRaven Publishers; 2008. 

5. Creek J, ed. Occupational Therapy and Mental Health. 3rd ed. New York, NY: Churchill Livingstone; 2002: 8.

6. Newton SM. The growth of the profession of occupational therapy. US Army Med Dep J. 2007;Jan–Mar:51–58. 

7. Department of the Army. Army Medical Specialist Corps. Washington, DC: Office of The Surgeon General; 1968. 

8. Neistadt ME, Crepeau EB, eds. Willard and Spackman’s Occupational Therapy. 9th ed. Philadelphia, Penn: LippincottRaven Publishers; 1998. 

9. US Department of the Army. Clinical Quality Management. Washington, DC: DA; 2004. Army Regulation 40-68.

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

4-02.51.

11. Kielhofner G. Model of Human Occupation: Theory and Application. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 

2008.

12. Corbari G. Performance enhancement program at the Center for Enhanced Performance. Paper presented at: Peak 

Performance Training Conference; November 2005; West Point, New York.

13. Newsom J, Knight P, Balnave R. Use of mental imagery to limit strength after immobilization. Sport Rehabil. 2003;12:249–

258.

Army OTs are human performance experts and dedicated leaders whose innovative programs and services 

help optimize soldier performance and readiness in 

theater and garrison. Providing a functional approach 

to healing through doing, OTs match the individual’s 

interests, skills, and abilities with activities that have 

meaning and purpose, along with a “just right” challenge. A focus on occupational performance helps to 

restore soldier confidence and competence. Life skills 

components of OT promote functional independence, 

which enhances future quality of life and productivity. 

Participation in work and productive activities promotes 

a sense of mastery, a positive self-identity, and a responsibility to take control over one’s future. Bridging the gap 

between medical care and military performance training, 

OTs help unit leaders retain their soldiers through assessing physical, social, and environmental factors and 

recommending interventions to enhance unit climate 

and living conditions. 

The practice of OT has been essential in the rehabilitation of military personnel since World War I. OTs 

use a variety of strategies to enhance occupational 

performance, a key factor in retention of the soldier 

who has sustained a physical or psychological injury. 

They also assess the soldier’s performance and help 

the service member gain the skills and resilience to 

remain functional whether returning to the battlefield 

or transitioning to the civilian community. OTs provide 

a vital link to practical living and a more satisfactory 

life through occupational engagement and enhancement of physical, psychological, cognitive, and social 

aspects of performance. 
374

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14. Nightingale L. What is interactive guided imagery? [1998]. Available at: http://www.nightingalecenter.com/guided.

html. Accessed October 25, 2010.

15. American Occupational Therapy Association. For prospective students. Available at: http://www.aota.org/Students/

Prospective. Accessed October 25, 2010. 

16. Mosey AC. Applied Scientific Inquiry in the Health Professions: An Epistemological Orientation. 2nd ed. Bethesda, Md: 

American Occupational Therapy Association; 1996.

17. Law M, Polatajko H, Baptiste W, Townsend E. Core concepts of occupational therapy. In: Townsend E, ed. Enabling Occupation: An Occupational Therapy Perspective. Ottawa, Ont: Canadian Association of Occupational Therapists; 1997.

18. US Department of Veterans Affairs. Compensated work therapy. Available at: http://www.cwt.va.gov/. Accessed 

October 25, 2010.

19. Department of the Army. MEDCOM Warrior in Transition Comprehensive Care Plan Policy. Washington, DC: DA; January 

2008. 

20. Pincus SH, House J, Christenson J, Adler LE. The emotional cycle of deployment: a military family perspective. Available at: http://hooah4health.com/deployment/familymatters/emotionalcycle.htm. Accessed October 25, 2010. 

21. Stern E. Driving behaviors of returning combat troops [unpublished survey results]. Minneapolis, Minn: University 

of Minnesota; 2008.

22. Stern EB, Erickson M. Readjustment to civilian life doesn’t stop at the garage door: driving infractions of post 

deployment citizen soldiers. Experience. 2008;18(2):22–24. [Published earlier under same title in Highway to Justice. 

2007;Spring:2–6.]
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Provider Fatigue and Provider Resiliency Training

Chapter 23

PROVIDER FATIGUE AND PROVIDER 

RESILIENCY TRAINING

MARY ANN PECHACEK, PsyD, LMFT*; GRAEME C. BICKNELL, PhD, LISW†; and LISA LANDRY, PhD‡

INTRODUCTION

TERMS AND DEFINITIONS

FIGLEY’S COMPASSION FATIGUE MODEL

FACTORS CONTRIBUTING TO COMPASSION STRESS 

SYNERGISTIC EFFECTS OF PROVIDER FATIGUE

WAYS TO IDENTIFY PROVIDER FATIGUE

Markers

Behavior Changes After Exposure to Trauma

US Medical Command Use of the Professional Quality of Life Scale

WAYS TO COMBAT PROVIDER FATIGUE

The EAT Model

Building Resiliency

A Holistic Approach to Renewal 

Leadership

SUMMARY

*Psychologist and Instructor/Writer, Department of Behavioral Health Sciences, Special Subjects Branch, Army Medical Department Center and School, 

3151 Scott Road, Building 2840, Fort Sam Houston, Texas 78234

†

Lieutenant Colonel, Medical Service Corps, US Army; Deputy Chief, Behavioral Health Division, US Medical Command, 2050 Worth Road, Building 

2792, Fort Sam Houston, San Antonio, Texas 78234-6010s 

‡

Instructor/Writer, Department of Behavioral Health Sciences, Army Medical Department Center and School, 3151 Scott Road, Building 2840, Office 

#32, Fort Sam Houston, Texas 78234 
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Combat and Operational Behavioral Health

INTRODUCTION

The effects of caring for traumatized individuals 

have been characterized in numerous ways and given 

different names over time during many traumatic 

events. Although each of these concepts was originally developed in a specific context with individual 

nuances, they have also been used interchangeably 

in connection with the phenomenon of secondary 

trauma—the reaction of caregivers to the traumatic 

events experienced by those they serve. Current military behavioral healthcare providers have built on the 

efforts of their predecessors, who have attempted to 

capture and understand the effects of trauma through 

the years. Providers are resilient by nature and military 

providers are especially so, as seen in their focusing, 

building, and reinforcing the resilience in achievable 

balanced health.

All members of the Department of Defense—

soldiers, sailors, airmen, marines, and civilians—have 

been affected by the global war on terror. The US 

military has developed many programs and services 

to aid military personnel and their families, addressing psychological, spiritual, and physical recovery; 

however, only a few programs are directed toward 

caregivers. One such program is Provider Resiliency 

Training (PRT), created and implemented by the Soldier and Family Support Branch at the Army Medical 

Department (AMEDD) Center and School at Fort Sam 

Houston, Texas. 

PRT has three phases. During the first phase of 

training, all care providers throughout the medical 

command (MEDCOM) watch a video on PRT and take 

the Professional Quality of Life (Pro-QOL) Scale (discussed in detail in this chapter). This phase takes approximately 30 minutes to complete. The second phase 

of PRT involves the development of initial self-care 

plans by all MEDCOM medical treatment facilities’ 

staff, and takes about 2 hours to complete. The third 

phase—annual maintenance of the plan—is completed 

during the care provider’s birth month and is used to 

readminister the Pro-QOL screening tool completed 

during the first phase. This allows trainers to review 

those results with individual participants. This third 

and final phase takes about 1 hour to complete.

PRT is a comprehensive course in definitions, concepts, models, and methods for dealing with provider 

fatigue. This training is designed for audiences at all 

levels of care provision. The first half of the introduction to PRT defines and clarifies the challenge of compassion fatigue/provider fatigue and the “cost of caring,” as well as principles of practical holistic renewal. 

The second half is focused on strength and resiliency: 

How do individuals stay strong? Where does resiliency 

come from? How might resiliency be encouraged in 

self, colleagues, systems, and soldiers? 

Like a mental gymnasium geared toward the 

overall fitness of caregivers and the development of 

their resiliency in the face of challenges, PRT aims 

to help providers find the inner strength to face fear 

and adversity with courage. Furthermore, PRT is focused on military providers who care for those who 

have experienced suffering and trauma. The stress of 

contemporary combat and operational environments 

is unlike that experienced by physicians, nurses, or 

chaplains in the civilian sector. 

TERMS AND DEFINITIONS

A number of terms have been used to capture 

secondary reactions to trauma, including “burnout,”1

“secondary victimization,”2

 “secondary traumatic 

stress disorder,”3–7 “secondary survivor,”8 “vicarious 

traumatization,”9,10 “traumatic countertransference,”11

and “compassion fatigue.” A similar concept, “emotional contagion,” is defined as an affective process in 

which “an individual observing another person experiences emotional responses parallel to that person’s 

actual or anticipated emotions.”12(p338) Furthermore, 

“rape-related family crisis”13,14 and “proximity effects” on female partners of war veterans15 are related 

concepts. The generational effects of trauma16,17 and 

the need for family “detoxification” from war-related 

traumatic stress18 have been noted. Finally, difficulties with client problems have been considered as 

simple countertransference and discussed within 

the context of posttraumatic stress disorder (PTSD) 

treatment.2,11,19,20 However, the concept is difficult to 

measure or to separate from other factors of clienttherapist transactions. 

Historically, compassion fatigue, compassion stress, 

vicarious traumatization, secondary PTSD, and the 

current military concept of provider fatigue all involve 

the empathic connection with people experiencing the 

emotions of trauma, resulting in the provider experiencing the same emotions. Provider fatigue is related 

to the other concepts, primarily compassion fatigue, 

previously the latest in an evolving concept known 

in the field of traumatology as “secondary traumatic 

stress.” Most often this phenomenon is associated with 

the “cost of caring”3 for others in emotional pain. 

The term “provider fatigue” was first used in 1992 

by Joinson,21 who described nurses worn down by 
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Provider Fatigue and Provider Resiliency Training

daily hospital emergencies. The same year, in his book 

Compassionate Therapy, Kottler22 emphasized the importance of compassion in dealing with extremely difficult 

and resistant patients. However, neither publication 

adequately defined “compassion.” Most past research 

emphasized only why practitioners lose compassion 

as a result of working with the suffering. On the other 

hand, some people, including military care providers, 

may feel that it is wrong for a practitioner to have deep 

feelings of sympathy and sorrow for a client’s suffering. And practitioners certainly must understand their 

limitations in helping to alleviate the pain suffered by 

patients.

The American Psychiatric Association’s Diagnostic 

and Statistical Manual of Mental Disorders (4th ed)23 notes 

that PTSD is possible when one is traumatized either 

directly (in harm’s way) or indirectly, for example, as 

a parent witnessing a child’s injury. Those involved 

in both types of incidents may experience trauma, 

although through different social pathways. The latter 

pathway is called ”secondary traumatic stress.” Few 

reports of the incidence and prevalence of this type 

of stress reaction exist; however, based on secondary 

data and theory analysis, it is possible that burnout, 

countertransference, worker dissatisfaction, and other 

related concepts may have masked this common problem.2

 Vicarious traumatization, for example, refers to 

a transformation in the therapist’s inner experience 

resulting from empathic engagement with clients’ 

trauma material. These effects are cumulative and permanent, and evident in both a therapist’s professional 

and personal life.10 Compassion or provider fatigue is a 

more user-friendly term for secondary traumatic stress 

disorder, which is nearly identical to PTSD except that 

it affects those emotionally affected by the trauma of 

another (usually a client or a family member). Terms 

as used in this chapter are defined as follows:

	 •	 Primary traumatic stress results from stressors inherent in an extreme event—what 

was immediately experienced or witnessed, 

especially things that contributed most to a 

traumatic response. For example, the military 

healthcare provider may be in danger of direct 

fire while assisting fellow soldiers. 

	 •	 Compassion stress is the residue of emotional 

energy from the empathic response to the client, as well as the ongoing demand for action 

to relieve the client’s suffering. It flows from 

having an empathic, caring response. Together 

with other factors it can contribute to provider 

fatigue unless the provider acts to manage the 

stress. 

	 •	 Compassion or provider fatigue is the emotional residue or strain of exposure from working with those suffering the consequences 

of traumatic events. A form of secondary 

traumatic stress—compassion or provider 

fatigue—is the result of a healthcare provider 

engaging in the treatment of individuals exposed to various traumas. It is natural and 

normal for providers to experience compassion fatigue; if a provider is doing a job well, it 

is normal to feel fatigued, similar to an athlete 

feeling fatigued after a good workout. Provider fatigue should be expected, mitigated, and 

processed by every professional caregiver.

	 •	 Burnout is a cumulative process marked 

by emotional exhaustion and withdrawal 

associated with increased workload and institutional stress. Burnout is not necessarily 

trauma-related; it can occur in any job with 

an ongoing overwhelming workload. Burnout occurs when a person loses the ability to 

care.

	 •	 Resiliency is the ability to recover rapidly 

from illness, change, or misfortune. (In objects, 

it is the ability to regain the original shape 

after being bent, stretched, or compressed.) 

Resiliency occurs on a continuum (it is not 

an either/or proposition) and relates to a 

person’s overall growth and development. 

Resiliency is about who the person is, while 

stress management is about what that person 

is doing; however, a provider’s level of resiliency is evident in how he or she responds to 

stressors. Resiliency grows through healthy 

responses to stressors. 

FIGLEY’S COMPASSION FATIGUE MODEL

In 1995, Charles Figley, a former Marine and leader 

in the field of traumatology, created a model of compassion fatigue delineating how exposure to suffering 

and an empathic response can lead to compassion 

stress and compassion fatigue.24 The same experiences 

can be seen in the area of provider fatigue, and will be 

further discussed in the next section. Elements in the 

model include the following:

	 •	 Emotional contagion is experiencing the feelings of the sufferer as a function of exposure 

to the sufferer. 

	 •	 Empathic concern is the motivation to respond to people in need. 
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Combat and Operational Behavioral Health

	 • Empathic ability is the aptitude for noticing 

the pain of others. 

	 • Empathic response is the extent to which the 

helper makes an effort to reduce the suffering 

of the sufferer. 

	 • Disengagement is the extent to which helpers can distance themselves from the ongoing 

misery of the traumatized person. 

	 • Sense of achievement is the extent to which 

helpers are satisfied with their efforts to help 

the client/sufferer. 

	 • Compassion stress is the compulsive demand 

for action to relieve the suffering of others. 

	 • Prolonged exposure is the ongoing sense of 

responsibility for the care of the suffering, over 

a protracted period of time. 

	 • Traumatic recollections are memories that 

trigger the symptoms of PTSD and associated 

reactions, such as depression and generalized 

anxiety. 

	 • Life disruption is the unexpected change in 

schedule, routine, and managing life responsibilities caused by experiences that demand 

attention (eg, changes in health, lifestyle, 

social status, or professional or personal circumstances). 

	 • Compassion fatigue is the state of tension 

and preoccupation with the traumatized by 

(a) reexperiencing the traumatic events; (b) 

avoidance/numbing of reminders, and (c) 

persistent arousal. It is a natural consequence 

of behaviors and emotions resulting from 

knowing about a traumatizing event experienced by another. 

	 • Compassion trap is the inability to let go of 

the thoughts, feelings, and emotions useful in 

helping another, long after they are useful.24

It is thought that “other-centered” people, who are 

good at providing care, are vulnerable to compassion 

fatigue. Those without as much compassion suffer 

these effects less dramatically. The first author of this 

chapter conceptualizes this as follows: “the caregivers’ 

gift is their burden.” Being a compassionate person 

is helpful in the healing process, but that compassion may become a challenge if it is not balanced by 

resiliency. 

Providers who are strongly empathetic may be most 

at risk of provider fatigue. No provider witnesses 

trauma in the abstract; for those who are strongly 

empathic it can be, and is, personal. The actual experience is felt vicariously as pain, with a consequential 

psychological impact. Often providers do not see 

self-care as a priority, which places them in jeopardy 

of burning out. 

Another factor that puts the provider at risk for 

secondary traumatization is a personal history of 

trauma. When providers have experienced a significant loss in their own lives, the experiences and 

images of trauma may trigger those memories and 

stimulate fresh grief. Many providers are secondary 

witnesses to trauma on a regular basis. As witnesses 

and providers, they are vulnerable to the emotional 

pain of victims. Providers picture bits and pieces of 

the trauma in their minds and may experience intense 

feelings in their bodies. 

Many military providers are both participants in 

the trauma (eg, being shot at) and caregivers of others affected. Figley summarized these experiences by 

noting that helping the traumatized can itself be quite 

traumatizing. An Army chaplain related the story 

of being part of a convoy in which a vehicle in front 

of him was blown up. He was in imminent danger 

himself. As he participated in helping his comrades 

through the trauma and debriefing that followed it, 

he found himself alone, wondering who would help 

him. He turned to his God and returned to camp. 

The next day was Sunday and his job took him to the 

pulpit, where he delivered an inspiring sermon to the 

soldiers he served.25 The point made is that one may 

be in the face of danger, help those in danger, be alone 

in danger, and then rise the next day to serve those in 

danger. This situation occurs in the life of the military 

care provider on a regular basis.

FACTORS CONTRIBUTING TO COMPASSION STRESS 

Empathic responses in the provider occur when 

the ability and desire to help others converges with 

exposure to suffering. Compassion stress flows from 

having an empathic, caring response to the work or 

to those who suffer. It is how providers feel (physically and/or emotionally) the trauma of the patients 

with whom they are working. For example, hearing 

of terrible abuse stirs within the provider a feeling of 

disgust and gastrointestinal upset. The level of stress 

is determined by how much the provider relates to or 

identifies with another’s suffering and trauma. The following characteristics, based on Figley’s model, often 

propel people to become healthcare providers, yet also 

predispose them to experience compassion stress: (a) 

the ability to be empathic, (b) the desire to help, and 

(c) the level of exposure to suffering. The chances of 

experiencing compassion fatigue are reduced to the 

degree that these features are lacking.2,24
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Provider Fatigue and Provider Resiliency Training

	 •	 Empathic ability is the aptitude of the provider for noticing the pain of others. Figley’s 

model suggests that without empathy, providers experience little if any compassion 

stress and no compassion fatigue. However, 

without empathy they feel little if any empathic response to suffering clients. Thus, the 

ability to empathize is key both to helping 

others and being vulnerable to the costs of 

caring.

	 •	 Empathic concern is the motivation to respond to people in need. The ability to be 

empathic is insufficient unless motivation exists to help others who require the services of 

a concerned psychotherapist. With sufficient 

concern, the empathic provider draws upon 

his or her talent, training, and knowledge to 

deliver the highest quality of services possible 

to those who seek it.

	 •	 Exposure to the client is experiencing the 

emotional energy of client’s suffering through 

direct exposure. Mental health professionals 

directly employed in human services may 

decide to become supervisors, administrators, or teachers because of the costs of direct 

exposure to clients (of course, determining 

individual motivation is difficult, and some 

make the shift from direct practice because of 

additional pay, improved working conditions, 

and higher status).24

	 •	 Empathic response is the extent to which the 

provider makes an effort to reduce the suffering of the client through empathic understanding. This insight into feelings, thoughts, 

and behaviors of the client is achieved by 

projecting one’s self into the perspective of 

the client. In doing so, the provider might experience the client’s hurt, fear, anger, or other 

emotions. Therein lie both the benefits and the 

costs of such a powerful therapeutic response. 

The benefits are immediately obvious to every 

provider who practices his or her skills with 

another. The benefit for the provider is that 

a sense of bonding and understanding with 

the hurting person may emerge. This may be 

demonstrated by the latter feeling understood 

and having the pain/trauma be normalized 

by the provider’s expression of empathy. The 

costs, rarely discussed, must be experienced 

for the provider to guard against or mitigate 

the effects.

	 •	 Compassion stress, the residue of emotional energy from the empathic response, 

is experienced as an ongoing demand for 

action to relieve the client’s suffering. As 

with any stress, compassion stress with sufficient intensity can have a negative effect 

on the immune system and quality of life. 

Together with other factors, this stress can 

contribute to compassion fatigue unless the 

psychotherapist acts to control it. Two major 

types of coping actions appear to help control 

compassion stress:

 ° A sense of achievement, the extent to 

which providers are satisfied with their 

efforts to help the client, can lower or prevent compassion stress. Having a sense of 

achievement involves a conscious, rational 

effort to recognize where the provider’s responsibility ends and the client’s begins.

 ° Detachment, the extent to which providers 

can distance themselves from the ongoing 

misery of the client between treatment 

sessions, can lower or prevent compassion 

stress. The ability to disengage also requires 

a conscious, rational effort to recognize that 

to live their own lives providers must “let 

go” of the thoughts, feelings, and sensations 

associated with clients. Disengagement 

is the recognition of importance of selfcare.24

Compassion stress can also be mitigated by both 

individual and unit management of stressors. If there is 

a sense of achievement, an ability to disengage, and the 

stress is well managed, the stress will be maintained 

at normal levels. If these are insufficient or not present, 

then the level of stress will rise. If compassion stress 

is permitted to build, despite the provider’s effort at 

disengagement and a sense of work satisfaction, the 

provider is at a greater risk of compassion fatigue. 

Three other factors play a role in increasing compassion/provider fatigue:

1. Prolonged exposure is the ongoing sense of 

responsibility for the care of the suffering, 

over a protracted period of time (eg, multiple 

sessions with one individual or multiple 

contacts from large-scale disasters such as the 

2004 tsunami in Asia). To prevent prolonged 

exposure, providers should have regular 

breaks from client appointments, lasting from 

a day off to a week’s vacation.

2. Traumatic recollections are memories that 

trigger symptoms of PTSD and associated 

reactions, such as depression and anxiety. 

These memories may be from the provider’s 

experiences with either demanding or threat-
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Combat and Operational Behavioral Health

ening clients, clients who were especially 

sad or suffering, or clients with experiences 

that have a connection to traumatic events 

experienced by the provider.

3. Life disruptions are unexpected changes 

in schedule, routine, and managing life 

responsibilities that demand attention (eg, 

personal home-front concerns while at war; 

illness; or changes in lifestyle, social status, 

or professional or personal responsibilities). 

Normally such disruptions would cause a 

certain but tolerable level of distress. However, when combined with the other factors, 

these disruptions can increase the chances 

of the provider developing compassion fatigue.24

SYNERGISTIC EFFECTS OF PROVIDER FATIGUE

For the military healthcare provider, numerous 

sources of stress may come together to bring about 

provider fatigue. Although the primary ingredient 

of provider fatigue is unmanaged compassion stress, 

operational stress also contributes to the provider 

fatigue of military healthcare providers, as well as 

chaplains, support staff, and family members. Unresolved primary traumatic stress, secondary traumatic 

stress, and burnout, when added to unmanaged 

compassion stress, directly affect the overall level 

of provider fatigue. For example, providers may 

experience burnout from a continuously heavy 

workload (unrelated to trauma); secondary trauma 

from repeated exposure to the suffering of coworkers 

or family members; or primary trauma in the form 

of direct or indirect fire in a war zone, or the sights, 

smells, and sounds of providing direct humanitarian care. The interactive effect of different types 

of stressors can shape the overall development of 

provider fatigue. Military healthcare providers are 

at increased risk of provider fatigue because of both 

exposure to others’ suffering and the risk of personal 

injury or death.

For many military providers, symptoms of secondary traumatization have a delayed onset. Many 

providers also have prior traumatic experiences that 

may cause no symptoms until associated with the 

stressors of working with traumatic material presented 

by patients. Some may develop clinical PTSD-like 

symptoms associated with their previously “benign” 

historical experiences. It is often necessary to resolve 

primary traumatic stress before addressing any issues 

of secondary stress or burnout. 

Primary stress, secondary stress, operational stress, 

and burnout symptoms have a synergistic or interactive effect with compassion stress (Figure 23-1). Experiencing symptoms from any one of these sources 

appears to diminish resiliency and lower thresholds 

for the adverse impact of the stressors, which can in 

turn lead to a rapid onset of severe symptoms that can 

become debilitating to the provider within a very short 

period of time. The experiences of military providers 

differ from those of civilian providers because of danger while delivering service, multiple deployments, 

working with detainees, cultural differences, and lack 

of time for reprieve. Military-specific operational stress 

includes 

	 •	 lack of reprieves, breaks, and exits during

operations;

	 •	 experience of primary trauma while helping

others;

	 •	 a cumulative effect of the provider’s and clients’ repeated deployments;

	 •	 isolation and relational issues;

	 •	 ethical issues, such as determining who the

client is; and

	 •	 competing demands fortreatment ofthe client

versus the provider. 

Burnout

Secondary

Traumatic

Stress

Operational Stress,

Military-Unique

Components

PROVIDER

Primary

Traumatic

Stress

Figure 23-1. Synergistic effects of primary, secondary, and 

operational stress, combined with burnout symptoms, on 

providers.
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Provider Fatigue and Provider Resiliency Training

WAYS TO IDENTIFY PROVIDER FATIGUE

Symptoms of provider fatigue may include withdrawal from family and friends; emotional numbing; 

loss of interest in things usually enjoyed; persistent 

thoughts and images related to the problems of others; 

physical symptoms such as headaches, gastrointestinal 

disturbances, and muscle tightness; sleep disturbance; 

and jumpiness. 

Markers 

Healthcare providers must monitor themselves 

and coworkers for the following markers. The more 

markers observed or felt, the greater the risk of provider fatigue. The markers fall into the categories of 

cognitive, emotional, behavioral, spiritual, somatic, 

and social.2

Cognitive Markers

	 •	 Intrusive thoughts and disturbing memories

	 •	 Preoccupation with trauma

	 •	 Lowered concentration

	 •	 Disorientation

	 •	 Thoughts of self-harm or harm to others

	 •	 Reduced sense of safety

Emotional Markers

	 •	 Powerlessness

	 •	 Anxiety or fear

	 •	 Anger

	 •	 Survivor’s guilt

	 •	 Numbness or inability to feel emotions

	 •	 Sadness

	 •	 Emotional roller coaster

	 •	 Feelings of depletion, being run down, or out

of steam

	 •	 Irritability

	 •	 Decreased self-esteem

Behavioral Markers

	 •	 Impatience

	 •	 Being snappy or short tempered with others

	 •	 Poor sleep

	 •	 Nightmares

	 •	 Appetite changes, eating more or less than

normal

	 •	 Being jumpy or on edge; startling easily

	 •	 Being accident prone

	 •	 Losing things

	 •	 Being rigid orinflexible, wanting to do everything the same way 

	 •	 Using ineffective or harmful self-care practices

Spiritual Markers

	 •	 Loss of hope

	 •	 Loss of purpose

	 •	 Anger at God

	 •	 Questioning prior religious beliefs

	 •	 Skepticism toward religion

	 •	 Reduced joy and sense of purpose with career

	 •	 Loss of compassion

Somatic Markers

	 •	 Shock

	 •	 Rapid heartbeat and sweating

	 •	 Breathing difficulties

	 •	 Aches and pains

	 •	 Dizziness

	 •	 Impaired immune system; being more prone

to illness

	 •	 Exhaustion

	 •	 Gastrointestinal problems and headaches

Social Markers

	 •	 Decreased interest in emotional intimacy

	 •	 Mistrust and isolation

	 •	 Being overprotective as a parent or as a leader;

not allowing others to have normal activities

	 •	 Loneliness

	 •	 Increased interpersonal conflicts

	 •	 Trouble separating work from personal life

Behavior Changes After Exposure to Trauma

Numerous problems including absenteeism have 

been documented after exposure to trauma. This is a 

real phenomenon that can affect military healthcare 

providers and their ability to do their jobs. In a mixed 

method study by Regehr, Goldberg, and Hughes,26

emergency workers routinely exposed to pain and 

suffering were examined to better understand factors 

leading to higher levels of distress within the theoretical 

framework of emotional and cognitive empathy. Researchers found a significant increase in alcohol-related 

problems, an increase in mental health stress leave, 

and an increase in use of psychiatric medications after 

these providers were exposed to a traumatic event. The 
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Combat and Operational Behavioral Health

study concluded that paramedics, who are exposed to 

many events outside the everyday experiences of the 

average person, have for the most part learned to deal 

with the events and take them in stride. A coping technique commonly used by paramedics is to deal with the 

events cognitively and technically while maintaining 

an emotional distance. At times, however, certain circumstances lead workers to develop an emotional connection with events based on their awareness of other 

aspects of the patient’s experience. Aspects that can 

trigger this connection include the victim’s alienation 

from others, profound loss, or the abuse of an innocent 

child. When this connection occurs, paramedics report 

increased symptoms of traumatic stress.26

Provider fatigue can be recognized on the job by its 

effects on work performance, morale, behavior, and 

relationships.2

Effects on Work Performance

	 •	 Decreased quality

	 •	 Decreased quantity

	 •	 Low motivation

	 •	 Avoidance of tasks

	 •	 Increased mistakes

	 •	 Setting perfectionist standards

	 •	 Obsession about details

Effects on Morale

	 •	 Decrease in confidence

	 •	 Loss of interest

	 •	 Dissatisfaction

	 •	 Negative attitude

	 •	 Apathy

	 •	 Demoralization

	 •	 Lack of appreciation

	 •	 Detachment

	 •	 Feelings of incompleteness

Effects on Behavior

	 •	 Absenteeism

	 •	 Exhaustion

	 •	 Faulty judgment

	 •	 Irritability

	 •	 Tardiness

	 •	 Irresponsibility

	 •	 Frequent job changes

	 •	 Overwork

Effects on Interpersonal Relationships

	 •	 Withdrawal from colleagues

	 •	 Impatience

	 •	 Decrease in quality of relationship

	 •	 Poor communication

	 •	 Subsuming own needs

	 •	 Staff conflicts

In addition to direct observation, compassion can be 

indirectly identified through self-administered survey 

instruments. 

US Medical Command Use of the Professional 

Quality of Life Scale

The ProQOL27 scale is the current version of the old 

Compassion Fatigue Self Test2 and has been widely 

used in assessing compassion fatigue. The ProQOL 

is a 30-item survey instrument that consists of three 

subscales: (1) compassion fatigue, also known as secondary trauma scale; (2) burnout; and (3) compassion 

satisfaction. In keeping with the tone of this chapter, 

the discussion will focus specifically on issues related 

to compassion fatigue. The compassion fatigue variable is measured with 10 questions, and each response 

option ranges from 0 (never) through 5 (very often). 

Stamm28 reported updated descriptive statistics for 

the ProQOL to include compassion fatigue. Based 

on a comprehensive reanalysis of existing published 

research, she found the compassion fatigue mean 

score to be 12, with a standard deviation of 6.9 and a 

Cronbach’s alpha reliability score of .80. Throughout 

the remainder of this discussion, Stamm’s new results 

and the research it was based on will be referred to 

as ProQOL data. Additionally, because the ProQOL 

attempts to identify persons who are “compassion 

fatigued,” the instrument uses quartile scores as cutoff 

scores. In the ProQOL data the top quartile score is 17, 

meaning that respondents scoring 17 or above on the 

compassion fatigue scale are considered compassion 

fatigued.

Compassion fatigue is described as “your workrelated, secondary exposure to extremely stressful 

events.”27 The list below contains the 10 items on the 

Trauma/Compassion Fatigue Scale taken directly from 

the ProQOL:

	 •	 I am preoccupied with more than one person

I help.

	 •	 I jump or am startled by unexpected sounds.

	 •	 I find it difficult to separate my personal life

from my life as a helper.

	 •	 I think that I might have been “infected” by

the traumatic stress of those I help.

	 •	 Because of my helping, I have felt “on edge”

about various things.
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Provider Fatigue and Provider Resiliency Training

	 •	 I feel depressed as a result of my work as a

helper.

	 •	 I feel as though I am experiencing the trauma

of someone I have helped.

	 •	 I avoid certain activities or situations because

they remind me of frightening experiences of 

the people I help.

	 •	 As a result of my helping, I have intrusive,

frightening thoughts.

	 •	 I can’trecall important parts of my work with

trauma victims.27

In 2008 the Surgeon General of the US Army, 

Lieutenant General Schoomaker, required all Army 

MEDCOM personnel to complete the ProQOL. This 

requirement met the intent to assess MEDCOM personnel on compassion fatigue, burnout, and compassion satisfaction. MEDCOM personnel accessed the 

ProQOL scale through a secure Army Web site. Respondents were assured that “[t]he information on the 

ProQOL is protected. Scores on the assessment are for 

use in helping individuals to develop a self-care plan. 

Employees are not required to share the information 

with their supervisors.”29 

The de-identified database was analyzed by personnel assigned to the Soldier Family Support Branch of 

the AMEDD Center and School, using SPSS (Version 

16, SPSS Inc, Chicago, Illinois) statistical software. To 

meet the Surgeon General’s intent of assessing the 

levels of compassion fatigue in MEDCOM personnel, the analysis started with descriptive statistics for 

MEDCOM population demographics and population 

scores. As the name implies, MEDCOM is a medical 

organization that has about 27,000 soldiers and 28,000 

civilian employees30 assigned across 35 medical treatment facilities. For parity’s sake, demographic description is limited to respondent medical specialty. Figure 

23-2 illustrates the percentage of MEDCOM personnel 

by medical specialty. 

Using inferential statistics, the data were then 

analyzed to see whether MEDCOM scores differed 

from ProQOL data scores in a statistically significant 

way. A P value of < .001 was considered statistically 

significant. Analysis then focused on establishing descriptive statistics specific to MEDCOM compassion 

fatigue scores. With valid N = 50,478, the MEDCOM 

mean score for compassion fatigue was 9.8823 (minimum = 0.00, maximum = 50.00, ST = 6.71681, variance 

= 45.116).

A one-sample t test is an appropriate statistical test 

to compare a sample score to a known population 

score.31 In this case, MEDCOM is considered a sample 

of the greater population represented by the ProQOL 

data scores. A one-sample t test was conducted to compare the MEDCOM compassion fatigue mean score 

of 9.88 to the ProQOL data compassion fatigue mean 

score of 12. The MEDCOM compassion fatigue mean 

score was lower than the ProQOL data score and the 

difference was statistically significant with a 2-tailed 

test (t12 = -70.835, P < .001, df = 50,477). The mean difference was -2.11768 (95% CI, -2.1763 to -2.0591). 

Physician

9%

Nurse

21%

Other

Credentialed

Professional

17% Enlisted

Direct Care

13%

Admin Staff

19%

Support

Staff

21%

Figure 23-2. Percentage of US Army Medical Command 

personnel, by specialty, who completed the ProQOL survey 

in 2008. N=50,478.

table 23-1

percentage of medical command

personnel who meet compassion

fatigue cut score

Frequency Percent Valid 

Percent

Cumulative 

Percent

Not 

Compassion 

Fatigued

43,595 86.4 86.4 86.4

Compassion 

Fatigued

6,883 13.6 13.6 100.0

Total 50,478 100.0 100.0
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Combat and Operational Behavioral Health

Another question of interest is how the percentage 

of MEDCOM personnel with compassion fatigue differs from the percentage of personnel with compassion 

fatigue in the ProQOL data. Stamm’s establishment of a 

compassion fatigue cut score of 17, representing 25% of 

the ProQOL data population, allows this comparison. 

The percentage of MEDCOM personnel that scored at 

or above 17 on the compassion fatigue score was 13.6% 

(Table 23-1). This is further graphically represented in 

Figure 23-3.

To determine whether this difference is statistically 

significant, a goodness-of-fit test was conducted. A 

goodness-of-fit test is appropriate when the data score 

is nonparametric,31 which is true in this case using 

quartile-based cut scores. The goodness-of-fit test compares the observed number of personnel (MEDCOM) 

that meet or exceed the cutoff score to the expected 

percentage (ProQOL data) of personnel that meet or 

exceed the cutoff score (Table 23-2). The difference was 

found to be statistically significant with a chi-square 

of 3,477.4 (df = 1, P value < .001).

This study focused on assessing the level of compassion fatigue among MEDCOM personnel and then 

comparing it to levels of compassion fatigue in the 

ProQOL data that represent the greater population. 

The findings establish that MEDCOM personnel report 

less compassion fatigue overall and MEDCOM has a 

lower percentage of personnel who meet criteria for 

compassion fatigue when compared to the cumulative 

samples in published research. Though important, 

speculations about the reasons for this difference are 

beyond the scope of this discussion; further research 

is warranted.

Fatigued

14%

Fatigued

25%

Not fatigued

86%

Not fatigued

75%

ProQOL Compassion Fatigue

Cut-off

MEDCOM Compassion Fatigue

(N = 50,478)

Figure 23-3. Percentage of ProQOL respondents with compassion fatigue compared to US Army Medical Command 

personnel with compassion fatigue.

MEDCOM: US Army Medical Command ProQOL: Professional Quality of Life scale

table 23-2

MEDical COMmand Observed

Compassion Fatigue cut Score

Frequencies Compared to Expected

Frequencies Based on ProQOL Data* 

Observed N Expected N Residual

Not 

Compassion 

Fatigued

43,595 37,858.0 5,737.0

Compassion 

Fatigued

6,883 12,620.0 -5,737.0

Total 50,478

*No cells (.0%) have expected frequencies less than 5. The minimum 

expected cell frequency is 12,620.0.

ProQOL: Professional Quality of Life scale
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Provider Fatigue and Provider Resiliency Training

WAYS TO COMBAT PROVIDER FATIGUE

The EAT Model 

The EAT model was created by Pechacek as a teaching tool for the AMEDD Center and School. The model 

offers a simple, easy-to-remember way for leaders, providers, wounded individuals, and anyone in the helping profession to articulate a way to manage provider 

fatigue and/or burnout. One way to combat provider 

fatigue is using the “EAT” action plan (Figure 23-4): 

Educate yourself; Assess your level of provider fatigue; 

and Take action to build resiliency, create a self-care 

plan, and seek professional help if needed. Figure 

23-5 is a visual reminder that focus on the provider 

is essential to combating provider fatigue. Providers 

are involved with many relationships, including those 

with a patient, soldier, and client, as well as those with 

a colleague who shares stories of trauma. The work 

environment may include many cases of trauma, and 

its resources may be stressed in the attempt to provide 

services to providers and others. Providers are also 

affected by war, disaster, or other traumatic event. 

Figure 23-4. “EAT” to combat provider fatigue.

Educate yourself:

 Who is affected? 

 What is provider fatigue?

 What is resiliency? 

Assess your level of provider fatigue:

 What is the provider fatigue severity level?

 What is the resiliency level?

 How might resiliency be increased?

Take action:

 Build up your resiliency

 Create a self-care plan

 Seek professional help if needed

The level of provider fatigue may be assessed with 

the markers and effects listed above through self and 

buddy observation and discussion, as well as through 

self-tests such as Figley’s Secondary Trauma Scale2 and 

the Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales–III.32

Building Resiliency

Resiliency training focuses on strength rather than 

on pathology. For providers, it is important to have a 

resiliency model and to know where resilient strength 

comes from. Providers should identify a resilient role 

model: Who has the qualities that you as a provider 

would like to have? Have any of the people you work 

with inspired you? Resiliency, like the “Battlemind” 

concept (see Chapter 4, Combat and Operational Stress 

Control, in this volume), is a person’s inner ability to 

face fear and adversity with courage, and the will to 

persevere and overcome adversity. 

To build resiliency, providers must accomplish two 

difficult tasks simultaneously in a stressful situation: 

“self-soothing” and “self-confronting.”33 Self-soothing 

PATIENT

PROVIDER

TRAUMA

WORK

SYSTEM

FELLOW

WORKERS

Figure 23-5. Focus on the provider is essential to combating provider fatigue. Providers are affected by their many 

relationships with patients and clients as well as colleagues, 

in a work environment with exposure to various types of 

trauma.
386

Combat and Operational Behavioral Health

is the ability to deliberately relax while facing a stressful situation. Examples of self-soothing activities 

include working out, running, taking a bubble bath, 

hiking, diving, dancing, or just breathing deeply. The 

purpose of self-soothing is to enable the second step, 

self-confronting. Self-confronting is the process of assessing one’s own anxiety and examining what might 

be learned from the situation. Providers should ask 

themselves questions such as:

	 •	 Why am I anxious?

	 •	 What am I trying to prove?

	 •	 Who am I trying to impress?

	 •	 What am I trying to fix?

	 •	 Am I depending on someone else to validate

my sense of self-worth? 

	 •	 What is the growth potential in this situation? 

Self-soothing without self-confronting leads to 

avoidance, such as withdrawing, being demanding or 

driven by emotions, overeating, or substance abuse. 

Self-confronting without self-soothing leads to the risk 

of negativity without the willingness to step back and 

look for growth opportunities.

A Holistic Approach to Renewal 

A provider can work to combat provider fatigue and 

build resiliency in five ways: (1) physically, (2) mentally, (3) emotionally, (4) spiritually, and (5) socially.

Physical Renewal

Nutrition is the first consideration in physical 

renewal. Under stress, some providers use food for 

comfort, and some refrain from eating. Maintaining 

good nutrition while avoiding fast food provides the 

best results. Furthermore, drinking the appropriate 

amount of water is important to fighting stress. Secondly, rest and relaxation are important for physical 

renewal, including sleep at night, breaks at work, and 

vacation time away from trauma. 

Other means of physical renewal are exercise and 

laughter. Exertion through exercise releases pent-up 

frustrations and renews energy. Studies have shown 

that consistent exercise is associated with improved 

depression scores in patients with depression, cancer, 

and cardiac disease, and even in healthy subjects.33

Other studies34 have shown that laughter can reduce 

or prevent hypertension. Laughter may initially cause 

blood pressure to increase, but it then decreases and 

breathing becomes deeper, sending oxygen-enriched 

blood and nutrients throughout the body. This increase 

in blood flow and oxygenation of blood can actually 

assist in healing. Not conducive to physical renewal are 

forms of avoidance such as substance abuse, gambling, 

or other addictions.

Mental Renewal

Fear is normal for providers, who may worry about 

how well they are taking care of patients or accomplishing other duties. Fear can also lead to feelings 

of shame and guilt. Like physical renewal, mental 

renewal results from relaxation, through activities 

like reading books, listening to music, or learning 

relaxation techniques from tapes or seminars. When 

the sympathetic nervous system is calmed and quieted 

by relaxation, muscle tension decreases, the heart rate 

slows, and a feeling of well-being occurs. 

Emotional Renewal

Emotional renewal means accepting and normalizing experience. Internalized anger, fear, depression, 

anxiety or other negative emotions can produce biochemical changes that have been shown to adversely 

affect the mind and body. The experiences of providing 

military medical care may cause troubling dreams or 

recurring thoughts. This is normal. Before providers 

can act to change their emotions, they must accept 

their situation. Emotional resiliency grows by thinking through daily events, sorting through emotions, 

talking with trusted friends, keeping a journal, and 

even laughing. Laughter can activate and strengthen 

the immune system by reducing four neuroendocrine 

hormones associated with the stress responses: epinephrine, cortisol, dopamine, and growth hormones.

Spiritual Renewal

Spiritual renewal is important to numerous military providers. Many have claimed that the sense of 

belonging to God or a higher power has assisted them 

in coping with anxiety and trauma. For many people, 

praise and worship with groups of people is uplifting 

and rejuvenating, listening to inspirational music or 

reading devotional books may be therapeutic, and taking time out to refocus attention on a greater “problem 

solver” reduces pressure when working in traumatic 

circumstances. Meditation can also be a source of provider resiliency; the ability to sit back, observe the 

mind, and direct attention to the present moment allows people to face challenges with renewed strength 

and flexibility. And for many, spiritual resiliency and 

renewal comes from forgiveness. Forgiveness is a way 

to avoid bitterness and recover from burnout; failing 

to forgive oneself and others often turns anger inward, 

resulting in bitterness, depression, and burnout.
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Provider Fatigue and Provider Resiliency Training

For many military healthcare providers, spirituality is a deep sense of comfort, support, and daily 

inspiration. Studies have demonstrated that religion 

and spirituality are associated with reduced risk of 

medical morbidity and mortality and lower rates of 

divorce, criminal behavior, suicide, and drug abuse.33

For some individuals, spirituality without a formal 

religion is their source of resiliency; however, according to a Gallup poll,34 religion plays a huge role in the 

lives of others: 

	 •	 for 70% of Americans, religion is a “very important” part of life;

	 •	 over 60% of Americans believe in angels;

and

	 •	 82% ofAmericans express interest in spiritual

growth.

Social Renewal

Humans are social creatures. Military providers 

need to be with and relate to others for growth and development. Making time for others increases positive 

mental health and builds resilience. Having a social 

network increases coping strategies, a key ingredient 

for building resiliency both on the job and in all aspects 

of life. Providers have often asked, “How do I keep 

from getting depressed, listening to people’s problems 

day after day?” The answer lies in the basic philosophy 

of looking for and emphasizing strengths rather than 

pathology in other people. Maddi35 studied hardiness 

and wrote extensively about how people obtain hardiness and thrive under adverse conditions. He has 

found that people who thrive under stress maintain 

three key beliefs that help turn adversity into advantage: (1) commitment: striving to become involved in 

ongoing events rather than feeling isolated; (2) control: 

trying to influence outcomes rather than lapsing into 

passivity; and (3) challenge: viewing stressful situations as opportunities for new learning.35

Leadership

Like all complex systems, the military is greatly 

affected by its leadership. It is imperative that leaders 

at all levels be familiar with the concepts discussed in 

this chapter and encourage their soldiers to practice 

them. Colonel Joseph Pecko, former chief of the Soldier 

and Family Support Branch of the AMEDD Center and 

School, commented on the role of leadership and its 

place in striving for resiliency: “Leadership may have 

many meanings, but leadership practices in regard to 

provider fatigue are very important.” Following the 

suggestions of PRT ensures strong leadership skills 

and the best results for all. Colonel Pecko encourages 

leaders to promote provider resiliency in the following ways:

	 •	 Place the care of the military care providers

as the highest priority. 

	 •	 Give credit and reward a job well done.

	 •	 Foster an environment of dignity and respect.

	 •	 Be available to talk with subordinates; spend

time with them. Embrace an open door as 

well as anonymous “back door” policy. Allow providers to talk about their experiences 

and feelings. Let providers know that you are 

aware of their situation and offer help. Often, 

providers cannot take action on their own 

because they are too close to the situation, so 

the suggestions and attitude from leadership 

can be helpful.

	 •	 Keep your staff informed. Clearly express

your policies and views on all matters. Allow 

subordinates to seek clarification on your 

policies without becoming defensive or seeing subordinates as disloyal. Try not to take 

subordinates’ actions personally.

	 •	 Allow providers sufficient time to recover

from duties, physically and mentally. Give 

them private time to do different work or 

catch up on tasks. Assist with the provider’s 

everyday tasks when possible.

	 •	 Establish a climate where subordinate leaders

can acknowledge stress and the desire to seek 

assistance. Teach leaders that seeking help 

takes courage. Encourage leaders to seek out 

and identify their most vulnerable and at-risk 

people. 

	 •	 Take care of yourself as a leader and set a

good example of self-care. Maintain a positive attitude during periods of adversity and 

challenge. The resiliency and mental toughness of the leader will shine through to others. 

Leaders setting an example in self-care and 

speaking the language of resiliency can bring 

about dramatic positive results in the work 

environment.

SUMMARY

In the 21st century, military care providers must 

understand provider fatigue and how it affects their 

care for those suffering from the effects of trauma. 

This chapter has defined types of fatigue related to 

the military healthcare provider and unit ministry 

teams, discussed Figley’s model of compassion 
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Combat and Operational Behavioral Health

fatigue, identified the symptoms and markers of 

provider fatigue, and listed methods of preventing 

provider fatigue as well as ways to promote renewal 

and resiliency for the provider, including the role of 

leaders. Promoting resiliency for the provider, like 

the broader mission of providing healthcare for all 

service members, depends on teamwork. At every 

level, leaders and providers must begin with self-care 

before promoting resiliency in their colleagues and 

subordinates.

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27. Stamm BH. The ProQOL Manual. The Professional Quality of Life Scale: Compassion Satisfaction, Burnout and Compassion 

Fatigue/Secondary Trauma Scales. Baltimore, Md: Sidran; 2005. Available at: http://www.proqol.org/ProQOl_Test_Manuals.html. Accessed December 10, 2010.

28. Stamm BH. Personal communication. June 9, 2009.

29. US Department of the Army. Provider Resiliency Training. Available at: http://www.behavioralhealth.army.mil/prt/

index.html. Accessed December 10, 2010.

30. US Department of the Army. Introduction to the US Army Medical Department. Available at: http://www.armymedicine.army.mil/about/introduction.html. Accessed December 10, 2010. 

31. Rubin A. Statistics for Evidence-Based Practice and Evaluation. Belmont, Calif: Thomas Higher Education; 2007.

32. Stamm BH. The Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales–III. Baltimore, Md: Sidran; 

1995–2002.

33. Funk JR. Balancing the Burdens of Caregiving: Avoiding Compassion Fatigue. Healthcare Chaplains Ministry Association; 

2002.

34. Seibert A. The Survivor Personality: Why Some People Are Stronger, Smarter, and More Skillful at Handling Life’s Difficulties...

and How You Can Be, Too. New York, NY: Practical Psychology Press; 1993.

35. Smallwood B. Do you have compassion fatigue? Available at: http://hodu.com/compassion.shtml. Accessed December 

10, 2010.
390

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393

Army Suicide Surveillance: A Prerequisite to Suicide Prevention

Chapter 24

ARMY SUICIDE SURVEILLANCE: 

A PREREQUISITE TO SUICIDE 

PREVENTION

GREGORY A. GAHM, PhD,* and MARK A. REGER, PhD†

INTRODUCTION

SUICIDE PREDICTION DEFINED

SUICIDAL BEHAVIOR PREDICTABILITY

IMPORTANCE OF SUICIDE PREDICTION

EPIDEMIOLOGICAL SURVEILLANCE STUDIES

Models for Suicide Research

An Army Suicide Surveillance System

THE SUICIDE RISK MANAGEMENT AND SURVEILLANCE OFFICE

History of the Office

Army Suicide Event Report Data Collection Process

SUMMARY

*Colonel, Medical Service Corps, US Army; Chief, Department of Psychology, Madigan Army Medical Center, 9933C West Hays Street, Fort Lewis, 

Washington 98431-1100

†

Research Psychologist, Department of Psychology, Madigan Army Medical Center, 9933C West Hays Street, Fort Lewis, Washington 98431-1100; 

Affiliate Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1925 NE Pacific Street, 

Seattle, Washington 98195-6340 
394

Combat and Operational Behavioral Health

INTRODUCTION

“Mental health specialists are now able to predict 

and prevent many suicides.” At first glance, this 

statement (and those similar to it) appears to be a 

reasonable expectation of behavioral health providers. 

Suicidal ideation is a common presenting problem in 

outpatient settings,1,2 and when suicides do occur, they 

inflict a tremendous emotional toll on family, friends, 

coworkers, and the broader community. Caring for the 

psychological needs of individuals requires providers 

to make suicide risk assessment and prevention a high 

priority. A general awareness of the significant amount 

of research that has been conducted to inform clinical 

decisions about suicidal patients may also suggest that 

clinicians can predict and prevent many suicides. Hundreds of studies have added to the body of knowledge 

about suicide, and there are a number of well-respected 

peer-reviewed journals dedicated solely to suicide research. Furthermore, there is a general recognition that 

behavioral health providers have specialized training 

in suicide intervention. Behavioral health providers 

are often viewed as experts in suicide assessment and 

prevention, and psychologists are regularly consulted 

about acute suicide potential in specific individuals, 

both within the military and in the civilian sector. 

However, a closer analysis of the literature supporting the quoted statement suggests that more caution may be indicated. What does it mean to predict 

suicide? What does current research demonstrate 

about clinicians’ abilities to predict suicide? How does 

prediction relate to prevention, and what does it mean 

to prevent suicide? This chapter will review some of 

the current literature on suicide prediction, suggesting that population surveillance studies provide an 

important tool to improve knowledge about suicidal 

behaviors in the military. It will describe an ongoing 

epidemiological surveillance project in the US Army, 

and propose future directions that will maximize the 

benefits of the program. 

SUICIDE PREDICTION DEFINED

What does it mean to predict suicide? Prediction 

requires an individual to “foretell on the basis of 

observation, experience, or scientific reason.”3

 Thus, 

suicide prediction implies an ability to anticipate future behavior. Obviously, truly knowing the future is 

not possible, but case law suggests that defendants in 

legal cases should have intervened when results were 

“reasonably foreseeable.”4 Certainly, clinical providers 

are tasked with predicting “reasonably foreseeable” 

suicide behaviors. Patients often present to providers 

with questions about their own safety. In addition, US 

Army commanders frequently consult psychologists 

for assistance in determining whether suicide is a “reasonably foreseeable” outcome for one of their soldiers. 

Providers are not only asked to assess if a patient will 

attempt or complete suicide, but when. A patient with 

a high risk of an imminent suicidal behavior requires a 

different intervention than an individual with chronic 

risk factors but no imminent risk of self-harm. 

A key question, therefore, relates to the definition of 

“reasonably foreseeable.” What research is available to 

help clinicians predict suicidal behaviors? How well 

can trained mental health experts currently foresee 

suicidal behaviors? The next section reviews some of 

the current research on suicide prediction in an attempt 

to inform future research priorities.

Research on the predictability of suicidAL behaviors

Can providers currently predict suicidal behavior? 

Extensive research has been conducted to identify 

factors that might help in suicide prediction. Many 

variables have been studied, including demographic 

factors, specific risk factors, periods of elevated risk, 

psychopathology, psychiatric comorbidity, medical 

disorders, substance use, personality disorders, and 

personality traits. This body of work has produced 

some helpful information. For example, individuals 

who complete suicide are more likely to be white male 

adolescents or older adults.5–7 Chronic or recurrent depression,8

 especially with comorbid alcoholism,9 also 

increases the risk of suicide. In addition, hopelessness, 

relationship problems, living alone, chronic medical 

problems, and a family history of suicidal behaviors 

appear related to suicide completion.10,11 Most individuals who complete suicide were seen in primary 

care within a month of their death,12 but were less likely 

to be under the care of a behavioral health provider.13

Individuals who complete suicide use methods more 

likely to be fatal, and therefore often die on their first 

attempt.14 At the same time, there is strong evidence 

that a prior suicidal behavior increases the risk of a 

future suicide attempt15 or completion.16

A variety of other risk and protective factors have 

varying degrees of support.10,11 Unfortunately, many of 

these are based on a single study, or on contradictory 

evidence.17 Although a significant body of research 

exists on the topic of suicide, few well-designed studies are available to answer some of the most basic 
395

Army Suicide Surveillance: A Prerequisite to Suicide Prevention

questions in the field. Suicide research is extremely 

complex because of the low base rate of completions; 

ethical problems associated with studying high-risk 

individuals; biases in retrospective data; the cost of 

conducting well-designed studies; and differences in 

suicide rates by gender, age, and ethnicity.

The literature supporting the risk factors reviewed 

above suggests that even when all the known risk factors are considered together, they may only account 

for a small proportion of the variance in suicidal behaviors. That is, the known risk factors do not provide 

clinicians with sufficient information to predict suicide. 

This assertion is strongly supported by studies that 

have attempted to predict future suicides using many 

of the known risk factors described above. In one study 

at a psychiatric hospital, 1,906 inpatients with affective 

disorders were linked to their manner of death during 

a 2- to 14-year follow-up period. Using suicide risk factors judged to have the most robust evidence, researchers attempted to predict which patients would later 

complete suicide. In the follow-up period, 46 patients 

completed suicide. None were correctly predicted by 

the researchers. 

In a similar study, 4,800 psychiatric inpatients were 

prospectively followed for 4 to 6 years.18 Using a variety of risk factors, the researchers explored several approaches to predicting future suicides. Like the study 

described above, they characterized their own results 

as wholly “unsuccessful,” even when alternative statistical approaches were employed in later studies.19

Other studies20,21 have reported similar results. 

Unfortunately, failure to prospectively identify appropriate numbers of suicide completions is only one 

of the problems related to suicide prediction. A second 

problem relates to the high false-positive rate of current suicide prediction models. That is, the probability 

that a person will complete suicide when known risk 

factors are positive is low.17 The implications of this 

problem are magnified exponentially by the fact that 

suicide is a very rare behavior. This problem is not 

simply a matter of statistical trivia, but has significant 

implications for the use of provider time and costs of 

treatment. 

To illustrate the point, the following is an adaptation of an example provided by Gaynes et al.22 Assume 

that a provider could predict suicidal behaviors with 

80% sensitivity and 70% specificity (rates similar to 

depression screening). A provider who saw 10,000 

patients over a number of years, 10 of whom truly 

attempt suicide, would correctly predict 8 suicide attempts while committing 2,997 false-positive errors. 

Thus, even if clinicians could predict suicide with this 

level of sensitivity and specificity, they would still miss 

20% of the suicides, and the low base rate of suicide 

behaviors would result in significant costs related to 

false-positive errors. 

In summary, behavioral health providers do not 

currently have the information they need to predict 

suicidal behaviors with any significant degree of accuracy. This conclusion is shared by many in the field. 

At the end of one of the prediction studies reviewed 

above, Pokorny stated, “Identification of particular 

persons who will (complete) suicide is not currently 

feasible.”18(p249) After reviewing the literature on suicide 

prediction, Paris stated that “it is not possible to predict suicide with any degree of accuracy.”23(p235) Bryan 

and Rudd stated that there is an “inability to predict 

suicidal behavior reliably.”24(p186)

Although many of the studies reviewed above 

were based on actuarial prediction models, conclusions about the accuracy of clinical judgment do not 

differ from those summarized for statistical prediction models. Gaynes et al stated, “Despite the public 

health import of suicide and the Surgeon General’s 

call to action, evidence to guide the primary care clinician’s assessment and management of suicide risk is 

extremely limited.”22(p831) Goldstein et al made the sobering statement that beyond identifying individuals 

with multiple risk factors, “it appears unrealistic for the 

general public or the legal system to expect that health 

professionals be able to predict suicide in specific patients based on our present knowledge.”25(p422) Many 

clinicians and researchers prefer to define the clinician’s role in terms of a “risk assessment process,”24

suggesting a general recognition that providers are 

not capable of predicting suicide. 

IMPORTANCE OF SUICIDE PREDICTION

Is suicide prediction important? Because current 

research to support suicide prediction is immature, and 

well-designed suicide research is extremely difficult 

and costly to conduct, it may be worth considering 

whether prediction is actually an important goal. Unfortunately, an analysis of the question results in the 

inescapable conclusion that without a reasonable ability to predict suicide, prevention efforts are extremely 

ineffective and costly.

Prediction is in many ways a prerequisite of prevention. In order to prevent a condition, prevention 

programs must generally be able to predict, with 

some degree of accuracy, who will benefit from a 

preventive effort. Without any predictive information, preventive actions can still be conducted, but 

high-risk individuals cannot be targeted, the effective 

components cannot be evaluated, and the costs are 

significant. Options for population-targeted preven-
396

Combat and Operational Behavioral Health

tion programs include conducting preventive activities with no one, with random individuals (or those 

with the most financial resources), or with groups 

who are believed to be at greater risk. These options 

are usually unacceptable. Clearly, when there is 

reason to believe that effective preventive efforts are 

available, failure to conduct any such activities is far 

from ideal. Performing preventive efforts among only 

those with sufficient economic resources devalues 

human life. However, applying preventive efforts 

to an entire population requires significant financial 

resources and exposes everyone in the group to any 

risks that are associated with the prevention efforts. 

Predictive information is essential for helping clinicians and patients balance the costs and benefits of 

specific preventive efforts. 

An example from the field of dementia illustrates 

the latter point. Results from a number of studies 

suggest that high-dose treatment with the antioxidant 

vitamin E may slow disease progression and reduce 

the incidence of dementia.26–29 Recently, however, 

new safety concerns related to high-dose vitamin E 

treatments have emerged.30,31 Although prophylactic 

vitamin E supplementation may not be indicated for 

all older adults, some patients with known risk factors 

for Alzheimer’s disease (eg, genetic vulnerabilities) 

may determine, after weighing the risks and potential 

benefits with their provider, that the risk–benefit ratio 

supports their use of vitamin E treatment. Advances in 

predicting dementia inform decisions related to preventive practices that may be associated with risks.

Similarly, suicide prevention efforts are not without 

risk. Although biological risks of suicide prevention 

may not apply, specific interventions to prevent suicide 

in a high-risk individual may violate confidentiality, 

harm the therapeutic relationship, increase stigma 

associated with treatment, decrease the probability 

of forthright conversations about suicidal ideation in 

the future, and increase the probability of treatment 

drop-out. In addition, population-based prevention 

efforts targeted at those for whom they are not appropriate may, at a minimum, reduce the effectiveness of 

the program, because messages can be “washed out” 

for everyone receiving nonspecific prevention efforts 

and training. 

Based on the low base rate of suicide behaviors 

and the current accuracy of suicide prediction, wellintentioned interventions are surely targeting many for 

whom the intervention is not needed. It may be argued 

that as long as the negative impact on nonsuicidal individuals is low and the intervention is palatable to the 

community, the effort is justified. However, when individuals are targeted for intervention efforts, clinicians 

are committing numerous false-positive errors. Many 

individuals who are not “truly suicidal” may be targeted with intrusive interventions and suffer adverse 

effects because of the inability to predict suicide.

This discussion is not arguing that efforts aimed at 

prevention should be ended; rather, it is emphasizing the importance of efforts to improve the ability 

to predict suicide behaviors. In fact, efforts aimed at 

prediction can contribute significantly to prevention efforts, because progress in prediction often illuminates 

keys for prevention programs. The following is another 

example from the literature on Alzheimer’s disease. 

Genetic research has now shown that mutations in 

three genes cause many of the early onset (before age 

65) Alzheimer’s disease cases and that these genetic 

mutations result in a build-up of a toxic protein fragment called amyloid beta, which may eventually lead 

to the death of nerve cells. This information has been 

helpful, not only for genetic counseling and predicting which family members will develop the disease, 

but also for defining new treatment approaches. The 

genetic data has informed exciting new approaches 

to treatment and prevention that attempt to “normalize” amyloid beta levels. Significant discoveries about 

suicide prediction would likely suggest information 

about the etiology of suicide that could potentially be 

leveraged by prevention programs. Although the road 

from prediction to prevention may be less direct for 

suicide, findings of significant predictive value would, 

at a minimum, suggest a narrower population in which 

to focus prevention efforts.

Epidemiological Surveillance Studies

Although research has demonstrated that clinicians 

are currently unable to predict which individuals will 

complete suicide with any degree of accuracy, suicide 

reduction is an extremely important health goal, and 

suicide prediction is in many ways a prerequisite to 

suicide prevention. This section reviews the use of 

epidemiological surveillance studies as an important 

tool for improving suicide prediction.

Suicide is not alone in the prediction challenges it 

presents due to its low incidence. A key challenge in 

many areas of medical and psychiatric research is the 

rarity of the disease or condition of interest. Improving the medical community’s ability to predict these 

rare events requires research methods that are effective for studying low base-rate behaviors or diseases. 

Epidemiological surveillance studies offer just such a 

methodology. 

Epidemiological methodologies are not composed 

of a single research design or statistical analysis. Rather, they comprise the body of methods that examine 
397

Army Suicide Surveillance: A Prerequisite to Suicide Prevention

the occurrence of health-related conditions or events in 

defined populations.32 Included among these are randomized controlled trials (RCTs), cohort studies, and 

case-control designs. In RCTs, subjects are randomly 

assigned to one of several exposures and prospectively 

followed to determine the effect on outcomes. Cohort 

studies are observational, in the sense that the researcher does not control which subjects are exposed to 

specific variables. A group of participants (a “cohort”) 

is instead identified and then classified based on its 

natural exposure to the variables of interest, and followed over time to measure outcomes. This approach 

allows for the study of some topics that cannot be studied through RCTs, but cohort studies are inefficient for 

rare outcomes because a huge sample size is required 

to identify a sufficient number of infrequent positive 

outcomes on which to base conclusions. In contrast, 

a case-control study identifies individuals who are 

positive for a specific outcome and compares them to 

controls who are negative for the outcome. 

Models for Suicide Research

Consideration of these basic methodologies indicates that RCTs obviously cannot be conducted to 

determine the effect of numerous exposure variables 

(eg, child abuse, combat exposure) on suicide. Large 

cohort studies have clear advantages, but they are 

extremely costly and inefficient for rare events with 

delayed outcomes such as suicide. Case-control studies 

offer an efficient, ethical approach to improving suicide 

prediction. A case-control surveillance system can efficiently identify individuals with suicidal behaviors 

and compare them to control subjects. 

An Army Suicide Surveillance System 

Although a number of suicide surveillance studies 

have been conducted in the United States and Europe 

(eg, the National Center for Injury Prevention, the 

World Health Organization Regional Office for Europe 

[WHO-EURO] Multicentre Study on Parasuicide), 

their results may not generalize to the US Army population. Soldiers represent a demographically distinct 

population that faces unique work-related stressors. 

The Army cohort is a younger, more ethnically diverse, 

and disproportionately male group compared to the 

broader US population.33 Many soldiers are exposed 

to unique experiences and stressors, and as the Army 

mission changes over time, these work-related stressors can shift. Therefore, civilian suicide surveillance 

efforts may be of limited relevance. 

An Army surveillance program offers a number 

of specific advantages. First, such efforts allow the 

Army to track trends over time as the military mission changes. Second, unique Army risk factors, such 

as deployments, combat exposure, training assignments, repeated geographic relocation, and others can 

be studied. Third, recommendations for refining the 

Army’s suicide prevention efforts can be generated. 

Finally, a suicide surveillance program may provide 

opportunities to evaluate the effectiveness of suicide 

prevention programs and policies.

Additional research on suicide in both the military 

and civilian sectors is clearly needed. Epidemiological 

surveillance studies represent one of the more efficient 

approaches to improving suicide prediction. The Army 

has recently established a long-term suicide surveillance 

program to supplement its other risk-tracking efforts. 

The Suicide Risk Management and Surveillance Office

History of the Office

To effectively execute the suicide surveillance mission, the US Army established the Suicide Risk Management and Surveillance Office (SRMSO), a Medical 

Command office based at Fort Lewis, Washington. In 

2002 and 2003, questions for an epidemiological data 

collection tool called the Army Suicide Event Report 

(ASER) were fielded, and content was clarified and 

revised. The ASER evolved from a scannable, paperbased data capture and processing approach, to an 

electronic Microsoft Word form, to a Web form submitted on a secure site. On February 4, 2004, Army Suicide Event Reporting Implementation Guidance was 

signed by Major General Kenneth Farmer, Jr, Deputy 

Surgeon General. This was followed by a widely circulated memorandum signed by Major General Joseph 

Webb, Jr, Deputy Surgeon General, stating that “the 

behavioral health leadership at each medical treatment 

facility will complete the ASER in accordance with the 

Implementation Guidance.” The ASER requirement is 

also specifically addressed in the revised Army Regulation 600-63, Army Health Promotion.

34 

Army Suicide Event Report Data Collection Process

The ASER is a data collection form intended to 

standardize the data collected on all suicidal behaviors among Army soldiers. Submission of an ASER is 

required for all suicide-related behaviors that result 

in death, hospitalization, or evacuation from theater. 

To support this requirement, SRMSO has worked 

with each medical treatment facility (MTF) to identify 

both a command and an ASER point of contact (POC). 

The command POC is generally the MTF commander 
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Combat and Operational Behavioral Health

who is responsible for ensuring regional compliance 

with ASER requirements. The command POC also 

appoints a provider to serve as the ASER POC, who is 

responsible for either personally completing the MTF’s 

ASERs, or ensuring that a qualified provider completes 

the requirements. 

For suicide completions, the data collection process 

generally begins when SRMSO receives notification 

from the Armed Forces Medical Examiner’s Office at 

the Armed Forces Institute of Pathology that a soldier’s 

death has been confirmed as a suicide (Figure 24-1). 

Upon such notification, the ASER and command POC 

for the MTF are notified and requested to complete an 

ASER within 60 days. Alternatively, ASERs are commonly submitted after a suicide completion is identified locally; SRMSO then confirms this determination 

with the medical examiner’s office.

For suicidal behaviors resulting in hospitalization or 

evacuation, the data-collection process requires ASER 

POCs to submit monthly reports for each MTF. This 

reporting generally involves coordination with inpatient psychiatric personnel and outpatient behavioral 

health clinic personnel. Because no central system formally tracks nonfatal suicide behaviors, these reports 

are currently used to determine how many ASERs are 

required for each MTF. ASER POCs are notified when 

expected ASERs are past due (30 days). 

Army Suicide Event Report Questions

Development of the current ASER content evolved 

from a structured review of the past versions and data, 

and a systematic review of the literature. The results of 

the review were assessed for evidence-based predictors of suicide risk, and additional identified questions 

were combined into the update of the ASER. 

For theoretically meaningful presentation of relevant risk factors for suicide and suicidal behavior, risk 

variables were organized into four categories using a 

prototype successfully implemented in the violence 

Figure 24-1. Army Suicide Event Report data collection.

AFME: Armed Forces Medical Examiner’s Office

ASER: Army Suicide Event Report

HOSP: hospital

MTF: medical treatment facility

POC: point of contact

SRMSO: Suicide Risk Management and Surveillance Office

COMPLETED 

SUICIDE

NOT

COMPLETED 

SUICIDE

SUICIDE EVENT

SRMSO AFME LIST 

CONFIRMS

POC SUBMITS 

MTF HOSP 

NUMBERS

POC 

COMPLETES 

ASER

NOTICE OR REMINDERS 

TO POC TO COMPLETE 

ASER 

POC 

COMPLETES 

ASER

 

 

  






399

Army Suicide Surveillance: A Prerequisite to Suicide Prevention

risk assessment literature35: (1) dispositional or personal factors (eg, demographics); (2) historical or developmental factors (eg, family history, prior suicidal 

behaviors, life events); (3) contextual or situational 

factors (eg, access to firearms, place of residence); and 

(4) clinical or symptom factors (eg, posttraumatic stress 

disorder, other psychiatric disorders or symptoms). 

This categorical banding of risks is intended to help 

organize the complex and multifaceted factors that 

contribute to suicidal behaviors. These factors were 

combined with a comprehensive set of questions 

related to the event (eg, method, location, injuries) to 

form the current ASER. 

Required Source Information

Completion of an ASER requires a review of all 

relevant and available records. In addition, interviews 

may be needed in some cases, especially when suicidal 

behaviors resulted in hospitalization or evacuation. 

These data sources are described in Table 24-1. 

Suicide Risk Management and Surveillance Office 

Reports

SRMSO drafts regular reports of suicide findings 

and also responds to requests from senior leaders for 

specific analyses. SRMSO generates quarterly and annual reports that are provided to the behavioral health 

consultants to the Surgeon General, the Army Suicide 

Prevention Program (G-1), and all ASER POCs and 

command POCs. 

Future Directions

Current SRMSO efforts are focused on improving 

data quality and accessibility for senior leaders. First, 

SRMSO is pursuing approaches to populating the 

ASER database from existing Army and Department 

of Defense data sources. As described above, the 

ASER POC must collect all relevant documents and 

data, extract the information that applies to specific 

ASER questions, and enter the data manually without 

errors. Populating the ASER database from existing 

databases with data quality assurances eliminates 

many opportunities for error. Significant conclusions 

and recommendations are drawn from ASER data, and 

the importance of this data is growing. For example, 

the Office of The Surgeon General has funded a new 

Suicide Prevention Office that is charged, in part, with 

facilitating new Army-wide prevention efforts based 

on empirical evidence derived from ASER research, 

the only Army-wide source of information on most 

aspects of Army suicide. Improving the reliability of 

ASER data provides Army leadership and the Suicide 

Prevention Office an improved capacity to make sound 

conclusions and recommendations. 

Second, SRMSO is exploring options to improve the 

accessibility of ASER data for senior leaders. Currently 

ASER data are available in an Oracle database at the 

Fort Lewis, Washington, SRMSO office. Qualified requesters must submit a request for a report to SRMSO. 

A researcher at SRMSO must then query the database 

and analyze the results. SRMSO then checks and rechecks the results to assure that they are accurate and 

will answer the questions asked. Finally, the SRMSO 

research team must determine the most meaningful 

graphical representation, create the graphs, and return 

the results to the requestor. Although SRMSO has a 

solid track record of timeliness and efficiency, this process is less than ideal, especially given the importance 

of suicide and the short suspense that Department of 

Defense leaders often face. 

SRMSO is exploring options for a user-friendly data 

reporting tool that can be configured to rapidly extract 

information from data sets and provide reports using 

predetermined statistical analyses and intuitive visual 

output. The Web-based Injury Statistics Query and 

Reporting System on the Centers for Disease Control 

and Prevention Web site provides a good example of 

such a tool.6

 The user is prompted to select types of 

data and appropriate categorical grouping variables. 

The graphical interface is not only informative but also 

Table 24-1

Source Information Required to Complete an Army Suicide Event Report

Event Required Data Sources

Completed 

suicide

Review of medical and behavioral health 

records

Personnel and counseling records

Investigative agency records (eg, Criminal 

Investigation Division)

Records related to manner of death (casualty 

reports, toxicology, autopsy, suicide notes)

Interview of coworkers and supervisors as 

needed and appropriate

Interview of responsible investigative agency 

officer, as needed and appropriate

Interview of other involved professionals 

and family members when appropriate

Attempted 

suicide 

Interview of patient

Review of medical and behavioral health 

records

Interview of coworkers and supervisors as 

needed
400

Combat and Operational Behavioral Health

interactive, allowing the user to drill down to get more 

specific information within a given domain. ASER 

data reported via a similar output generator would be 

delivered as an intuitive, interactive graphical output, 

rapidly generated to support the mission of senior 

leadership and healthcare providers. 

A number of additional future directions are in the 

planning stages. One goal is to provide behavioral 

health clinicians access to relevant local ASERs to 

improve clinical care and safety planning. In addition, SRMSO is pursuing software functionality for 

command and ASER POCs to view regional ASER 

data over time. Efforts are also underway to improve 

the size and quality of control samples to compare to 

Army data. A large control sample drawn from the 

Army at large would be of significant value. Finally, 

SRMSO is focusing on developing a longitudinal data 

set. Even with a population as large as the Army, some 

topics cannot be studied because of the low base rate 

of suicide completions (eg, many questions related to 

suicides in Iraq). Longitudinal data over several years 

will allow for richer analysis.

Summary

This chapter reviewed the issues and expectations associated with the prediction of suicides. 

A generally pessimistic conclusion was drawn 

regarding the ability to predict suicides with the 

current level of knowledge. After reviewing methods that may improve prediction of suicide risk, 

the authors recommended a surveillance model. 

Finally, the surveillance process within the Army 

was reviewed in detail, outlining its process, challenges, and goals. 

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Army Suicide Surveillance: A Prerequisite to Suicide Prevention

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15. Leon AC, Keller MB, Warshaw MG, et al. Prospective study of fluoxetine treatment and suicidal behavior in affectively 

ill subjects. Am J Psychiatry. 1999;156(2):195–201.

16. Schneider B, Philipp M, Muller MJ. Psychopathological predictors of suicide in patients with major depression during 

a 5-year follow-up. Eur Psychiatry. 2001;16(5):283–288.

17. Oquendo MA, Currier D, Mann JJ. Prospective studies of suicidal behavior in major depressive and bipolar disorders: 

what is the evidence for predictive risk factors? Acta Psychiatr Scand. 2006;114(3):151–158.

18. Pokorny AD. Prediction of suicide in psychiatric patients. Report of a prospective study. Arch Gen Psychiatry. 

1983;40(3):249–257.

19. Pokorny AD. Suicide prediction revisited. Suicide Life Threat Behav. 1993;23(1):1–10.

20. Thomas CB, Greenstreet RL. Psychobiological characteristics in youth as predictors of five disease states: suicide, 

mental illness, hypertension, coronary heart disease and tumor. Johns Hopkins Med J. 1973;132(1):16–43.

21. Motto JA, Heilbron DC, Juster RP. Development of a clinical instrument to estimate suicide risk. Am J Psychiatry. 

1985;142(6):680–686.

22. Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2004;140(10):822–835.

23. Paris J. Predicting and preventing suicide: do we know enough to do either? Harv Rev Psychiatry. 2006;14(5):233–

240.

24. Bryan CJ, Rudd MD. Advances in the assessment of suicide risk. J Clin Psychol. 2006;62(2):185–200.

25. Goldstein RB, Black DW, Nasrallah A, Winokur G. The prediction of suicide. Sensitivity, specificity, and predictive 

value of a multivariate model applied to suicide among 1906 patients with affective disorders. Arch Gen Psychiatry. 

1991;48(5):418–422.

26. Sano M, Ernesto C, Thomas RG, et al. A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer’s disease. The Alzheimer’s Disease Cooperative Study. N Engl J Med. 1997;336(17):1216–1222. 

27. Masaki KH, Losonczy KG, Izmirlian G, et al. Association of vitamin E and C supplement use with cognitive function 

and dementia in elderly men. Neurology. 2000;54(6):1265–1272.

28. Morris MC, Beckett LA, Scherr PA, et al. Vitamin E and vitamin C supplement use and risk of incident Alzheimer 

disease. Alzheimer Dis Assoc Disord. 1998;12(3):121–126. 

29. Engelhart MJ, Geerlings MI, Ruitenberg A, et al. Dietary intake of antioxidants and risk of Alzheimer disease. JAMA. 

2002;287(24):3223–3229.

30. Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-analysis: high-dosage vitamin 

E supplementation may increase all-cause mortality. Ann Intern Med. 2005;142(1):37–46.

31. Lonn E, Bosch J, Yusuf S, et al. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: 

a randomized controlled trial. JAMA. 2005;293(11):1338–1347.

32. Last JM. A Dictionary of Epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.

33. Office of Army Demographics. Army Profile FY-05. Washington, DC: Department of the Army; 2005. 

34. US Department of the Army. Army Health Promotion. Washington, DC: DA; 2007. Army Regulation 600-63. 
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35. Steadman HJ, Silver E, Monahan J, et al. A classification tree approach to the development of actuarial violence risk 

assessment tools. Law Hum Behav. 2000;24(1):83–100.
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Suicide Prevention in the US Army: Lessons Learned and Future Directions

Chapter 25

SUICIDE PREVENTION IN THE US 

ARMY: LESSONS LEARNED AND 

FUTURE DIRECTIONS

ELSPETH CAMERON RITCHIE, MD, MPH*; WALTER MORALES, MSA†; MICHAEL RUSSELL, PhD‡; 

BRUCE CROW, PsyD§; WAYNE BOYD, MDiv¥; KELLY FORYS, PhD¶; and STEVEN BREWSTER, MD, MPH**

INTRODUCTION

HISTORY OF SUICIDE PREVENTION IN THE US ARMY

ARMY SUICIDE PREVENTION PROGRAM

Initiatives and Efforts to Minimize Suicidal Behavior

Recent Initiatives

OPERATION IRAQI FREEDOM THEATER SUICIDE ASSESSMENT

Discussion

Summary of Theater Suicide Assessment

PSYCHIATRIC EPIDEMIOLOGICAL CONSULTATIONS IN THE US ARMY

Description and Background

Initiation of an Epidemiological Consultation and Operational Support

Epidemiological Consultation Activities on the Ground and Data Sources

Methods in the Epidemiological Consultation

Results and Lessons Learned

SUMMARY

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

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

Avenue NE, 4th Floor, Washington, DC 20002

†

Sergeant Major, US Army (Retired); Program Manager, Army Suicide Prevention Program, Army G-1, Headquarters, Department of the Army, 300 

Army Pentagon, ATTN: Army G-1 (DAPE-HR), Washington, DC 20310-0300

‡ Lieutenant Colonel, Medical Service Corps, US Army;Army Medical Department Neuropsychology Consultant, Warrior Resiliency Program, Lincoln 

Center, Suite 300, 7800 Interstate 10 West, San Antonio, Texas 78230

§

Colonel, Medical Service Corps, US Army; Clinical Psychology Consultant to the Surgeon General, US Army, and Director, Warrior Resiliency Program, 

Southern Regional Medical Command, Brooke Army Medical Center, San Antonio, Texas 78234

¥

Colonel, Chaplain Corps, US Army; Staff Officer, Comprehensive Soldier Fitness, Headquarters, Department of the Army, Zachary Taylor Building 

(NC3), 2530 Crystal Drive, Room 512B, Arlington, Virginia 22202; formerly, Program Manager, Directorate of Health Promotion and Wellness, US 

Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland 

¶

Psychologist, Department of Outpatient Behavioral Health, Landstuhl Regional Medical Center, CMR 402, Box 1045, APO AE 09180; formerly, Psychologist, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland

**Colonel, Medical Corps, US Army; Commander, US Army Medical Activity–Bavaria, Vilseck, Germany, Unit 28038, APO AE 09112 formerly, Directorate 

of Epidemiology and Disease Surveillance, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland
404

Combat and Operational Behavioral Health

INTRODUCTION

The goal of all the military services is to provide the 

serving men and women the best available support to 

assist them in overcoming the stressors that military 

service entails. The services utilize training and 

education, counseling, intervention, and postvention 

measures to help them find alternative and appropriate ways of dealing with stress and minimize the risk 

of suicide. 

The spectrum of suicide behaviors (which ranges 

from gestures to serious attempts to completed suicides) and stress from the high operational tempo 

continue to have an effect on readiness and mission 

accomplishment. The Army Suicide Prevention Program’s mission is to preserve readiness for soldiers, 

families, and Department of the Army civilians by 

continuing to develop policies and procedures that 

are designed to minimize suicidal behavior. Unfortunately, the Army-wide suicide rate has been trending 

upward every year since 2004. The total Army suicide 

rate in 2009 was 21.7 per 100,000, an increase from the 

rate of 9.8 per 100,000 observed at the beginning of 

hostilities in 2001.1

This chapter first describes the history of suicide 

prevention in the Army, then delineates current initiatives and some recent results of the Epidemiological 

Consultation Teams, and provides a theater update. 

This chapter is focused mainly on the Army because 

the authors are all affiliated with that service. However, 

all the military services have robust suicide prevention 

programs and the suicide prevention managers meet 

regularly. For example, there is a regular Suicide Prevention and Risk Reduction Committee meeting, formerly 

hosted by Health Affairs and more recently by the Defense Center of Excellence. Likewise, there is an annual 

Suicide Prevention Conference, which in recent years 

has included the Department of Veterans Affairs.

HISTORY OF SUICIDE PREVENTION IN THE US ARMY

Psychological characteristics and ideas that can lead 

a soldier to engage in a heroic disregard of personal 

safety on the battlefield can also lead to self-destructive 

behaviors when not at war. In 1897, Emile Durkheim 

advanced the first theories of suicide in the military. 

He defined suicide as those cases of death that resulted 

either indirectly or directly from something that the 

victim had done, knowing that death would result 

from this action.2

 Of note were those individuals who 

were not sufficiently bound to social groups, alienated, 

and who were said to engage in egoistic suicide. At the 

opposite end of the psychological spectrum, Durkheim 

proposed the idea of altruistic suicide, said to be a result 

of excessive integration, in which individuals become 

so immersed into social groups that they lose sight of 

individuality and are willing to sacrifice themselves 

to the group’s interests, even at the cost of their own 

lives. Not surprisingly, the most common cases of 

altruistic suicide were said to occur among members 

of the military.3

The idea that at least some suicides were preventable evolved slowly throughout the 20th century. In 

the 1930s, Karl Menninger, a psychiatrist, wrote the 

influential book Man Against Himself,

4

 which extended 

Freud’s concept of the death instinct. In the 1950s, two 

psychologists, Norman L Farberow and Edwin S Schneidman, introduced several key concepts in suicide 

research and prevention. These concepts led to the 

opening of the Los Angeles Suicide Prevention Center, 

which provided a model for immediate consultation, 

guidance, and assistance to the suicidal person.5

This activity spurred the Los Angeles County 

coroner to first engage mental health professionals 

in determining cause of death via a “psychological 

autopsy,”6

 which is a methodology for determining 

not just how a person died, but why. It is a diligent 

process that requires gathering information from all 

available records as well as extensive interviews with 

those who knew the deceased.7 The US Army relied 

on psychological autopsies during the 1990s, but that 

process has now been replaced by the Army Suicide 

Event Report,8 which will be covered in more detail 

in this chapter. Currently, psychological autopsies are 

principally used to help determine the manner of death 

in equivocal cases, that is, when there is a question as 

to whether it was an accident, suicide, or homicide. 

The American Association of Suicidology (AAS), 

founded in 1968, was the first national organization 

aimed at understanding suicide and its prevention.9

Coincident with this national presence, publications 

dealing with the problem in the military began to appear, although no formal suicide prevention program 

was yet established.10

Army research psychologists and psychiatrists at 

the Walter Reed Army Institute of Research (WRAIR) 

in Washington, DC, became interested in the causes 

of suicide among Army personnel and began several 

influential reviews of suicide deaths.11 In 1988, Colonel Nicholas Rock published an influential 10-year 

review of suicide and suicide attempts in the Army.12

A number of articles by Dr Joseph Rothberg and others followed.13–20
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Suicide Prevention in the US Army: Lessons Learned and Future Directions

The 1980s were a time of increased interest and 

dramatic progress in military suicide prevention efforts. On November 1, 1985, the Department of the 

Army (DA) published DA Pamphlet (PAM) 600–70, 

Guide to the Prevention of Suicide and Self-Destructive 

Behavior,

21 which discussed many of the myths of 

suicide and suggested a strategy to prevent selfdestructive behavior. This was followed on September 30, 1988, by DA PAM 600–24, Suicide Prevention 

and Psychological Autopsy,

22 which detailed many of 

the principles of suicide prevention first suggested 

by Farberow and Schneidman, and later the AAS. 

This pamphlet set forth policy and procedures for 

establishing the Army Suicide Prevention Program 

(ASPP) and conducting psychological autopsies. It 

provided guidance for all suicide-prevention activities of the Army and it also provided the rationale, 

circumstances of use, and guidance for reporting 

psychological autopsies. 

In 1999, the Army contracted with the AAS to 

produce Suicide Prevention: A Resource Manual for 

the United States Army,

9

 which used principles of 

community mental health to establish prevention 

programming “intended to save lives and reduce the 

impact of self-harm behaviors using a three-tiered 

approach to achieve the best-coordinated prevention possible.”9(p3) In general, the first level—primary 

prevention—consisted of those command programs 

100

90

80

70

60

50

40

30

20

10

87

59

49 46

34

25

34 35

24

24 34 35 19 22 31 30 41 44

CY01 CY02 CY03 CY04 CY05 CY06 CY07 CY08 CY09

0 0 0 6 12 15 19 18 43

Confirmed

Pending

0

Figure 25-1. Active duty suicides in the US Army January 1, 2001, through June 15, 2009. Data includes active duty, Army 

Reserve, and Army National Guard. “Pending” data not available for 2001 through 2003.

CY: calendar year

Data source: US Army G-1, Human Resources Policy Directorate.

designed to anticipate critical junctures in a person’s 

career and make these less stressful. The next level—

secondary prevention—included those command 

programs of special support and crisis counseling 

needed when persons encounter times of crisis and 

may be helped by a caring professional. The final 

level—tertiary prevention—was designed to provide 

immediate care for a potentially life-threatening 

crisis, and required care by a mental health professional. These common suicide prevention strategies 

are still in use today. 

In December 1999, the chief of staff, US Army, 

directed a review of the ASPP. In 2000, the Army G-1 

(formerly the Army Deputy Chief of Staff for Personnel), in collaboration with the Office of The Surgeon 

General (OTSG) and the Office of Chief of Chaplains, 

completed a review and determined that the program 

was basically sound, but needed to emphasize leadership involvement and offer more advanced training. In 

2001, the Army implemented the Suicide Prevention 

Campaign Plan, which emphasizes preventive and 

intervention measures, directs commanders to take 

ownership of the program, and synchronizes and 

integrates resources at installation level. More recent 

efforts by the Army Suicide Prevention Task Force 

have built upon these actions. Despite these efforts, 

the rate of suicide in the Army has continued to rise 

(Figure 25-1).
406

Combat and Operational Behavioral Health

ARMY SUICIDE PREVENTION PROGRAM

Initiatives and Efforts to Minimize Suicidal 

Behavior 

Army G-1 

The Army G-1 is the Army’s proponent for the ASPP 

and collects demographic data on completed suicides. 

These data assist the Army G-1, commanders, program 

managers at the installation level, and “gatekeepers” 

Army-wide in the identification of trends and the 

development of new initiatives, tailored and targeted 

training, and policies to minimize suicidal behavior. 

The ASPP, as detailed in DA PAM 600-24,22 also established a Suicide Prevention Task Force at each installation. In 2006, the Army G-1 formed an “Integrated 

Product Team” to integrate and synchronize efforts 

at the Headquarters, Department of the Army level. 

The team met regularly to identify ongoing initiatives, 

gaps in resources, and trends. Of main concern was the 

implementation of tailored and targeted training for 

soldiers and leaders. 

Army programs have focused on training the 

gatekeepers—leaders, chaplains, behavioral health 

officers, and others. In the October 26, 2005, issue of 

the Journal of the American Medical Association, Mann 

and colleagues noted: 

Where the roles of gatekeepers are formalized and 

pathways to treatment are readily available, such as 

in the military, educating gatekeepers helps reduce 

suicidal behavior. Demonstration projects for other 

gatekeepers with intermediate outcome measures, 

such as referral rates and psychiatric treatment rates, 

should be conducted.23

To educate gatekeepers, the Army G-1 has contracted with outside organizations like Living Works 

Education and the QPR (Question, Persuade, Refer) 

Institute from Spokane, Washington, to provide suicide 

awareness training.

For several years, the mainstay of Army suicide 

intervention was the “Applied Suicide Intervention 

Skills Training” (ASIST) program,24 a commercial product of LivingWorks, Calgary, Alberta, Canada. In 2002, 

the Army funded service-wide ASIST workshops25

with accompanying computer interactive-training 

software. In 2005, the Army G-1 funded QPR workshops26 Army-wide to provide additional resources 

in suicide-prevention awareness training, prevention, 

intervention skills, and risk identification to installations throughout the Army. Organizations have the 

option to use the training resource that best meets their 

needs; many continue to use Living Works Education, 

which has certified over 700 “gatekeepers” in suicide 

prevention and intervention,25 as their primary training resource. In addition, QPR Institute has certified 

hundreds of trainers in suicide prevention.26

The G-1 also conducts many other training activities, to include:

	 •	 Ensuring suicide-prevention training is provided to all deployed soldiers as part of the 

deployment cycle support process.

	 •	 Revitalizing the Installation Suicide Prevention Committee/Task Force to adopt Army 

key strategies for suicide prevention and 

actively coordinate with efforts of major subordinate units.

	 •	 Developing and distributing suicide awareness cards that focus on buddy care, warning 

signs/risk factors, and resources (the card is 

a graphic training aid [GTA #12-001-01] that 

can be ordered through the installation and 

community Training Audiovisual Support 

Center). 

The Medical Command and The Surgeon General 

The OTSG and the US Army Medical Command 

(MEDCOM) support the ASPP by providing medical 

care, research and data analysis, and assessment of 

medical support systems. In 2007, OTSG established a 

dedicated Suicide Prevention Office within MEDCOM 

to ensure greater visibility of programs, obtain data, 

identify trends, and provide timely information to 

leaders. This office sought to standardize methods and 

procedures for future epidemiological consultation 

(EPICON) teams, improve behavioral health surveillance methods for postmortem review, and continue 

Department of Defense Suicide Event Reports (DoDSER) for suicide attempts and/or completions, which 

are reported to the installation suicide prevention 

program manager. However, currently its functions 

were subsumed under a new suicide surveillance cell 

managed by the former US Army Center for Health 

Promotion and Preventive Medicine (CHPPM), recently renamed Public Health Command (Provisional) 

or PHC(P). In the subsequent discussion, CHPPM will 

be used for past efforts and PHC(P) for current and 

future efforts. 

CHPPM also supported the ASPP by focusing on 

continuous research and the development of awareness and training resources. For example, during calendar year 2006, CHPPM’s main effort was to distribute 

2,000 suicide awareness training kits to chaplains. Topics in this training program include suicide awareness, 

warning signs of suicidal thinking and behavior, and 
407

Suicide Prevention in the US Army: Lessons Learned and Future Directions

intervention skills development. 

These suicide prevention activities are part of an 

ongoing effort, which includes suicide awareness 

briefings tailored for populations, tip cards, and 

warning signs and risk factors cards for distribution 

during training. CHPPM developed the acronym 

ACE — “Ask,” “Care,” and “Escort” — to serve as the 

intervention centerpiece idea to assist buddies who 

may be suicidal (Figure 25-2). “Ask” centers around 

the idea of asking the buddy about state of mind and 

whether the buddy is suicidal (ie, “Are you thinking 

about suicide?”). “Care” focuses on employing active 

listening skills and understanding the situations to 

provide the right mix of resources or help. “Escort” 

involves not leaving the buddy alone, but rather either 

escorting or finding someone to take this soldier to a 

professional for help.

Awareness is a key piece of the ASPP. CHPPM took 

the lead in promoting awareness by the development 

of posters for dissemination throughout the Regular 

Army, the Army National Guard (ARNG), and the US 

Army Reserves (USAR). In 2007, CHPPM finalized and 

initiated distribution of suicide awareness briefing 

content, via chaplains’ channels, to enhance soldiers’ 

skills in identifying personnel at risk, to assist interventions with the individual, and to provide guidance 

for referring or escorting the soldier to professional 

help. Chaplains and other facilitators can obtain all 

supporting materials (ie, tip cards, brochures, posters, 

briefings) through CHPPM’s suicide prevention Army 

Knowledge Online (AKO) Web site (https://www.

us.army.mil/suite/page/334798) and their Health Information Operations Web site (http://chppm-www.

apgea.army.mil/hio_public/orders.aspx).

MEDCOM’s Suicide Risk Management and Surveillance Office (SRMSO) managed the primary tool for 

surveillance of Army suicide, the DoDSER, which is a 

reporting and tracking mechanism for completed suicides and nonlethal events that result in hospitalization 

and/or evacuation. The original Army Suicide Event 

Report (ASER) was developed, with initial validation 

conducted by the US Army Medical Research Unit, 

Europe, as a means to track in near, real-time, suicides 

and suicidal behaviors of Army personnel within the 

US Army, Europe.27

Following the recommendation of the Mental 

Health Advisory Team (MHAT) I,28 MEDCOM issued 

a policy directing that the ASER be used throughout 

the Iraqi Theater of Operations. The SRMSO, located 

at Fort Lewis, Washington, had operational oversight 

of the ASER, and conducted routine data analyses and 

published reports of these findings. In 2008, all the 

services began using this report form, which became 

the DoDSER. The SRMSO also has responsibility for 

updating changes to the DoDSER. 

The SRMSO has directed that the DoDSER should 

be completed for all fatalities, hospitalizations, and 

evacuations where the injury or injurious intent is 

self-directed. It is not meant to replace the psychological autopsy, which is limited to fatalities in which the 

manner of death is equivocal, (eg, it is unclear whether 

it is an accident, suicide, or homicide). The DoDSER 

is available at: https://dodser.t2.health.mil/dodser/. 

(Chapter 24 in this volume discusses suicide surveillance programs.) CHPPM (now PHC [P])assumed 

operational control of the Army suicide surveillance 

program in 2009.

Chief of Chaplains

The Army Chaplaincy continues its “Strong Bonds” 

program (enriching and developing lasting relationships for both married and single personnel through 

the use of relationship-building seminars and workshops) Army-wide through the efforts of its 1,500 active 

duty chaplains and 1,200 reserve component chaplains. 

Suicide prevention awareness and intervention training continues to be its main effort in support of the 

ASPP. The Chaplaincy provides extensive counseling 

Ask your buddy

Care for your buddy

Escort your buddy

• Have the courage to ask

the question, but stay calm

• Ask the question directly,

e.g. Are you thinking of

killing yourself?

• Remove any means that

could be used for self-injury

• Calmly control the situation;

do not use force

• Actively listen to produce relief

• Never leave your buddy alone

• Escort to the chain of

command, a Chaplain,

a behavioral health

professional, or

a primary care provider

Figure 25-2. “ACE” card developed by US Army Center for 

Health Promotion and Preventive Medicine.
408

Combat and Operational Behavioral Health

to soldiers and family members, some of whom may 

need to see a mental health professional. The Office of 

the Chief of Chaplains has worked very closely with 

CHPPM to develop a standardized suicide prevention 

awareness briefing for all chaplains and leaders. This 

training support package was completed in 2007, 

and is now available to all Army chaplains. Furthermore, the ACE (Peer) Suicide Intervention Program 

for soldiers and junior leaders is now being taught at 

the Chaplain Annual Sustainment Training course. 

Approximately 200 chaplains received this training 

in 2008. 

Installation Management Command

Garrison commanders provide support to tenant 

units at the installation level. As such, they are charged 

with coordinating suicide prevention activities at the 

installation level. The Installation Management Command (IMCOM) has established the garrison director 

of human resources as responsible for ASPP execution 

at the installation levels. One of the initiatives is to 

eliminate confusion about the roles and responsibilities in support of the ASPP. Senior leaders throughout 

IMCOM support the program by engaging the leadership at the region and installation levels. An additional 

support to the Army’s ASPP is the establishment of 

community health promotion councils (CHPCs) on 

every Army installation. The Army, via Army Regulation (AR) 600-63, Army Health Promotion,

29 has directed 

each Army installation to create a CHPC. The CHPC 

will ensure a proactive, coordinated, and synchronized 

local program. It will be the responsibility of each 

CHPC to ensure that suicide prevention activities 

are carried out in accordance with guidance from the 

Army’s ASPP plan.

Army National Guard 

The ARNG coordinates extensively with the active 

Army for training and policy development, workshops, conferences, and marketing. The ARNG Suicide 

Prevention Program reflects the active Army’s program, with several differences due to the nature of the 

ARNG. The main differences and challenges involve 

data collection and availability of resources. 

Like the active Army, the ARNG program takes a 

holistic approach that addresses suicide prevention, 

intervention, and postvention. Leaders and program 

managers initiate proactive measures to prevent suicide within their states by enhancing life skills in areas 

such as alcohol and drug abuse prevention, stress and 

anger management, communication, and conflict resolution training. In addition, personnel receive training 

in suicide risk identification and learn procedures for 

crisis intervention and referral. And finally, considering the devastating impact a suicide has on those who 

knew the deceased, the ARNG suicide prevention 

program includes postvention, which is also known 

as “prevention for the next generation.”

In April 2007, the ARNG directed that all states appoint a suicide prevention program manager (SPPM) 

at each Joint Forces Headquarters. Having a program 

manager at the state level will allow a greater degree 

of suicide surveillance for states, as well as more 

accurate national oversight. The SPPM administers 

a statewide ARNG Suicide Prevention Program for 

both military and civilian leaders, managers, supervisors, soldiers, and family members. Administering 

a program of this magnitude requires coordination 

with commanders, surgeons, chaplains, personnel 

officers, mental health staff, health promotion staff, 

and public affairs personnel throughout the state, 

as well as local agencies and helping services, local 

law enforcement, civilian coroners, and hospitals. 

The SPPMs receive suicide intervention training and 

conduct suicide prevention, intervention, and postvention training and awareness activities throughout 

their respective states. 

The ARNG goal is to provide intervention skills 

training to at least one soldier per company-sized 

unit. All soldiers will receive annual suicide awareness 

training. To maximize valuable resources, the ARNG 

SPPM has compiled a directory of all ASIST-trained 

National Guardsmen to share with active Army and 

USAR. The services often collaborate to provide training to the different components. The state SPPM tracks 

and reports all attempted and completed suicides to its 

state’s Joint Forces Headquarters and to the National 

Guard Bureau SPPM. The state SPPM identifies trends 

and provides decision support when possible factors 

lead to an increase of suicides. 

The challenges inherent in collecting accurate 

data about the suspected suicide of a soldier serving 

in a traditional status (“M Day,” or one weekend a 

month) lie in the fact that the details of the suicide are 

contingent upon reports by family members, medical 

authorities, and local law enforcement investigations. 

Most ARNG soldiers who died by suicide had been 

in a traditional drilling status, rather than on active 

duty in a Title 10 status. Although AR 600-63, Army 

Health Promotion, requires a review to be conducted 

by a mental health officer for any active or reserve 

component soldier on active duty whose death meets 

specific criteria for suicide or suspected suicide,29(chap5, 

para5-8) there is no such requirement for ARNG soldiers 

not on active duty.

In addition to tracking and reporting, the ARNG 
409

Suicide Prevention in the US Army: Lessons Learned and Future Directions

differs from the active Army in terms of resources 

available. Whereas active duty soldiers deploy from 

and return to a post where all resources for support 

are usually available without charge, easily identifiable, and in a designated geographic area, the ARNG 

deploys from and returns to communities across the 

state. Resources available to each ARNG member are 

dependent on what the local community provides, and 

therefore vary from member to member. Because the 

state SPPMs are from the local community, they will 

be familiar with these local resources. They will ensure 

soldiers and families are aware of these resources and 

are able to identify problems and refer personnel in 

crisis to an appropriate source of help. This information is included in annual suicide prevention briefings 

and published in Army suicide prevention policies 

and guidelines.

An increasing number of benefits have become 

available to all ARNG soldiers. The TRICARE Transitional Assistance Membership Program is available 

for 6 months to ARNG soldiers returning from deployment, with the option to buy in to the TRICARE program for a length of time determined by the amount of 

time the soldier was deployed. In addition, all soldiers, 

regardless of whether they were ever deployed, can 

take advantage of Military OneSource (available at 

www.MilitaryOneSource.com), which will contract 

with a local mental healthcare professional to provide 

six counseling sessions at no cost to the soldier. 

The ARNG SPPM has created two suicide-prevention Web sites for soldiers and families. One is public 

and can be found at http://www.virtualarmory.

com/WellBeing/suicide. The other site is restricted to 

members of the ARNG who have a Guard Knowledge 

Online (GKO) account and password and is located at 

https://gkoportal.ngb.army.mil/C15/C5/SuicidePreventionProgram.

Army Reserves

The USAR faces all of the challenges described by 

the ARNG. Furthermore, their regions are large, and 

soldiers are often “cross-leveled” from one area of the 

country into another. Thus gathering accurate data is 

an enormous challenge. Recent initiatives in the USAR 

have included: (a) implementing suicide-awareness 

training into family programs, (b) appointing ASPP 

managers at major subordinate commands, (c) forming 

community health promotion councils, (d) developing policy guidance for referral of soldiers to mental 

health, and (e) directing chaplains to develop reporting 

requirements for suicide prevention training. 

Recent Initiatives

The Army Campaign Plan for Health Promotion, 

Risk Reduction, and Suicide Prevention 

The vice chief of staff for the Army established the 

Army Suicide Prevention Task Force (ASPTF) in March 

2009 in response to the Army’s increasing suicide rate. 

The ASPTF’s effort has resulted in approximately 250 

tasks throughout the Army that are currently being 

executed. The resultant effort of the ASPTF has been 

published as the “Army Campaign Plan for Health 

Promotion, Risk Reduction, and Suicide Prevention,” 

which is directly monitored by the vice chief of staff for 

the Army; the tasks identified will substantially change 

the way the Army provides care to its extended family. 

This campaign plan reaffirms the Army’s commitment 

to care for its greatest strategic assets—soldiers, families, and civilians. 

Behavioral and Social Health Outcomes Program

The Army has established an epidemiological surveillance program that will utilize the public health 

process approach to developing a behavioral health 

and social outcomes capability. The mission of the 

PHC(P) Behavioral and Social Health Outcomes Program is to protect combat readiness and soldier health 

by addressing psychological and social threats through 

surveillance and in-depth analysis of behavioral health 

and disease outcomes; tracking rates and changes in 

trends in deployed and nondeployed populations; 

and projecting BH epidemiology. In addition, working 

with the Army G-1, a specialized suicide analysis cell 

was funded to conduct suicide-specific analysis and 

surveillance in support of the ASPP.

In 2008, the Army contracted with the National 

Institute of Mental Health to assist the Army in a 

comprehensive research effort that will lead to better prevention strategies and fewer suicides. This 

memorandum of agreement spans over 5 years and 

represents an Army investment of $50 million. The 

Behavioral and Social Health Outcomes Program and 

National Institute of Mental Health are collaborating 

to provide and analyze these data. 

OPERATION IRAQI FREEDOM THEATER SUICIDE ASSESSMENT

The previous MHATs have reviewed the status of 

the Operation Iraqi Freedom (OIF) theater’s suicide 

prevention and surveillance program, including an 

analysis of completed suicides (see Exhibit 25-1 for 
410

Combat and Operational Behavioral Health

a discussion of the first MHAT). The MHAT V conducted a similar review of Multi-National Force-Iraq’s 

prevention and surveillance program and a detailed 

analysis of completed suicides.

A team was requested by the Multi-National 

Corps-Iraq (MNC-I) commander to do a theater 

assessment in the fall of 2007. The team worked in 

parallel with MHAT V and with information from 

the Criminal Investigations Division (CID) and a 

review by SRMSO. A detailed “Summary of Theater 

Suicides” for 2007 was presented by the forensic investigator, MNC-I CID, on October 2, 2007.30 A similar 

review, limited to Army personnel, was performed by 

the SRMSO at Fort Lewis, Washington, 2 weeks later, 

with a focus on soldiers in Iraq and Iraq suicides. 

The results of all studies are similar, and thus will be 

examined together. 

As has been consistently true for reviews going 

back as far as 20 years,12 military suicide is most often 

precipitated by the loss of a relationship—either a 

spouse or other intimate partner. The SRMSO study 

reflected that 68% of Iraq suicides had had an intimate 

relationship failure, compared to 56% of the suicides 

in the non-Iraq population. This highlights the importance of the “Dear John” letter or e-mail, or other 

messages communicating the end of a relationship, as 

an implicated factor in the deployed setting.

A second major cause implicated in suicide is loss of 

career, usually through the Uniform Code of Military 

Justice (UCMJ) or other criminal charges. Approximately 35% of Army suicide cases in the Iraqi theater 

of operations had recent UCMJ charges—higher than 

the suicides in the continental United States. The CID 

review for all services found a 24% incidence of UCMJ 

charges.30 These two factors alone—loss of relationship 

and loss of career—appear to account for the majority 

of the suicides seen in the Iraqi theater of operations.

The Iraq CID review suggests that 60% of the 2007 

suicides showed behavioral changes or signs of depression prior to their suicides. The SRSMO review of DoDSER data also suggests that a substantial percentage 

of Army personnel who commit suicide sought help: 

50% of all suicides presented to a medical treatment 

facility (MTF) for care within 30 days of the event. 

This supports research literature, which suggests that 

although people considering suicide may not be able 

to accurately identify their problems as emotional in 

nature, or marshal the right resources to help them, 

they manifest an awareness that something is wrong 

and may seek out primary care.31–35 This highlights the 

importance of suicide prevention and awareness in the 

primary care and pastoral settings. 

EXHIBIT 25-1

OPERATION IRAQI FREEDOM AND SUICIDE PREVENTION

In 2003, the Office of The Surgeon General (OTSG) deployed a Mental Health Advisory Team (MHAT) to Kuwait 

and Iraq to assess soldiers’ mental health issues. Every year since then, an MHAT team has visited the theater of 

operations and produced a comprehensive report. MHAT II and V included Afghanistan. The full reports are available on the www.armymedicine.mil Web site. Recommendations that are especially relevant to suicide prevention 

include: 

1. Establishing a behavioral health consultant position in theater that will synchronize and coordinate behavioral health resources needed across the area of operations.

2. Establishing a modified theater suicide prevention program based on both current installation-based strategies and lessons learned from epidemiological consultations and MHAT visits to the theater of operations. 

These strategies include:

 a. Designating proponents to manage the suicide prevention program. (The proponent for the Operation 

Iraqi Freedom theater of operations was appointed in June 2006.)

 b. Establishing a command climate that encourages help-seeking behavior.

 c. Maintaining vigilance by leaders and soldier-peers (buddy care).

 d.Conducting continuous training throughout the deployment cycle.

 e. Implementing the surveillance of completed suicides/suicide attempts using the Army Suicide Event 

Report . 

Nonetheless, military suicide continues to be a significant problem in Iraq. Theater rates of suicide have trended 

upward since 2004, and remain elevated compared to both the total Army rate and rates observed in the civilian 

population. 
411

Suicide Prevention in the US Army: Lessons Learned and Future Directions

Discussion

The US Public Health Service considers suicide 

risk and prevention in terms of relative risk factors

and protective factors for suicide.36,37 These factors have 

been adopted by the Centers for Disease Control and 

Prevention (CDC) and are used to frame the discussion of suicide in Iraq.

Risk Factors

Risk Factors most relevant to Army suicide in Iraq 

include:

1. Loss (relational, social, work, or financial). This 

has consistently been the key variable associated with suicide. It appears that long tour 

duration, in itself, does not increase rate of 

suicide, but rather serves as a secondary factor in provoking marital disruption and in 

kindling the loss of relationships.

2. Isolation, a feeling of being cut off from other 

people. The Soldier Survey assesses this directly by asking whether soldiers are “feeling 

distant or cut off from people.” Results note 

that 51.8% of all soldiers surveyed have experienced these feelings of isolation. Morale, 

Welfare and Recreation efforts to deliver mail 

and enhance Internet and phones, have probably helped, but this variable should continue 

to be monitored over time, and efforts to keep 

soldiers feeling engaged in what is going on 

“back home” should be encouraged.

3. Barriers to accessing behavioral health treatment. 

As the troop footprint in Iraq surged, the 

supply of behavioral healthcare providers in 

theater expanded less robustly in 2006 and 

2007.

4. Easy access to lethal methods. It has been proposed that the ready availability of weapons 

is a contributory factor for the elevated 

suicide rate in theater. Although firearms 

do increase the lethality of suicide attempts, 

epidemiological studies do not clearly support a finding that either gun ownership, 

in general, or living in a country that bans 

firearms result in a lower population suicide rate. Furthermore, the troops that have 

been deployed in Iraq since 2003 have had 

weapons readily available. Any rise in this 

rate cannot solely be attributed to weapons 

availability.

5. Unwillingness to seek help because of the stigma 

attached to mental healthcare. Stigma continues to be a major issue in the willingness of 

service members to seek care. Soldier and 

leader interviews indicate first-line supervisors are the primary barriers to seeking care. 

This is fueled by a perception that seeking 

behavioral healthcare is “shamming” or attempting to avoid duty. A need for further 

efforts to educate these first-line supervisors 

is indicated (Exhibit 25-2).

EXHIBIT 25-2

STIGMA ASSOCIATED WITH SEEKING 

BEHAVIORAL HEALTHCARE 

Four types of stigma are generally seen: (1) career, 

(2) leadership, (3) peer-to-peer, and (4) personal. 

Stigma was reported differently across rank groups; 

lower enlisted were more concerned about peer and 

self-perceptions, senior enlisted were most concerned about their careers and perceived leadership 

abilities.

Career

•	 On permanent record, affects future promotion and employment

	 •	 End career, lose retirement

	 •	 Lose security clearance

	 •	 “Boarded out” rather than rehabilitated

Leadership

	 •	 Some “old school,” senior NCOs, and early

promoted NCOs create/maintain stigma

	 •	 More stigma for senior enlisted, others think

they can’t lead, fear of affecting retirement

	 •	 Many squad/platoon leaders don’t support

	 •	 Treated differently; doubt “warrior” abilities;

ridicule those with a profile

Peer-to-Peer

	 •	 Peer stigma is the worst

	 •	 More stigma if never deployed

	 •	 Treated differently, ridiculed

	 •	 Gossiped about/perceived as faking

Personal

	 •	 Weak, isolated, embarrassed

	 •	 Profile makes them feel worthless

	 •	 Pride/denial

	 •	 Don’t want to be viewed as a “bad” soldier
412

Combat and Operational Behavioral Health

Protective Factors

Protective factors for suicide buffer individuals from 

suicidal thoughts and behavior. To date, protective 

factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding 

protective factors is, however, equally as important as 

researching risk factors. Protective factors that act to 

reduce suicide probability in Iraq include:

1. Lack of intoxicants. Alcohol is a known risk 

factor for both civilian and military suicides. 

The relative lack of availability of intoxicants 

in the theater of operations should therefore 

act to lower the rate of suicide. It has long 

been known that intoxicants make the act of 

suicide more likely through disinhibition effects. (The National Violent Death Reporting 

System examined toxicology tests of those 

who committed suicide in 13 states, and 

33.3% tested positive for alcohol; 16.4% for 

opiates; 9.4% for cocaine; 7.7% for marijuana; 

and 3.9% for amphetamines.38)

2. Effective clinical care for mental, physical, and 

substance abuse disorders. Certain units within 

the theater of operations deployed with a 

comprehensive plan for deployment cycle 

support, and a number of best practices for 

effective soldier support, which appear to 

have produced a significant decrease in aberrant behaviors, including suicide, after the 

program was implemented.39 These results 

suggest wider adoption of the deployment 

cycle support model for the brigade combat 

team.

3. Easy access to a variety of clinical interventions 

and support for help seeking. Recent redistribution of troops in the battle space calls for 

equally agile shifts in behavioral health support, which is a strong argument for locating 

the theater mental health consultant at the 

MNC-I level. This also calls for increased efforts to destigmatize the act of seeking mental 

healthcare services.

4. Family and community support. Efforts to 

strengthen family and unit bonds should 

be encouraged, and the definition needs to 

be broadened to include significant others 

regardless of marital status.

5. Skills in problem solving and conflict resolution. 

Relationship enrichment and training, at both 

the soldier and the family readiness group 

level, designed to improve communication 

will assist in reintegration and strengthening 

relationships. All available evidence supports 

stabilizing relationships as the single most 

effective suicide prevention intervention.

6. Cultural and religious beliefs that discourage 

suicide and support instincts for self-preservation.

There have long been observed differences 

in suicide rates across gender, as well as 

racial and cultural lines.40 This illustrates 

the powerful basis of cultural beliefs for acceptable and socially appropriate behavior. 

For example, certain cultural beliefs support 

the idea of suicide in response to dishonor. 

Similar idea threads permeate the military 

culture (ie, death before dishonor, respect for 

the Samurai as portrayed in the media, popularity of movies in which suicide or death is 

seen as a logical approach to failure.) This 

opens up the possibility of “suicide-proofing” 

the military culture with carefully crafted 

messages against soldier suicide (ie, “Don’t 

let the enemy win,” “Don’t let your buddies 

down,” “Make it home alive”).

Summary of Theater Suicide Assessment

The Multi-National Force-Iraq has an active suicide 

prevention committee, chaired by the chief of clinical 

operations for the command surgeon. This has recently 

been augmented by the MNC-I Suicide Prevention 

Board, which is chaired by the corps chief of staff. The 

current suicide training program is being completely 

reconfigured into a much more robust program, which, 

once established, will require further review to gauge 

effectiveness. 

The DoDSER is being widely used in the theater by 

behavioral healthcare providers, but only for suicides 

or suicidal gestures by Army personnel. Although 

numerous service-specific mental health tracking 

systems exist, a single, joint tracking system capable 

of monitoring suicides, mental health evacuations, and 

use of mental health/combat stress control services in 

a combat environment does not exist. 

PSYCHIATRIC EPIDEMIOLOGICAL CONSULTATIONS IN THE US ARMY

Description and Background 

Sending a behavioral health EPICON team to investigate an apparent suicide cluster is an emerging 

strategy in the US Army (Table 25-1). An epidemiological consultation is analogous to any other medical consultation in that the existence of a problem is verified 

through history and examination/investigation of the 
413

Suicide Prevention in the US Army: Lessons Learned and Future Directions

Table 25-1

Common behavioral health epidemiological consultation themes

Theme

Ft 

Leonard 

Wood 

2001 

(suicide)

Ft Bragg 

2002 

(homicide)

Ft Riley 

2005 

(suicide)

Ft Hood 

2006 

(suicide)

Ft 

Campbell 

2008 

(suicide)

Ft Carson 

2009 

(homicide)

Individual Risk Factors

Deployment: length, multiple, unpredictability    

Combat intensity 

Family separation, relationship stress, lack of 

support

    

Increased violence against persons including 

spouse/family

    

Increased use of alcohol and drugs, and related 

offenses

   

Previous gestures/attempts/BH contact      

Manipulating, malingering    

Legal and financial issues     

History of misconduct 

Systems Issues

Stigma: personal, leadership, career     

Poor service delivery for dependents   

Transition, reintegration (one size fits all)     

Problems with BH services, FAP, ASAP      

Lack of standardized screening, tracking, intervention, data collection

     

Leadership/management climate      

ASAP: Army Substance Abuse Program

BH: behavioral health

FAP: Family Advocacy Program

Data source: US Army Center for Health Promotion and Preventive Medicine.

problem, a differential list of potential causes may be 

established, and data analysis is used to generate recommendations for remedy and prevention. EPICONs 

are public health investigations of clusters, outbreaks, 

or epidemics of symptoms or illnesses. They are modeled after the CDC’s “EPIAID,” which is a service that 

CDC provides to state and local health departments. 

The concepts behind an EPICON are drawn from the 

public health literature and are adapted to behavioral 

health. The EPICON mission was originally established at the WRAIR in 1969 and transferred to CHPPM 

in 1994. In the Army, EPICONs were originally limited 

exclusively to infectious diseases and environmental 

exposures. However, this mechanism was expanded to 

include clusters of behavioral health problems after an 

outbreak of suicidal behaviors at Fort Leonard Wood, 

Missouri, in 2000. 

Every suicide case in the US Army receives a thorough investigation, with participation from multiple 

organizational entities on an installation, to collect data 

to determine if current factors or conditions exist that 

may be mitigated to prevent future suicides (Figure 

25-3 and Figure 25-4). It is occasionally necessary to 

replicate this process using the population-based approaches of an EPICON to look at communities and 

organizations in a similar manner. The authors and 

others have participated in the five EPICONS that 

have been performed since 2000: (1) Fort Leonard 
414

Combat and Operational Behavioral Health Percentage of Population

Number/Severity of Risk Factors

Very Low

Risk

Lower

Risk

Average Risk Higher

Risk

Very High

Risk

 Facts

Individual

• Criminality/Misconduct

• Alcohol/Drugs

• BH Issues (untreated/undertreated)

Unit

• Turnover

• Leadership (Stigma)

• Training/Skills

Environment

• Turbulence

• Family Stress/Deployment

• Community

• Stigma

Individual, Unit, and

Environment Factors

Population Interventions

Percentage of Population

Number/Severity of Risk Factors

Very Low

Risk

Lower

Risk

Average Risk Higher

Risk

Very High

Risk

Army Campaign Plan:

• Health Promotion, Risk Reduction, and

Suicide Prevention

• Increase Resiliency

• Decrease Alcohol/Drug Abuse

• Decrease Untreated/Undertreated BH

• Decrease Stigma to Seeking Care

• Decrease Relationship/Family Problems

• Decrease Legal/Finance Issues

Installation:

• Reintegration (Plus)

 Mobile Behavioral Health Teams

 Mental Toughness Training

Resiliency Training

 Military Family Life Consultants

Decompression Reintegration

Warrior Adventure

• Consistent Stigma Reduction themes

Figure 25-3. Causal factors. Multiple individual, unit, and community factors appear to have converged to shift the population risk to the right. This would put more soldiers in the “very high risk” category, making clustering more likely.

BH: behavioral health

Figure 25-4. Suicide factors to consider. Although it is important to identify and help individual soldiers, the biggest impact 

will come from programs that shift the overall population risk back to the left. Effective medical treatment can prevent individuals from increasing in risk or decrease their risk, but it cannot shift overall population risk very much.

BH: behavioral health

Wood, Missouri, in 2000, following the deaths of two 

recruits by suicide; (2) Fort Bragg, North Carolina, in 

2003 following two murders and two murder-suicides; 

(3) Fort Riley, Kansas in 2005, following six suicides 

in 14 months; (4) Fort Hood, Texas, which had 22 suicides between 2003 and 2005, and (5) Fort Campbell, 

Kentucky, with 14 soldier suicides between 2006 and 

2007. There was an EPICON at Fort Carson, Colorado, 

in 2008, which focused on homicides, but included 

other violent crimes and suicides. At the time of this 

writing, there is another EPICON to examine suicides 

and accidental deaths in the warrior transition units. 

An EPICON may become necessary when the 

requirements for epidemiological expertise or even 

simple personnel exceed the resources of a theater or 

regional medical command. EPICON teams hold the 

benefit of bringing in new resources capable of focusing solely on the issue at hand, free of the distractions 

and demands inherent to supporting a community or 

organization. Additionally, the higher level of tasking 
415

Suicide Prevention in the US Army: Lessons Learned and Future Directions

authority associated with EPICONs may open doors 

to data sources and collaboration that are difficult to 

achieve when such investigations are conducted with 

a local approach. It is important to note that EPICONs 

are not staff assistance visits or inspections, nor are they 

research endeavors. EPICONs provide a mechanism 

to investigate a disease cluster on an urgent/emergent 

basis. They can be conducted as a public health initiative without a research protocol. The perception that 

there is a problem (eg, increased numbers of suicide 

behaviors, homicides, etc) can lead to request for an 

EPICON.

Initiation of an Epidemiological Consultation and 

Operational Support

The request for an EPICON usually originates from 

local leadership (eg, hospital, brigade, or installation 

commander). Implementing an EPICON requires extensive coordination and approval, particularly from 

the local leadership of the installation that is involved, 

as well as OTSG, MEDCOM, and other stakeholders. 

Both AR 40-5, Preventive Medicine,

41 and DA PAM 40-

11, Preventive Medicine,

42 task the commander, PHC(P), 

with the responsibility to provide EPICON support 

worldwide. PHC(P) responds to such taskings from 

MEDCOM and OTSG through the Proponency Office for Behavioral Health and the Proponency Office 

for Preventive Medicine. PHC(P) is readily able to 

assemble a team of experts (often pulling resources 

from throughout the Army) to deploy on short notice. 

All tasking should come through OTSG/MEDCOM 

for purposes of validation, command visibility, and 

resourcing approval. The process of validation is one 

that should take place between the theater or regional 

medical command and MEDCOM/OTSG. 

It may be necessary to draw on resources from 

the Armed Forces Health Surveillance Center and 

PHC(P) to analyze data in this process. Command 

interest, political pressure, and media attention may 

all influence the validation of an EPICON. The PHC(P) 

operational support section is capable of facilitating 

country clearances, travel orders, funding citations, 

travel reservations, hotel accommodations, and even 

work environment requirements such as computer 

connections, meeting room reservations, and rental 

cars. In preparing for an EPICON, it is a great help 

to prearrange for a meeting room that can accommodate the entire EPICON team during evenings and on 

weekends. This working space should have computer 

connections and the ability to accommodate screen 

projection of computer documents. 

A team leader will be selected, usually a senior 

officer. EPICONs have had teams of varying sizes 

from 4 to 14 people, composed of individuals from 

OTSG, PHC(P), the regional medical centers, installation, and subject matter experts from throughout the 

Army. The challenge is balancing the need to include 

all of the stakeholders, but not overwhelm the local 

environment. Appropriate agency representatives 

may include behavioral health, chaplains, installation 

management activity, and the G-1. The local behavioral 

health leadership should be included as much as possible, as they will need to contribute to the analysis 

and implementation of recommendations. 

The following representatives should be considered 

as members of any behavioral health EPICON team:

	 •	 team leader: senior preventive medicine officer or behavioral health specialist;

	 •	 local senior behavioral health clinician (social

work, psychology, psychiatry);

	 •	 epidemiologist with appropriate database

development support;

	 •	 chaplain;

	 •	 Army Substance Abuse Program representative;

	 •	 safety officer representative with knowledge

of Army risk reduction data;

	 •	 health risk communication specialist;

	 •	 G-1 representative; and

	 •	 unique representation depending on the

target population (such as senior noncommissioned officers, unit behavioral health specialist, division surgeon, local civilian resources, 

and unit/installation public affairs officer).

Once a team has been established, it is essential to 

formulate a schedule from which all of the team members can work. This timeline will establish the necessary planning meetings, the dates of deployment, and 

deadlines for work to be done in preparation for the 

EPICON, as well as documentation requirements. 

All members must understand the importance of 

meeting the timelines established by the EPICON 

leader. Scheduling the time for the team to visit is 

always a challenge. Most assessments have taken 1 to 

2 weeks, and may require repeated visits. An inbrief 

and outbrief must be arranged with the local installation command, and often the hospital command. 

Other important agencies with whom to communicate 

include behavioral health, chaplains, CID, and Army 

Community Services, including Family Advocacy, 

Risk Reduction Program, and the Army Substance 

Abuse Program. Clinical records, including medical, 

behavioral health, family advocacy, and substance 

abuse, should be reviewed on the index cases. Much 

of this work can be done in advance of the actual 
416

Combat and Operational Behavioral Health

EPICON visit by the installation and local MTF in 

the interest of efficiency and to maximize use of time 

on the ground once the team arrives. It would be 

helpful for all established EPICON team members to 

review previous copies of installation-level EPICONs 

conducted in the past. Such EPICONs are available 

through the PHC(P) Directorate of Epidemiology and 

Disease Surveillance. 

The content of the inbrief to be presented to the 

installation and MTF commands should be completed 

in advance of the EPICON deployment. The inbrief 

should clearly reflect the team’s understanding of the 

command’s intent for the EPICON. This will often 

include an initial hypotheses held by those who are 

at the installation. (Note that initial hypotheses are 

often wrong, but it is critical to recognize both the 

concerns and the questions asked by leadership as a 

starting point.) The inbrief should include a description of the team composition, a schedule (to include 

the outbrief date), a plan of action, and realistic requirements for support. It is important to establish a 

senior unit or installation leader to serve as a point 

of contact in advance of the EPICON’s deployment. 

Discussions prior to the visit with the point of contact 

and relevant staff will help to reduce any misunderstandings or communication shortfalls in advance of 

the prebrief to senior leadership, which is most often 

a general officer.

Epidemiological Consultation Activities on the 

Ground and Data Sources 

As previous team members have performed this 

mission, they have learned many lessons, both in the 

science and practical application of this consultative 

service. Whenever possible, the EPICON team should 

arrive at its destination on the same day. It is important 

to have a team meeting immediately after arrival to 

review the overall plan, schedule, and ground rules. 

No overt activity or interviews should be conducted 

before the command has received its prebrief and has 

given the team permission to proceed. Engaging the 

command staff early and frequently throughout the 

EPICON process can be very beneficial.

Outbreaks of completed suicides are hard to study 

because they are very rare and present challenges for 

epidemiological analysis. As of 2008, the rate in the 

US Army was 20/100,000/year. This compares to the 

demographically matched population of 20/100,000/

year. Even more rare in the Army are homicides paired 

with suicides. However, similar psychological dynamics may lead to both suicides and suicide-homicides. 

These dynamics are usually in the context of broken 

intimate relationships, with accompanying fears of humiliation, rejection, and loss. In general the motives for 

suicide and methods of suicide are reflective of the historical Army findings. The top apparent motivations 

for suicide in soldiers were found to be relationship 

failures, followed by legal and occupational difficulties 

and financial problems. Severe mental illness leading 

to suicide is rare in the military population but may occur. Among soldiers, impulsivity and substance abuse 

are more often than not contributing factors. Chronic 

pain, medical disability, and individual perceptions of 

general health all merit further analysis as risk factors 

for suicide in the military. Deaths by firearm, hanging, 

and jumping are the most common methods. All of the 

findings above mirror historical trends and substantiate the importance of looking across the spectrum of 

medical and social data on an installation during an 

EPICON. 

The following data sources have proven helpful in 

evaluating individual suicides in the military:

	 •	 medical and behavioral health records,

	 •	 ASERs,

	 •	 CID files,

	 •	 AR 15-6 (commander’s inquiry reports),

	 •	 RCA reports,

	 •	 Post-Deployment Health Assessment/PostDeployment Health Re-Assessment records,

	 •	 deployment data (date arriving and departing, location, days in theater),

	 •	 enlistment medical waiver data,

	 •	 Army Substance Abuse Program records,

	 •	 Family Advocacy Program data,

	 •	 line-of-duty reports, and

	 •	 Armed Forces Institute of Pathology data.

The most useful individual suicide data sources 

have proven to be DoDSERS, RCA reports, and CID 

reports. It is important to get the installation commander’s support to gain access to all of these data 

sources. Although the above data are useful for looking at the index cases on an installation (see following 

section on epidemiological methods), it is also useful 

to evaluate population data from the community. 

Population-based data from an installation or theater 

can reveal important information on trends related to 

leadership, morale, operations tempo, mental health 

support, alcohol-related events, domestic violence, 

and so forth. All of these are important indicators of 

the behavioral health of a community and may offer 

insight in the generation of hypotheses or reveal associations in the course of epidemiological analysis 

that lead to recommendations. 

The following are useful sources of population data 

on Army installations:
417

Suicide Prevention in the US Army: Lessons Learned and Future Directions

	 •	 installation population size and demographics (denominator data),

	 •	 installation deployment cycle and impact on

population calculations,

	 •	 behavioral health utilization and workload,

	 •	 behavioral health staffing,

	 •	 Army risk reduction data,

	 •	 Military OneSource reports,

	 •	 Army Substance Abuse Program data, and

	 •	 installation-level Family Assistance Program

data.

Additionally, it may be helpful to conduct interviews and focus groups to explore concerns of the 

soldiers (junior enlisted and junior noncommissioned 

officers), military leadership, MTF staff, communitybased agencies and installation support staff, and 

military family members or familiy readiness groups. 

Such sessions, when conducted by experienced health 

risk communications specialists, can reveal important 

information on prevailing perceptions, stigma associations, knowledge status, and morale within subpopulations on an installation. When collected early, this 

information can help guide the course of the EPICON. 

It also can be useful in targeting intervention strategies 

at the community level. 

Likewise, surveys can be of great assistance when 

applied to an appropriate number of individuals. In 

most of the EPICONs that have been completed, staff 

from WRAIR or PHC(P) performed anonymous soldier 

surveys. The surveys ask about a wide range of issues, 

including access to care and command climate. The 

most recent survey administered by PHC(P) looked 

for associations with self-reported suicidal ideation. 

Surveys contribute to the inclusion of quantifiable 

data into the report. The hardest challenge in working 

with the command is finding time for their soldiers 

to take the surveys, especially in a high operations 

tempo environment. PHC(P) has the ability to generate electronic form surveys, which can greatly reduce 

data-entry workload and errors in analysis. 

During the EPICON visit, it is essential to establish 

a close working relationship with both the MTF and 

the installation PAOs. All information released publicly 

must go through these individuals. Similarly, after the 

EPICON document summary is drafted, it must go 

through the local PAOs for review prior to the submission to command or OTSG/MEDCOM. 

While working an EPICON, it is necessary to generate daily situation reports, which must be forwarded 

to PHC(P) Operations and up to OTSG. EPICONs are 

high visibility missions with tremendous sensitivity 

to the command. The team should document each 

day’s activities (interviews, meetings, surveys, presentations) to reference in writing the EPICON final 

document. 

Methods in the Epidemiological Consultation 

Suicide outbreaks are unique from other types 

of disease outbreaks because the perception of the 

outbreak itself may lead to further cases, especially 

in an adolescent population. This characteristic must 

be taken into consideration in EPICON activities. Behavioral health assessments may use concepts from 

infectious diseases epidemiology, such as “exposure” 

to index cases, “contagion,” and “isolation.” Epidemiologic methodology in an EPICON should be guided by 

the services of an experienced epidemiologist on the 

team. Although the outline presented below is not the 

focus of this chapter, it is important to briefly discuss 

epidemiologic methods for understanding behavioral 

health EPICONS. 

During an EPICON, basic epidemiological strategies should be followed, to include: 

	 •	 defining the questions or current hypotheses

(one of these may determine if there is an 

actual outbreak), 

	 •	 conducting hypothesis-generating interviews

to broaden knowledge of the subject and what 

should be evaluated more thoroughly, 

	 •	 establishing a case definition for this public

health study, 

	 •	 conducting an investigation using epidemiological methods, 

	 •	 completing initial analysis,

	 •	 providing initial findings and recommendations to leadership, and 

	 •	 completing final analysis and write-up.

In general, epidemiologic methods of study include: 

(a) case series (clinical, forensic, etc); (b) case-control 

studies (eg, suicide cases vs controls); (c) cross-sectional 

studies (eg, compare cases with rest of battalion); (d) 

soldier surveys (usually done by WRAIR or PHC(P)); 

and (e) focus-group interviews.

The basic questions are: 

	 •	 Is there a real outbreak of suicidal behavior?

	 •	 Is the rate significantly higher than expected

(eg, when compared to like installations or the 

overall Army)? 

	 •	 What factors contributed to the outbreak

and how can they be compared against one 

another?

	 •	 What recommendations can be made to address the problem? 
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Combat and Operational Behavioral Health

When defining inclusion criteria for cases, the team 

must determine an outbreak time frame, the individuals included, and their location. An index case definition must also describe who is not included as a case. 

An example from the Fort Campbell, Kentucky, index 

case definition is described below:

Index cases were defined as all confirmed and pending suicides occurring between January 1, 2006 and 

October 31, 2007 based on Army G-1 and Armed 

Forces Institute of Pathology (AFIP) data. There were 

a total of 14 index cases in this time period. Cases 

were restricted to active duty soldiers who were assigned to Fort Campbell, Kentucky, at time of death. 

Family member, civilian, and retiree suicides were 

not included in this analysis because of limitations to 

medical and legal data available on non–active-duty 

deaths. 

One useful tool inherent to any EPICON is an “epicurve.” Traditionally, a team shows the time course of 

an epidemic by drawing a graph of the number of cases 

by their date of onset. This graph, called an epidemic 

curve, or “epi-curve,” gives a simple visual display of 

the outbreak’s magnitude and time trend. 

Suicides and suicide rates on an installation are 

always sensitive issues. It is critical to keep the command informed of the status of the assessment. The 

command must be briefed on the results before any 

information is released outside of the command. It is 

important to clarify the level of detail (ie, full report 

or briefing slides) desired by the command.

Writing the report is a laborious and time-consuming process, especially if the team members have 

been gone for several weeks for the mission. Upon 

their return, other duties often interfere with report 

writing. Different sections of the report may be assigned to different people. It is helpful to develop 

and adhere to a time line, which is set by the senior 

officer. Another practical suggestion is that plane 

rides home should be dedicated to report writing; 

team members should ensure that computer batteries 

are charged. PHC(P) uses a standardized EPICON 

report format that may easily be transformed into a 

publishable document.

Media attention may or may not be present. There 

was intensive media attention on the Fort Bragg EPICON. The redacted report was eventually put on the 

Army medicine Web site (www.armymedicine.army.

mil). In other cases, media interest is less prominent. 

However, all team members should be reminded not 

to discuss their work with the media without appropriate clearances. 

Results and Lessons Learned

Each EPICON has led to recommendations based on 

internal assessments of the particular installation that 

was evaluated. Although each installation’s situation 

is unique, the overall recommendations will be summarized here, as the reports have had some parallel 

themes. However, it must be noted that these assessments have been performed on installations where 

there were apparent suicide clusters, and thus may not 

be indicative of Army installations as a whole. 

The common findings are: 

	 •	 there is a perceived shortage of behavioral

health assets, despite efforts of local commanders to hire more resources, 

	 •	 there is a stigma involved in seeking help,

	 •	 forward-deployed assets are more effective,

	 •	 marital therapy should be more available,

	 •	 more integration of resources is desirable,

	 •	 command is very interested in solving these

problems, and 

	 •	 the effort is essential to maintaining the

strength of the fighting force. 

Both the local and the overall command have been 

very interested in these results. In all cases commanders and the medical departments have taken the recommendations seriously. Some examples follow:

	 •	 The Fort Leonard Wood, Missouri, report led

to the expansion of the “Medical Moment 

of Truth” at the reception battalion, and to a 

reexamination of the “unit watch” protocol.

	 •	 The Fort Bragg, North Carolina, EPICON

spurred development of the Deployment 

Cycle Support program.

	 •	 The Fort Riley, Kansas, EPICON led to an

increase in marital therapy resources.

	 •	 The Fort Hood, Texas, EPICON reinvigorated

the installation-wide risk reduction committees.

	 •	 The Fort Campbell, Kentucky,EPICON recommended an improvement in the quality of the 

“risk reduction” data.

SUMMARY

Suicide prevention is a continuing challenge. The 

rate continues to increase, despite development and 

use of educational and training materials. The behavioral health epidemiological consultation process is 
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Suicide Prevention in the US Army: Lessons Learned and Future Directions

a useful method of assessing clusters of suicides and 

suicidal behaviors. The results help to guide both installation and Army-wide efforts to focus on gaps in 

outreach, education, and treatment.

There are caveats, however. It is notoriously difficult 

to measure the effectiveness of any suicide prevention 

program. Because the focus is often on completed suicides, it is not known how many have been prevented 

via proactive measures by the command and staff. 

Additionally, the suicide rates are not necessarily a 

good marker of the mental health of the force. There 

are other instruments available to assess effectiveness of suicide prevention programs and the quality 

of services delivered. These include, for example, the 

DoDSER, unit surveys, and gatekeeper training.

Suicide affects the psychological and physical health 

of soldiers, units, family members, and friends. The 

approach to prevention, intervention, and postvention 

must be an integrated, multifactorial endeavor involving all levels of the command and family resources. The 

information presented here illustrates the current initiatives, many of which were developed from lessons 

learned in the past. Building products and strategies 

based on those lessons should enhance the ability to 

save lives in the future. 

The rate of suicides has doubled in the Army in the 

last 6 years. Every suicide is a tremendous tragedy, for 

the soldier, for the family, and for the Army. Risk factors for suicide include a break-up in a relationship and 

trouble at work. Medical issues, especially chronic pain 

or disability, may precipitate a suicide attempt. Alcohol 

abuse can disinhibit someone in many ways and result 

in self-injury. In recent years, there has been a rise of 

suicides in senior noncommissioned officers, senior 

officers, female soldiers, and soldiers in the warrior 

transition units. Medical soldiers are not immune.

There are numerous educational resources for 

soldiers and families detailing suicide awareness and 

intervention for someone in trouble. To take care of 

fellow soldiers (“Ask, Care, and Escort”), ask about 

their issues, take care of them, and do not leave them 

alone. Get them to a chaplain, a medic, combat stress 

control, or their command. “Shoulder to shoulder: No 

Soldier stands alone.”

REFERENCES

1. Deputy Chief of Staff for Personnel, US Army. The Pentagon, Washington, DC.

2. Durkheim É. Suicide: A Study in Sociology, translated by Spaulding JA, Simpson G. 1897. Reprint, Glencoe, Ill: Free 

Press; 1951.

3. Thompson K. Emile Durkheim. London, UK: Tavistock Publications; 1982.

4. Menninger K. Man Against Himself. New York, NY: Harcourt, Brace; 1938.

5. Shneidman ES, Farberow NI. Clues to Suicide. New York, NY: McGraw-Hill; 1957.

6. Shneidman ES, Leenaars AA. Lives and Deaths: Selections From the Works of Edwin S. Shneidman. Philadelphia, Penn: 

Brunner/Mazel; 1999.

7. Russell S. What is a psychological autopsy? Author’s Den. 2004. Available at: http://www.authorsden.com/visit/

viewarticle.asp?AuthorID=8848&id=14997. Accessed January 28, 2010.

8. Ritchie EC, Gelles M. Psychological autopsies: the current Department of Defense effort to standardize training and 

quality assurance. J Forensic Sciences. 2002;47(6):1370–1372.

9. The American Association of Suicidology and the US Army Center for Health Promotion and Preventive Medicine. 

Suicide prevention: a resource manual for the United States Army. 1999. Available at: http://www.medtrng.com/

suicideprevention/suicide_prevention.htm. Accessed January 28, 2010.

10. Newby JH Jr, Van Der Heide CJ. A review of 139 suicidal gestures: discussion of some psychological implications and 

treatment techniques. Mil Med. 1968;133:629–637.

11. Gaines T Jr, Richmond LH. Assessing suicidal behavior in basic military trainees. Mil Med. 1980;145:263–266.

12. Rock NL. Suicide and suicide attempts in the Army: a 10-year review. Mil Med. 1988;153:67–69.
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13. Rothberg JM, Rock NL, Jones FD. Suicide in United States Army personnel, 1981–1982. Mil Med. 1984;149:537–541.

14. Ritchie EC, Keppler W, Rothberg J. Suicidal admissions in the United States military. Mil Med. 2003;168(3):177–181.

15. Rothberg JM, Jones FD. Suicide in the US Army: epidemiological and periodic aspects. Suicide Life Threat Behav. 

1987;17:119–132.

16. Rothberg JM, Ursano RJ, Holloway HC. Suicide in the United States military. Psychiatric Annals. 1987;17:545–548.

17. Rothberg JM, Rock NL, Shaw J, Jones FD. Suicide in United States Army personnel, 1983–1984. Mil Med. 1988;153:61–

64.

18. Rothberg JM, McDowell CP. Suicide in United States Air Force personnel, 1981–1985. Mil Med. 1988;153:645–648.

19. Rothberg JM, Bartone PT, Holloway HC, Marlowe DH. Life and death in the US Army: in corpore sano. JAMA. 

1990;264:2241–2244.

20. Rothberg JM, Fagan J, Shaw J. Suicide in United States Army personnel, 1985–1986. Mil Med. 1990;155:452–456

21. US Department of the Army. Guide to the Prevention of Suicide and Self–Destructive Behavior. Washington, DC: DA; 1985. 

DA PAM 600–70.

22. US Department of the Army. Suicide Prevention and Psychological Autopsy. Washington, DC: DA; 1988. DA PAM 600-

24.

23. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294:2064–2074. 

Available at: http://jama.ama-assn.org/cgi/content/full/294/16/2064. Accessed November 27, 2009.

24. Applied Suicide Intervention Skills Training (ASIST) Manual, 10th ed. Calgary, Alberta, Canada: Living Works; 2008. 

Available at: http://www.livingworks.net/LW_Str.php. Accessed November 27, 2009.

25. ASIST workshop: Calgary, Alberta, Canada: Living Works; 2002. Available at: http://www.livingworks.net/AS-T4T.php.

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26. Information on the QPR Workshop can be obtained from the QPR Institute, PO Box 2867, Spokane, Washington 99220. 

Available at: http://www.qprinstitute.com/. Accessed November 27, 2009.

27. Dolan CA, Schroeder ED, Wright KM, Thomas JT, Ness JW. USAREUR suicide surveillance project: data summary 

and program evaluation. Heidelberg, Germany: US Army Medical Research Unit–Europe; 2003. USAMRU-E Technical 

Report.

28. Mental Health Advisory Team (MHAT). Operation Iraqi Freedom (OIF). Report. The US Army Surgeon General and 

HQDA G-1. December 16, 2003. Available at: www.armymedicine.army.mil/reports/mhat.html. Accessed September 

4, 2008.

29. US Department of the Army. Army Health Promotion. Washington, DC: DA; 2007. Army Regulation 600–63.

30. MNC-I Criminal Investigations Division (CID). October 2, 2007. Personal communication. 

31. Nutting PA, Dickinson LM, Rubenstein LV, Keeley RD, Smith JL, Elliott CE. Improving detection of suicidal ideation 

among depressed patients in primary care. Ann Fam Med. 2005;3(6):529–536.

32. Meats P, Solomka B. A perspective on suicides in the ‘90s. Psychiatr Bull. 1995;19:666–669.

33. Vassilas C, Morgan HG. Suicide prevention: service contacts and coordination between primary and secondary care 

[letter]. Br J Psychiatry. 2001;179:271.

34. Vassilas CA, Morgan HG. General practitioners’ contact with victims of suicide. Br Med J. 1993;307:300–301.
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35. Appleby L, Shaw J, Amos T. National confidential inquiry into suicide and homicide by people with mental illness. 

Br J Psychiatr. 1997;170:101–102.

36. Centers for Disease Control and Prevention. Suicide: risk and protective factors. Atlanta, Ga: CDC; 1999. Available at: 

http://www.cdc.gov/ViolencePrevention/suicide/riskprotectivefactors.html. Accessed January 28, 2010. 

37. US Department of Health and Human Services. Office of The Surgeon General. The Surgeon General’s call to action to 

prevent suicide. Washington, DC: OTSG; 1999. Available at: http://www.surgeongeneral.gov/library/calltoaction/

default.htm. Accessed January 28, 2010.

38. Karch D, Crosby A, Simon T. Toxicology testing and results for suicide victims–13 states, 2004. MMWR. 2006;55:1245–

1248.

39. Christopher H Warner, Major, Medical Corps, US Army; Division Psychiatrist, Multi-National Division—Center, Iraq. 

Personal communication [face-to-face conversation as part of a site visit]; 2007.

40. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). 

Atlanta, Ga: CDC. Available at: http://www.cdc.gov/injury/wisqars/index.html. Accessed January 28, 2010.

41. US Department of the Army. Preventive Medicine. Washington, DC: Headquarters, DA; May 25, 2007 [rapid action 

revision]. Army Regulation 40-5.

42. US Department of the Army. Preventive Medicine. Washington, DC: Headquarters, DA; October 19, 2009 [rapid action 

revision]. Department of the Army Pamphlet 40-11.
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423

Suicide and Homicide Risk Management

Chapter 26

SUICIDE AND HOMICIDE RISK 

MANAGEMENT: RATIONALE AND 

SUGGESTIONS FOR THE USE OF UNIT 

WATCH IN GARRISON AND DEPLOYED 

SETTINGS

SAMUEL E. PAYNE, MD*; JEFFREY V. HILL, MD†; and DAVID E. JOHNSON, MD‡

INTRODUCTION

RATIONALE FOR UNIT WATCH

SUICIDE RISK ASSESSMENT

RECOMMENDATIONS FOR UNIT WATCH PROCEDURES

In Garrison

Deployed Settings

MEDICOLEGAL ISSUES

SUMMARY

*Colonel, Medical Corps, US Army; Chief, Outpatient Behavioral Health Services, Dwight D. Eisenhower Army Medical Center, Building 300, Room 

13A-15, 300 South Hospital Road Fort Gordon, Georgia 30905

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Child and Adolescent Psychiatry, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 

402 Box 1356, APO AE, 09180; formerly, Chief, Outpatient Psychiatry, Landstuhl Regional Medical Center

‡

Major, Medical Corps, US Army; Chief, Behavioral Health, US Army MEDDAC Bavaria, IMEU-SFT-DHR, ATTN: OMDC Schweinfurt, Unit 25850, 

APO AE 09033 

An earlier version of this chapter was originally published as: Payne SE, Hill JV, Johnson DE. The use of unit watch or command interest 

profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional. Mil Med. 

2008;173:25–35.
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Combat and Operational Behavioral Health

Unit watch procedures are routinely used in both 

garrison and operational settings as a tool to enhance 

the safety of unit personnel when a soldier presents 

with suicidal or homicidal thoughts. To date, no specific body of literature or US Army publication offers 

either a rationale or a set of guidelines for their use. 

This chapter provides both a rationale and a set of 

suggestions for the use of unit watch based on fundamental military psychiatric principles, review of the 

relevant literature, and anecdotal experience. Finally, 

the chapter includes a discussion of the medicolegal 

issues specific to the use of unit watch. 

RATIONALE FOR UNIT WATCH

The management of suicidal and homicidal patients 

in the military environment is somewhat different from 

the management of such patients in the civilian sector for several reasons. One reason is that the military 

community provides additional resources, such as the 

chain of command and fellow soldiers, to assist the 

military clinician in addressing suicide and homicide 

risk. Another important reason is the necessity of 

managing suicide and homicide risk in a deployed or 

geographically isolated setting. Finally, management 

of suicide and homicide risk in the military requires 

addressing the challenge of heightened access to firearms in many settings. Unit watch has evolved within 

these circumstances as a practical and effective means 

to enhance the safety of the soldier and others and has 

gained some legitimacy in the psychiatric community.1–3 Unit watches have been used in many environments from the battlefield to the garrison, primarily 

in cases involving a level of risk that is concerning but 

does not necessarily warrant hospitalization. 

Psychiatric hospitalization, although often necessary for patients at high risk for attempting suicide or 

homicide, is not always the best option for managing 

suicide or homicide risk in a military setting for several reasons.1

 Hospitalization necessitates removal of 

the soldier from the unit and in some cases (notably 

those involving low to moderate risk of suicide) may 

delay recovery, especially when the symptoms are precipitated by battle fatigue.4–6 Anecdotally, the authors 

have observed cases in which hospitalization seemed 

to exacerbate the symptoms by placing the soldier in 

the role of a psychiatric patient. Psychiatric hospitalization carries significant stigma in the military as in 

the general population and may permanently impede 

the soldier’s reintegration into the unit. Fellow soldiers 

often make comments about hospitalized soldiers 

being “psycho” or needing to be “locked in a rubber 

room.” Some soldiers lose their sense of self-worth and 

belonging when they are separated from their units 

and cannot maintain occupational functioning. 

The unit watch (also known as the “command interest profile”) is a term describing the use of the military 

system to limit the suicidal or homicidal soldier’s access to people, places, or objects that might increase 

that soldier’s chances of harming self or others. Based 

on recommendations from the clinician, a variety of 

interventions are carried out by the command team, 

which may include searching the soldier’s belongings 

and living quarters for dangerous items, removing 

such items from the soldier’s possession, prohibiting 

access to alcohol and drugs, minimizing contact with 

people who may negatively influence the soldier’s 

mental health, continuously observing the soldier, 

and ensuring that the soldier returns for mental health 

follow-up.

A unit watch is an excellent example of the military 

clinician working with the command team to address a 

soldier’s mental health needs in the least restrictive setting possible through application of the time-honored 

military psychiatric principles of “PIES” (proximity, 

immediacy, expectancy, and simplicity), or “BICEPS” 

(brevity, immediacy, centrality, expectancy, proximity, and simplicity).7,8 Many soldiers with suicidal or 

homicidal thoughts have been experiencing stressful 

life circumstances. Sometimes these circumstances are 

the direct result of the wartime environment and may 

represent battle fatigue. Suicidal or homicidal thoughts 

may occur in the absence of a diagnosable mental illness and may respond to simple interventions such 

as rest, expectation of recovery, command attention, 

and support from other members of the soldier’s unit. 

Utilization of the PIES doctrine has demonstrated that 

suicidal or homicidal soldiers often benefit from brief, 

immediate care and support near their units. The unit 

watch is one mechanism for enhancing safety while 

providing this care and support.

A unit watch can reduce the chances of misperception about the soldier’s condition because unit members see and interact with the soldier on a daily basis. 

Soldiers often report that just talking to other unit 

members proved helpful. Commanding officers and 

senior noncommissioned officers often provide invaluable support for soldiers on unit watch by listening to 

the soldier’s concerns, sometimes modifying their style 

of interaction with the soldier based on a heightened 

sensitivity to the soldier’s personal problems, and by 

providing social support and advice as they perform 

their roles in “watching” the soldier. 

INTRODUCTION
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Suicide and Homicide Risk Management

Though often useful, unit watch may not always 

be the best approach. The treating mental health 

professional uses clinical judgment to determine the 

best course of action. One factor to consider is that 

a unit watch carries some risk of stigmatization by 

peers. Fellow soldiers may become frustrated with 

the soldier because of increased workload and potentially increased hazards as they attempt to cover the 

soldier’s battlefield responsibilities or provide personnel to monitor the soldier. This frustration may be 

exacerbated if the soldiers experiencing suicidal and 

homicidal thoughts, who often have a limited ability 

to give and receive social support, have already marginalized themselves. Many soldiers on unit watch 

have described to healthcare professionals episodes 

of ridicule and verbal harassment by both peers and 

leaders in their units. Regardless of the setting, stigma 

associated with receiving mental healthcare can be 

significant.9

 Adequate education of the unit leaders, 

who then train unit members to envision a unit watch 

as analogous to “helping a family member in distress,” 

may help alleviate some of the stigma. 

Leadership, unit cohesion, and group identification 

play decisive roles in a soldier’s ability to cope with 

peacetime or wartime duties. A unit watch may focus 

the command team’s attention on issues or stressors 

affecting their soldiers. In addressing these stressors, 

the command team may provide enhanced support 

to the soldier and may actually resolve some of the 

issues that are contributing to the heightened suicide 

or homicide risk. Ideally, the command team will 

consistently communicate the expectation that the 

unit watch is a team effort designed to help one of 

their own and to enhance both unit cohesion and the 

soldier’s ability to contribute. Such support can reduce 

the agitation and hopelessness often present in soldiers 

with suicidal or homicidal thoughts.4,10 Working with 

a command to ensure a unit watch environment that 

builds social support can be extremely helpful for the 

soldier. Strengthening such social support may play a 

key role in the soldier’s recovery.11,12

Although some risk remains, the authors contend 

that unit watch significantly reduces the risk of a soldier accessing lethal means such as firearms, ropes, 

medication, or knives. Of these weapons, firearms 

deserve special mention. In 2004 and 2005, firearms 

were the most common method of suicide completion 

within the US Army (62% and 69%, respectively, per 

year).13,14 By limiting access to firearms, a unit watch is 

likely to reduce the soldier’s risk of suicide completion 

early in the course of treatment, thus allowing time 

for the treatment and supportive interventions by the 

command to take effect.

Among US Army soldiers attempting or completing 

suicide in 2005, 57% of attempts and 17% of completions involved alcohol or drug use.14 Such substance 

use may impair judgment and lower inhibitions 

against acting on suicidal or homicidal impulses. A 

properly executed unit watch ensures that soldiers at 

risk are not given access to alcohol or drugs, thereby 

reducing risk. Also, by limiting contact with people 

who might exacerbate the soldier’s condition or become a victim of the soldier’s homicidal intent, a unit 

watch may further reduce risk and prevent adverse 

outcomes. 

Finally, the utilization of a unit watch for a soldier 

who presents with “military-specific” suicidal or 

homicidal ideation may be highly effective in reducing secondary gain, a term that describes the tangible 

advantages and benefits that result from being sick.15

The terms “military-specific suicidal ideation” and 

“military-specific homicidal ideation” refer to the 

verbal expression of suicidal or homicidal thoughts 

with the implicit (as determined by the clinician) or 

explicit goal of avoiding a military duty such as a 

field training exercise or deployment, of receiving a 

transfer to another unit or occupational specialty, or of 

obtaining a separation from active duty. In such cases, 

soldiers essentially imply or state that they may or will 

kill themselves or a leader in their unit unless they are 

allowed to achieve the stated goal. Such statements 

are often accompanied by allegations of harassment 

against the unit chain of command that may or may 

not be well founded. In many cases of military-specific 

suicidal or homicidal ideation, the soldier’s threats are 

directly linked to a desire to get out of the military. 

Such soldiers may believe that reporting suicidal or 

homicidal thoughts is an easy way to “get chaptered” 

(seek honorable administrative discharge) without 

negative consequences. In the absence of risk factors 

requiring hospitalization, military-specific suicidal or 

homicidal ideation is an indication for a unit watch, 

thus conserving inpatient treatment services for other 

service members who are more likely to benefit from 

these services. Additionally, soldiers in the unit rapidly 

develop an awareness that the mental health system 

is not there primarily to provide an escape from duties and responsibilities, but to provide supportive 

treatment, helping them function more effectively in 

a military environment. 

While useful in the management of military-specific 

suicidal or homicidal ideation in garrison, unit watches 

in a theater of operations are even more valuable. 

Military-specific suicidal and homicidal ideation are 

arguably two of the most common presenting behavioral health symptoms on today’s battlefield and could 

easily develop into an evacuation syndrome if not 

managed appropriately.11 A force that is well-versed 

in unit watches from its garrison experience is much 

more likely to successfully employ the intervention 
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Combat and Operational Behavioral Health

in wartime or other operations and thus benefit significantly in conserving its fighting, or peacekeeping, 

strength. However, the system as utilized in garrison 

requires modification in a deployed setting (discussed 

later in the chapter).

Two caveats warrant discussion when considering 

the rationale for the use of unit watch as a tool for 

enhancing the safety of soldiers at risk for suicide and 

homicide. The first is that although the unit watch may 

be beneficial for the soldier, it is only one component of 

a multifaceted treatment plan. Military mental health 

clinicians must provide psychological and pharmacologic treatment, as appropriate, to soldiers who present 

for care, whether or not a unit watch is used to enhance 

safety. For example, treating symptoms such as anxiety 

and insomnia is often essential in reducing suicide 

risk.1 Treatment of these symptoms should be a priority in soldiers presenting with suicidal thoughts, and 

treatment should occur independently of the decision 

to utilize a unit watch.

The second caveat is that essentially no research exists that directly addresses the safety and efficacy of a 

unit watch as an intervention. The Army Suicide Event 

Report (ASER) does provide some data that obliquely 

address the safety of “under command observation” 

(defined further on the ASER form as “eg, CIP,” a reference to command interest profile). In calendar year 

2004, ASER data were received for 54 of 70 suicide completions and 259 other suicide events (including both 

suicide attempts and other events that did not involve 

a suicide attempt, eg, hospitalization and evacuation 

for suicidal thoughts). In that year, one soldier who 

completed suicide (1%) and one (.4%) who attempted 

suicide were under command observation.13 In calendar 

year 2005, 2 of the 723 reported suicide events (.2%) in 

the active duty Army population occurred while the 

soldier was under command observation (of the five 

ASER reports identified as “under command observation,” two cases involved ideation only with no attempt, 

and one was from another branch of service). During 

the same year, none (0%) of the 71 completed suicides 

reported to the Suicide Risk Management and Surveillance Office occurred under command observation.14

(ASERS were not submitted for 12 of the 83 completed 

suicides that year; therefore, 71 reports were available.) 

Considering the widespread use of unit watch procedures in the US Army, these data offer some support 

to the hypothesis that unit watches are safe and may 

be effective in reducing suicidal behaviors in the shortterm while treatment is initiated. Although a controlled 

study evaluating the safety and efficacy of unit watch 

procedures may be difficult to design, research about 

this common practice is certainly warranted. In the 

meantime, the decision to use unit watch must be based 

on clinical judgment and experience with consideration 

of the potential risks and benefits. 

SUICIDE RISK ASSESSMENT

Essential to the appropriate use of unit watches 

is the ability to assess and document the soldier’s 

risk for suicide in a format that clearly explains the 

clinician’s decision-making process. Much has been 

written about the factors most often associated with 

completed suicide in both the civilian population and 

the US military population.14–17 These factors can be 

incorporated into a risk assessment that guides the 

clinician in appropriately choosing a unit watch or 

hospitalization. Although discussion of a comprehensive suicide risk assessment is beyond the scope of this 

chapter, a few risk factors are particularly relevant in 

a military setting.

One of the risk factors most highly correlative with 

completed suicide is diagnosis. Almost 95% of patients 

who attempt or commit suicide have a diagnosis of a 

mood disorder, a psychotic disorder, a substance-abuse 

disorder, dementia, or delirium. In populations under 

30 years of age, the most common diagnoses among 

suicide completers in one study were antisocial personality disorder and substance-abuse disorders.18 Based 

on anecdotal experience, a significant proportion 

of soldiers presenting with military-specific suicidal 

thoughts do not meet criteria for these diagnoses. 

However, the absence of a psychiatric diagnosis must 

be interpreted with caution in the active duty Army 

population, because the ASER data from 2005 indicate 

that only 26% of suicide completers were given a psychiatric diagnosis. 

An “unambiguous wish to die” over a “primary 

wish for change” as well as “communication internalized” (self-blame) versus “communication externalized” have been cited as important factors associated 

with high suicide risk.19 The majority of soldiers with 

military-specific suicidal thoughts are primarily interested in a change (leaving the military, the theater of 

operations, or their units) and are angry at an external 

entity (the military or their chains of command), rather 

than blaming themselves for their dissatisfaction. Additionally, the association of suicide completion with 

a conflicted romantic relationship or recent divorce 

has been particularly well described in the military 

population.16

When many or all of the above-described risk factors for suicide completion are absent, this is often 

an indication that a unit watch is more appropriate 

than hospitalization. It is important that the clinician 

clearly document these and other factors in a formal 
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Suicide and Homicide Risk Management

suicide-risk assessment that provides a rationale 

for the decision to utilize a unit watch. In a military 

setting, collateral history from the unit commander 

or from others in the unit is an important source of 

information in the suicide-risk assessment. Current 

practice in the field of suicide-risk assessment also 

emphasizes the ongoing nature of the evaluation. 

Individuals on unit watch should undergo frequent 

reassessments by the mental health professional to 

determine whether the suicide risk has increased to 

the point that inpatient hospitalization is now indicated. Homicide risk assessment and management is 

similar to that described for suicide-risk assessment 

and management, with examination of risk factors 

and frequent reassessment playing crucial roles in 

the decision process.

RECOMMENDATIONS FOR UNIT WATCH PROCEDURES

In Garrison

There are many different approaches to the implementation of unit watch in the military system. A 

model for conceptualizing the role of unit watches in 

a garrison setting is presented in Table 26-1. Whatever 

approach is taken by the clinician, the unit watch should 

be regarded as a “temporary profile,” a recommendation to a commander regarding the soldier’s temporary 

duty restrictions that is likely to be helpful in ensuring 

the soldier’s health and welfare. Most Army commanders are familiar with the concept of unit watch and will 

support such recommendations, especially when notified via a memorandum signed by the mental health 

professional. The memorandum format ensures that 

instructions are written and easily understood. 

The memorandum is given to the soldier’s escort, 

usually a noncommissioned officer, who signs for its 

TABLE 26-1

MANAGING SUICIDE AND HOMICIDE RISK in garrison

Full Duty Buddy Watch 24-Hour Watch Admit to Psychiatric 

Ward

Least restrictive  Most restrictive

Actions Return to duty 1. Secure weapons and medication

2. Soldier is under direct observation from first formation 

until lights out

1. Secure weapons and 

medications 

2. Soldier is under direct 

observation 24 h/day

Admit to psychiatric ward

Examples 1. SI/HI without plan/

intent, few 

risk factors, 

contracts for 

safety

1. Primary indication is “military-specific” SI/HI, no intent, 

few risk factors

2. SI/HI due to psychiatric 

disorder but risk level does not 

warrant 24 h watch or hospitalization

 3. Step down from unit watch

1. Primary indication 

is “military-specific” 

SI/HI with plan and/

or intent but few risk 

factors

2. SI/HI due to psychiatric disorder but risk 

level does not warrant 

hospitalization

1. High suicide or homicide 

risk requiring psychiatric 

hospitalization 

2. Suicide/homicide risk 

not diminishing after (no 

more than) 5 days despite 

treatment while on 24 h 

or buddy watch

Advantages 1. RTD

2. No stigma

1. Less stigma than 24 h watch

2. Some safety precautions

3. Lower personnel demands 

than 24 h watch

4. Reasonable likelihood of RTD

1. High level of safety 

precautions

2. Reasonable likelihood 

of RTD

Highest level of safely 

precautions

DisadvantagesNo safety precautionsFewer safety precautions vs 24 

h watch

Stigma, high personnel 

demands for unit

Low likelihood of RTD, 

stigma, loss of social 

and occupational roles 

that sometimes support 

recovery

HI: homicidal ideation; RTD: return to duty; SI: suicidal ideation
428

Combat and Operational Behavioral Health

receipt and is instructed to deliver it to the commander 

or first sergeant. This allows the clinician to release 

the service member with a recommendation for a unit 

watch at times when the clinician may not be able to 

contact the commander immediately. As with all medical profiles, the commander may choose to ignore the 

clinician’s recommendation, but then assume significant responsibility for the outcome of the case. 

The garrison system proposed in this chapter consists of two types of unit watches. The first is called 

a “buddy watch”; it recommends that the soldier be 

under direct observation only from first formation 

until lights out, rather than 24 hours a day, for up to 5 

days from the initiation of the watch until a reevaluation occurs. This watch is generally for lower-risk 

individuals, provides more flexibility for use (eg, over 

a weekend), and is generally better received by the 

chain of command and the soldier. It is valuable in a 

EXHIBIT 26-1 

buddy watch memorandum

DATE:

MEMORANDUM FOR (COMMANDER, UNIT)

SUBJECT: Buddy Watch for _______________________ (Soldier’s name and last 4)

1. The soldier was evaluated at the ___________ Behavioral Health Clinic. The results of the evaluation indicate 

that this Soldier is at some risk for self-harm or harm to others. The risk level at this time does not warrant hospitalization, but a Buddy Watch for both support and safety is recommended.

2. Buddy Watch procedures are as follows:

a. Command should assign someone to constantly monitor the soldier from first formation until lights out. The 

Soldier may be allowed to go to the latrine alone if the latrine doorway is monitored by the buddy or NCO 

assigned to watch the Soldier. During the night, constant monitoring is not required, but the soldier must 

not sleep in a room alone. Actions that specifically identify a Soldier on a Buddy Watch to large numbers of 

unit personnel (e.g. having the Soldier wear a road guard vest throughout the day) are not authorized.

b. Health and welfare inspection of the soldier’s room to remove hazardous material (e.g. pills, knives, etc.). 

c . No access to alcohol or dangerous objects such as:

 1) Personal weapons, knives, cigarette lighters, jewelry with sharp edges, blow dryers (silverware other than 

sharp knives is acceptable). .

 2) Pills (medication should be dispensed one dose at the time by medic, PA, NCO, etc).

 3) The Soldier may carry a military-issued firearm if the firing pin or bolt has been removed from the 

weapon.

d. It is recommended that the Soldier perform his/her regular (noncombat) duty and PT. Physical exercise often 

improves behavioral health symptoms.

3. This plan will be in effect from today until it is terminated by the Behavioral Health clinician in agreement with 

the commander. Continuing a buddy watch after a Behavioral Health clinician has recommended termination 

is not authorized and may be perceived as harassment.

4. If this Soldier’s condition worsens, the Soldier’s supervisor should call the Behavioral Health clinic at xxx-xxxx 

during duty hours or bring the Soldier to the __________ Emergency Room after hours. If phone contact cannot 

be established with a Behavioral Health clinician during the duty day, escort the Soldier immediately to the 

Behavioral Health clinic for evaluation. 

This Soldier’s next appointment at the _______________ Behavioral Health clinic is on_____________________(date)

at__________________________ (time).

________________________________ ______________________________

Representative from Command Clinician

Adapted from a form developed at the 2nd Infantry Division, initially by Captain Sally Chessani (now Colonel Sally Harvey), licensed 

clinical psychologist. 

NCO: noncommissioned officer; PA: physician’s assistant; PT: physical training
429

Suicide and Homicide Risk Management

variety of situations, including the typical presentation 

with military-specific suicidal ideation and very few 

risk factors for suicide completion.

Another scenario in which this watch may be useful 

is in managing soldiers who are urgently commandreferred for verbal expression of suicidal thoughts or 

self-injurious behavior the previous night when they 

were intoxicated. On presentation, the service member 

may have no current suicidal ideation, may claim to 

have no memory of the statements or self-injurious 

EXHIBIT 26-2 

24-hour watch memorandum

DATE:

MEMORANDUM FOR (COMMANDER, UNIT)

SUBJECT: 24 Hour Watch for _______________________________ (Soldier’s name and last 4)

1. The Soldier was evaluated at the _____________ Behavioral Health clinic on ______________________ The results 

of the evaluation indicate that this Soldier is at some risk for self-harm or harm to others. The risk level at this time 

does not warrant hospitalization , but a 24 Hour Watch for both support and safety is recommended.

2. 24-Hour Watch procedures are as follows:

a. Continuous monitoring should occur at all times, including accompanying the soldier to the latrine and 

during meals. 

b. The soldier should sleep in a room with a unit member who is awake at all times or in a dayroom (cleared 

of dangerous items) near the Staff Duty/CQ area so that the Soldier is constantly monitored throughout 

the night. Other actions that specifically identify the Soldier on a 24 Hour Watch to large numbers of unit 

personnel (e.g. having the Soldier wear a road guard vest throughout the day) are not authorized and may 

be perceived as harassment. 

c. Health and welfare inspection of the soldier’s room to remove hazardous materials (e.g., pills, knives, weapons, etc.). Instead of removing the Soldier’s weapon, the weapon may be inactivated (e.g., removing the bolt 

or firing pin from an M-16.

d. Other than family members, visitors from outside the unit must be cleared by the commander.

e. No access to alcohol or dangerous objects such as:

1) Personal weapons, knives, cigarette lighters, jewelry with sharp edges, blow dryers (silverware other 

than sharp knives is acceptable).

2) Pills (medication should be dispensed one dose at a time by medic, PA, NCO, etc.).

3) The Soldier may carry a military-issued firearm if the firing pin or bolt has been removed from the 

weapon.

3. Soldier should perform his/her regular (noncombat) duty and PT. Physical exercise often improves behavioral 

health symptoms.

4. This plan will be in effect from today until it is terminated by the Behavioral Health clinician in agreement with 

the command. Continuing a 24 hour watch after a Behavioral Health clinician has recommended termination is not 

authorized and may be perceived as harassment.

5. If this Soldier’s condition worsens, the Soldier’s supervisor should call the Behavioral Health clinic at xxx-xxxx 

during duty hours or escort the Soldier to the Emergency Room (or TMC in theater) after duty hours. If phone 

contact cannot be established with a Behavioral Health clinician during the day, bring the Soldier to the Behavioral 

Health clinic during duty hours for evaluation. 

6. This soldier’s next appointment at the_______________________ Behavioral Health clinic is 

on________________________ at _______________________.

________________________________ ______________________________

Representative from Command Clinician

CQ: charge of quarters; NCO: noncommissioned officer; PA: physician’s assistant; TMC: troop medical clinic
430

Combat and Operational Behavioral Health

EXHIBIT 26-3 

Information paper for commanders

MCXC-BH

INFORMATION PAPER

SUBJECT: Management of Soldiers with Suicidal or Homicidal Ideation

1. References: FM 4-02.55 COMBAT AND OPERATIONAL STRESS CONTROL, FM 22-51 Leader’s Manual for Combat 

Stress Control

2. Purpose. To provide information to commanders regarding the use of unit watches in the management of Soldiers 

who express suicidal and homicidal ideation.

3. Overview:

When it is brought to the commander’s attention that a Soldier has expressed suicidal ideation, the commander 

should immediately contact his supporting behavioral health activity to insure that an evaluation of risk is performed. Procedures for this are not within the scope of this information paper. Once the Soldier is evaluated, the 

behavioral health professional will have examined the risk factors (e.g. the psychiatric diagnosis, any history of 

previous attempts, family history of attempts, the presence and lethality of a plan for suicide) and will make recommendations to the commander. These recommendations will include one of the following: return to full duty with 

close monitoring and support for low risk soldiers, Buddy Watch (or Basic Precautions in Operational environments) 

for low to moderate risk Soldiers, 24 Hour Watch for moderate risk Soldiers, and hospitalization for soldiers at high 

risk. The value to the soldier and commander of Basic Precautions, Buddy Watch, and 24 Hour Watch as opposed 

to hospitalization are as follows:

The soldier is able to maintain occupational functioning at some level and maintains social connection in the unit. 

This helps to prevent feelings of worthlessness and a sense of isolation that sometimes result from psychiatric 

hospitalization.

The soldier avoids the stigma that is unfortunately commonly associated with psychiatric hospitalization. While 

there may be some stigma associated with a unit watch, at least the soldiers in the unit see the soldier on a daily 

basis and are much less likely to develop misperceptions about the Soldier’s problem, e.g. that the Soldier is “psycho” and is “locked in a rubber room”. These misperceptions are prevalent in our culture and are sometimes very 

damaging in the Soldier’s reintegration to the unit after a psychiatric hospitalization.

The Soldier has the opportunity to address his or her concerns with the chain of command. NCOs often provide 

significant relief from depressed feelings when they listen to and support a Soldier who has expressed suicidal 

ideation. In this way, the unit implements the Army’s concept of the unit as the Soldier’s “family” and provides 

extra care and support to a unit member in distress.

Soldiers with “military specific” suicidal ideation (e.g. “I will kill myself if you don’t let me out of the Army”) 

become aware more rapidly that the behavioral health system does not provide an escape route from their duties 

and responsibilities, though it does react to help the Soldier adjust to their situation. This message is transmitted to 

the entire unit and is likely to lessen the number of Soldiers who develop “military specific” suicidal ideation. This 

MAY ENHANCE RETENTION AND COMBAT READINESS by reducing the number of soldiers that seek out the 

mental health system as an escape route from the Army.

The unit chain of command gains significant experience in managing Soldiers who express suicidal ideation. This 

experience and familiarity with unit watches MAY ENHANCE COMBAT READINESS because the unit will most 

likely need to employ similar procedures in an operational environment. The proficient use of unit watches in a 

combat setting may prevent an “evacuation syndrome” in which significant numbers of Soldiers who express suicidal 

thoughts are evacuated from theater because units have not been trained in the management of this problem.

4. Types of Unit Watches:

a. Buddy Watch: A unit member is assigned to constantly monitor the soldier from first formation until lights out. The 

soldier should not sleep in a room alone but constant monitoring is not required at night. The Soldier will follow 

up with Behavioral health within 5 days (usually sooner) of the initiation of the watch so that the risk level can 

(Exhibit 26-3 continues)
431

Suicide and Homicide Risk Management

act, and may demonstrate minimal risk factors for a 

suicidal act. However, there is clearly some risk, especially if alcohol use is resumed. The buddy watch 

significantly minimizes the opportunity for continued 

alcohol use, and thus may reduce the suicide risk while 

outpatient treatment, including referral to the Army 

Substance Abuse Program, is initiated. Other situations 

in which a buddy watch may be valuable are situations 

in which “stepping down” from hospitalization or 24-

hour watch is prudent. Exhibit 26-1 is an example of 

specific procedures for buddy watch. 

The second type of unit watch is called a “24-hour 

watch,” avoiding another commonly used term, “CQ 

(charge-of-quarters) watch,” for two reasons. Some 

units do not have a CQ duty and the commander 

may infer from the term that the unit is being asked 

to perform a task for which it is not equipped. The 

commander may also infer from “CQ watch” that the 

clinician is recommending that the soldier be moved 

to a central area (eg, dayroom) in the unit where observation is possible by soldiers performing CQ duty. 

Moving the soldier to a central area is sometimes necessary but should be avoided whenever possible because 

such a move may enhance the sense of humiliation or 

stigma. The primary characteristic of a 24-hour watch is 

that the soldier is under constant observation during a 

24-hour period, after which an evaluation by a mental 

health officer must take place. Specific procedures for 

be reassessed. If significant risk remains at that point, the Soldier is often hospitalized so that the unit’s combat 

readiness is not unduly affected by an extended period of observation of the soldier.

b. 24-Hour Watch: A unit member is assigned to constantly monitor the Soldier throughout an entire 24 hour period. 

Unit commanders often use a Staff Duty NCO or CQ personnel for this purpose. This type of watch is generally 

only used in “military specific” suicidal ideation where the Soldier is making specific threats related to a wish for 

release from the Army or a deployment but does not have other risk factors (eg, a depressive disorder, a history 

of suicide attempts) that would warrant hospitalization. The Soldier will generally be seen back within 24 hours 

due to the time-intensive nature of this procedure for the unit. At that point, the clinician will again assess the risk 

and make a determination regarding the appropriate recommendation.

c. Recommendation for Basic Precautions: While a recommendation for Basic Precautions is not technically a unit 

watch, it is a set of safety precautions used only in an operational environment. The essential elements of Basic 

Precautions are that the Soldier does not participate in combat (or “off-FOB”) duties and that the firing pin or bolt 

is removed from the Soldier’s weapon. 

5. The Homicidal Soldier:

Soldiers who express homicidal thoughts should also be referred to Behavioral Health for an evaluation so that the 

mental health professional can rule out a mental disorder as a cause of the homicidal thoughts, assess the risk, and 

initiate treatment if there is evidence of a behavioral health disorder. In the absence of a serious behavioral health 

disorder contributing to the homicidal thoughts, the presence of homicidal thoughts is often not an indication for 

psychiatric hospitalization. The mental health professional will generally take steps to insure that the commander 

warns the personnel who are threatened, and may recommend a Buddy Watch or 24 Hour Watch as a method of 

protecting the threatened individual. If the risk level is very high, the commander has the option of consulting SJA 

regarding the possibility of placing the Soldier in pretrial confinement if hospitalization is not indicated. 

6. Summary:

The use of unit watches is a valuable tool for the commander in supporting Soldiers and enhancing combat readiness. Behavioral Health clinicians will work with you to determine the appropriate management tool and will 

hospitalize the Soldier if the risk level warrants this intervention. Behavioral Health clinicians can not predict suicide 

or homicide but are trained to follow clear guidelines about the level of risk that warrants hospitalization. Your 

supporting Behavioral Health clinicians will insure that your Soldier receives the most appropriate intervention 

for their level of risk.

________________________________ ______________________________

Representative from Command Clinician

CQ: charge of quarters; FOB: forward operating base; FM: field manual; NCO: noncommissioned officer; SJA: Staff Judge 

Advocate

Exhibit 26-3 continued
432

Combat and Operational Behavioral Health

EXHIBIT 26-4 

STANDard OPERATING PROCEDURES FOR BUDDY WATCH AND 24-HOUR WATCH

STANDARD OPERATING PROCEDURES

Buddy and 24-Hour Unit Watch

1. PURPOSE: To establish procedures for the use of Buddy and 24 Hour Unit Watches in the management of Soldiers undergoing evaluation and treatment for suicidal statements or behaviors.

2. SCOPE: All personnel assigned to or working in the Department of Behavioral Health.

3. GENERAL:

a. All patients seen in the clinic who describe a history of current or recent (i.e. within the past two weeks) 

suicidal ideation, suicide attempt, or homicidal ideation must be seen by a Behavioral Health clinician prior 

to release of the soldier. (Risk assessments after clinic hours will be performed by Emergency Department 

staff, in consultation with the on-call Behavioral Health clinician.)

b. The evaluation of potential for harm will include a thorough psychiatric history and examination of risk 

factors. The suicide risk factors assessed will include at a minimum the following: history of previous attempts, frequency and duration of suicidal ideation/plan/intent, access to lethal means, presence or absence 

of substance abuse, signs and symptoms of mood and anxiety disorders, current significant stresses, social 

supports, reality testing, and any family history of completed suicide. The homicide risk factors assessed 

will include at a minimum the following: history of previous violence, frequency and duration of homicidal 

ideation/plan/intent, and determination of access to lethal means.

c. The disposition should be appropriate based on the assessment and must address the safety of all involved.

d. Documentation of the assessment will be completed on the day of the evaluation.

4. PROCEDURES:

a. A Buddy Watch may be recommended to the commander if there is some risk for harm to self or others, but 

the mental health officer clearly documents a risk assessment explaining that the Soldier’s risk is not high 

enough to warrant hospitalization. The Buddy Watch allows for monitoring the Soldier while treatment is 

initiated, and may have advantages over hospitalization. These are described in Attachment C.

b. A 24-Hour Watch may be recommended for Soldiers who require more constant supervision than provided 

by a Buddy Watch and is typically implemented for Soldiers who make specific threats to harm themselves 

or others in order to avoid duty or to force a discharge from service (eg, “I will kill myself if you don’t let 

me out of the Army”). The risk assessment explaining the clinician’s conclusion that the Soldier’s risk is not 

high enough to warrant hospitalization must be clearly documented.

c. The procedures for Buddy Watch and 24-Hour Watch are explained in detail in Attachments A and B. The 

essential difference in these two procedures is that a Soldier on Buddy Watch requires observation only from 

first formation until lights out, whereas a Soldier on 24 Hour Watch must be observed at all times.

When a Soldier is placed on a watch, the Behavioral Health clinician will make an attempt to contact the commander 

to discuss the reasons for the watch and other pertinent concerns. The appropriate form will be forwarded to the 

commander through the Soldier’s escort. If the commander requests additional information about unit watch or expresses uncertainty about unit watch, the information paper titled Management of Soldiers With Suicidal or Homicidal 

Ideation will be forwarded to the commander through the Soldier’s escort. A Soldier on a Buddy Watch will be seen 

for a follow up appointment at least every five working days until the watch is discontinued. A Soldier on a 24-Hour 

Watch will be seen for re-evaluation within 24 hours. A Behavioral Health clinician will evaluate the Soldier at each 

return appointment until the watch is discontinued. The decision to recommend discontinuation of a unit watch will 

be made only by a Behavioral Health clinician. A memorandum recommending discontinuation of the watch will be 

signed by the Behavioral Health clinician and forwarded to the commander.

Unit watches are recommendations to commanders. Behavioral Health clinicians must discuss their recommendations 

with the commander and be sensitive to specific command and unit circumstances. In all cases, the safety of the Soldier 

and others that might be at risk will be the primary concern.

The Buddy Watch or 24-Hour Unit Watch will only be used for soldiers who have been assessed for their level of risk 

by a clinician at this institution. Unit watches may be utilized by Emergency Department clinician if the on-call mental 

health care clinician has been consulted by the Emergency Department clinician and they are in agreement regarding 

the disposition.
433

Suicide and Homicide Risk Management

this watch are outlined in Exhibit 26-2. 

The procedures outlined for both types of unit watch 

are designed to give the commander specific guidance 

regarding measures to ensure the soldier’s safety. This 

written guidance helps to reduce confusion, which often results if a more vague verbal recommendation for 

a unit watch is used to communicate with the chain of 

command. The 24-hour watch is at times useful in the 

management of a soldier with military-specific suicidal 

or homicidal ideation who has very few risk factors 

except for a verbalized threat, such as “I will kill myself 

(or my squad leader) if I have to go back to my unit.” 

It is often, though not necessarily, used in conjunction 

with an environmental change, for instance, an agreement with the commander that the service member 

will be moved to a different platoon, if the threats of 

suicide or homicide are specific to alleged harassment 

by a noncommissioned officer in the service member’s 

section, squad, or platoon.

In addition to the memoranda outlining specific recommendations, the authors suggest that a unit watch 

information paper (Exhibit 26-3) be forwarded to the 

commander, especially if the commander expresses 

confusion or skepticism about the recommendation for 

a unit watch. This document provides education for the 

command team and may alleviate concerns about the 

safety and value of a unit watch. Command support 

of the unit watch is crucial. If not fully informed and 

educated about the unit watch, unit leaders may feel 

compelled to intervene further and attempt to force the 

mental health system to psychiatrically hospitalize the 

service member. 

Exhibit 26-4 is an example of a standard operating 

procedure for the behavioral health team, providing a 

general guide for the use of unit watch in a garrison setting. Clinicians’ beliefs about the need for psychiatric 

hospitalization in various situations differ significantly, 

so no absolute guidelines about which clinical factors 

require hospitalization over unit watch are included in 

this chapter. This variation in decisions regarding hospitalization reinforces the critical role of documenting 

the clinical assessment and decision-making process in 

each case. Finally, when the clinician decides to recommend discontinuation of the unit watch, it is helpful to 

forward to the command team a standard document 

with this recommendation. Commanders may wait for 

such written notification before discontinuing a watch. 

Exhibit 26-5 is a sample memorandum.

EXHIBIT 26-5 

UNIT WATCH DISCONTINUATION MEMORANDUM

Date: 

MEMORANDUM FOR (Commander, Unit)

SUBJECT: Release from Twenty Four Hour Watch/Buddy Watch for _____________________________

SSN: _____________________________________________________________________

1. The above named service member was recommended for Twenty Four hour Watch/Buddy Watch on ________ .

2. The above named service member was evaluated at _____________ Behavioral Health clinic again on ________ . I 

currently do not believe that the service member is an imminent risk to self or others and recommend the service 

member be removed from Twenty-Four Hour Watch/Buddy Watch.

3. Although this service member is not currently at significant risk for dangerousness to self or others, please understand that the service member’s risk level may change.

4. If the service member experiences a recurrence of suicidal or homicidal thoughts or demonstrates other behaviors 

indicating there is risk for harm to self or others, the service member should be escorted to the clinic (duty hours) 

or to the Emergency Department (after hours) for evaluation. 

5. The service member’s next scheduled appointment at Outpatient Behavioral Health Services is on __________________ 

at ____________.

6. Point of contact for this memorandum is the undersigned at xxx-xxxx. 

________________________________

Clinician
434

Combat and Operational Behavioral Health

Deployed Settings

The garrison system for unit watch must be modified to function in a deployed setting for two reasons. 

The first is a recognition that access to lethal weapons is 

heightened immeasurably in a deployed setting; thus, 

the buddy watch must be removed from the range of 

options. The 24-hour watch is used instead for soldiers 

at heightened risk who do not require hospitalization. 

Another option for lower risk soldiers used during the 

deployment has been dubbed “basic precautions.” The 

essential elements of the basic precautions profile are 

removal of the firing pin (or bolt) from the soldier’s 

weapon and suspending combat duties until further 

notice. Exhibit 26-6 shows the basic precautions memorandum that was used to successfully communicate to 

the commander the necessary precautions by one of 

the authors (SP) during a 2006–2007 deployment. During this deployment, basic precautions were applied 

extensively in a variety of situations, including those 

involving vague suicidal or homicidal thoughts but 

few other risk factors in soldiers requiring a period of 

treatment before return to full duty. 

The second reason is that, depending on the unit, 

the clinician may have ready access to a “patient hold” 

area such as that operated by the medical company 

in a brigade support battalion. Although traditional 

combat stress control doctrine has emphasized separation of soldiers presenting with psychiatric issues 

from those presenting with medical and surgical 

illness, utilization of the patient hold area for brief 

management of suicide risk has been effective in 

deployed settings. Based on these two modifications, 

a model for conceptualizing the role of unit watches 

in a deployed setting is presented in Table 26-2. This 

model was used by one author (SP) to train primary 

care clinicians and mental health professionals in the 

management of suicide and homicide risk during the 

2006–2007 deployment. The following is an example 

of a unit watch used in a deployed setting. 

Case Study 26-1: A 31-year-old married African-American man deployed to a combat zone came to the mental 

health clinic after learning that his wife planned to leave 

him. He stated that if only he was given the chance to go 

home, he could save his marriage. He reported that he was 

EXHIBIT 26-6 

Basic precautions

________ TMC

FOB ____, Iraq

Date _________________

MEMORANDUM FOR Commander,

SUBJECT: Basic Precaution for _____________________________ SSN:________________________

This service member was evaluated at the FOB ______ TMC. Based on this evaluation of the service member’s recent 

behaviors and current mental status, the following precautions are recommended to the commander for the service 

member’s support and safety. The evaluation did not indicate a high enough risk of dangerousness to warrant hospitalization or a unit watch at this time.

2. Precautions:

a. Remove the firing pin (or bolt) from this service member’s weapon.

b . No combat or “Off-FOB” duties until further notice.

c. Service member should perform duties not involving combat operations and should participate in PT. PT may 

help improve the service member’s behavioral health symptoms.

3. If this service member’s condition worsens, the service member’s supervisor should call FOB ________ TMC Behavioral Health at xxx-xxxx or escort the service member to the TMC for evaluation.

This service member’s next appointment at FOB _______ TMC is on_______________________

at __________________________ with ___________________________________________.

________________________________ ______________________________

Representative from Command Clinician

FOB: forward operating base; PT: physcial therapy; SSN: social security number; TMC: troop medical clinic
435

Suicide and Homicide Risk Management

suicidal and would kill himself if he wasn’t allowed to leave. 

During the initial evaluation, he didn’t describe a defined 

plan for carrying out his suicide and reported never before 

experiencing suicidal thoughts. He denied any previous 

mental health history, had no medical illness, and was not 

using alcohol, street drugs, or medications. A 24-hour watch 

was recommended to the commander, along with frequent 

mental health treatment to help him cope with his emotional 

crisis. On meeting to discuss a safety plan for the soldier, 

the command team reported that he had recently been 

serving well in his role as a member of a logistics team. 

During the meeting the soldier’s first sergeant reminded 

the soldier how proud the battalion commander was of the 

soldier’s proficiency in a recent task. He then expressed 

how the command team valued the soldier, not just as a 

“number” but as a person and team member. The command 

team agreed to provide 24-hour supervision for the soldier 

in a nonstigmatizing manner by removing the bolt from his 

weapon and removing his ammunition and knives from his 

possession, as well as allowing him to remain on base where 

he would probably not need his weapons. He was allowed to 

choose the soldiers who would be assigned to monitor him, 

selecting those with whom he felt the closest connection. 

He was then returned to duty with mental health follow-up 

planned in 2 days. He reported that during the day while on 

24-hour watch he spent time talking to his escorts about his 

problems. During this time period, he continued his usual 

work schedule and came to the clinic every other day for a 

brief assessment and supportive therapy. Within 2 weeks, 

he had come to terms with his pending divorce, realizing that 

his presence at home would probably not have affected his 

wife’s plans. He also noted that his distress over the loss of 

his marriage wouldn’t resolve by throwing away his life or 

military career. The 24-hour watch was discontinued at that 

point. His bolt, ammunition, and knives were returned to him 

and, though his wife did leave him, he was able to continue 

with the mission and complete the deployment. His emotional 

state had returned to near baseline approximately 1 month 

after his initial presentation. After several months of monthly 

follow-up, he required no further treatment for the remainder 

of the deployment. 

The soldier in this case presented with suicidal 

ideation in acute emotional crisis after learning of his 

wife’s plan to divorce him. His access to a weapon and 

his primary stressor of interpersonal loss placed him at 

significant risk for a suicide attempt. However, he did 

not have a formulated plan for suicide, a significant 

medical or mental health history, or a substance-use 

TABLE 26-2

MANAGING SUICIDE AND HOMICIDE RISK during deployment

Full Combat 

Duty

Basic Precautions 24-Hour Watch (or admit 

patient to hold)

Evacuation to Combat Support Hospital

Least restrictive  Most restrictive

Actions Soldier verbally 

contracts for 

safety

1. Secure bolt from weapon 

until further notice

2. No off-FOB duties until 

further notice

1. Secure weapons and 

medications 

2. Soldier is under direct 

observation 24 h/day

Enact evacuation procedures

Examples Suicidal 

thoughts, few 

risk factors, 

able to contract 

for safety

1. Primary indication is 

military-specific SI/HI

2. Psychiatric disorder with 

SI/HI but risk not high 

enough to warrant unit 

watch

3. Step down from unit 

watch

1. Military-specific SI/

HI but risk not high 

enough to warrant 

hospitalization

2. Psychiatric disorder 

with SI/HI but risk not 

high enough to warrant 

hospitalization

1. Suicide or homicide risk 

high enough to warrant 

hospitalization

2. Medically serious suicide 

attempt (overdose, lacerations requiring sutures)

3. Suicide/homicide risk not 

diminishing after (no more 

than) 5 days despite treatment while on unit watch

Advantages 1. RTD

2. No stigma

1. Much less stigma than 

unit watch

2. Some level of safety precautions

1. High level of safety 

precautions

2. High likelihood of RTD

3. Consistent with PIES

Highest level of safety precautions

DisadvantagesNo safety precautionsFewer safety precautions vs 

unit watch

1. Stigma

2. “Sick role” with patient 

hold

Low likelihood of RTD, 

stigma, violates PIES unless clearly indicated

FOB: forward operating base; HI: homicidal ideation; PIES: proximity, immediacy, expectancy, and simplicity; RTD: return to duty; 

SI: suicidal ideation
436

Combat and Operational Behavioral Health

problem. Thus, his treating clinician decided that the 

appropriate treatment setting would be to ensure the 

patient’s safety via a 24-hour watch, long enough for 

his immediate emotional crisis to resolve. An adequate 

nonstigmatizing safety environment was created for 

the soldier, and the unit provided emotional support 

as well as safety. As expected, his emotional crisis 

resolved within 2 weeks and his symptoms resolved 

within 1 month as he gained understanding and acceptance of his changing life situation. 

In a garrison or deployed setting, the clinician must 

clearly document the suicide or homicide risk assessment, giving a clear rationale that makes the case for 

the specific treatment setting (eg, buddy watch, 24-

hour watch, basic precautions, patient hold) rather 

than hospitalization or evacuation. The military unit 

is a unique and cohesive community that often allows 

these interventions to effectively reduce suicide or homicide risk. However, because these interventions are 

relatively unknown in the civilian sector, meticulous 

documentation of suicide risk factors and the reason 

that unit watch was considered a safe intervention 

for the soldier are essential in each case. Documentation of discussions with command, education given 

to the command, and assurance that the command is 

capable of carrying out a proper unit watch are also 

recommended. Finally, the widespread use of the 

unit watch by military mental health providers, and 

its inclusion in the American Psychiatric Association 

practice guidelines, may help establish this as an 

appropriate, if not yet evidence-based, intervention 

within the military.1 

MEDICOLEGAL ISSUES

The legal implications of using a unit watch are of 

concern to many clinicians. There is no exact equivalent to the unit watch in the civilian sector, although 

it is loosely analogous to sending a patient home with 

parents or family members who promise to watch the 

patient and confiscate weapons or excess pills. Suicide watches in a prison may use similar procedures, 

despite the obvious differences between a prison environment and an Army barracks. Although the need 

for collaboration with the legal community on these 

issues is obvious, no literature specifically addresses 

this aspect. The following brief summary lays out the 

basic medicolegal issues involved. 

Mental health clinicians in the civilian community 

have serious concerns about liability when a patient 

completes a suicide or commits a homicide. Many 

malpractice lawsuits involve plaintiffs who complete 

suicide after a psychiatric assessment concluded that 

hospitalization was not indicated. Factors in finding 

the mental health clinician liable for damages often 

include inadequate risk assessment or inadequate 

response to that risk.20 Inadequate documentation of 

the risk assessment is a frequent factor that leads to 

a verdict against the clinician. Failure to frequently 

reevaluate the suicide risk may also be a basis for a 

finding of malpractice. Prison staff and supervisors 

have been found liable in cases of completed suicides 

in civilian prisons because of their responsibility for 

the health and well-being of their wards. Insufficient 

training of personnel or inadequate adherence to 

standard operating procedures may result in findings 

of negligence. 

Military commanders and clinicians have a unique 

protection from liability in the form of the Feres doctrine, which is an exception to the Federal Tort Claims 

Act. The doctrine stems from Feres v US,

21 which consolidated three lawsuits concerning the injury or death 

of three service members due to possible negligence 

on the part of the military. Two of the cases involved 

physician malpractice. The US Supreme Court ruled 

that there was no cause of action under the Tort Claims 

Act for wrongful death of or personal injury to a member of the armed forces if the injury or death was “in 

the course of activity incident to their service in the 

Armed Forces.”21 Many lawsuits alleging malpractice 

or seeking consortium for loss of finances have been 

barred because of the Feres doctrine, including suits 

in which unit commanders were accused of failure 

to take appropriate actions when there was direct 

evidence of a soldier’s suicidal intent. Legal action 

by both active duty members suing through military 

courts and civilian dependents suing through federal 

courts have been barred. 

The suicide of a soldier while that individual is 

under unit watch could potentially call into question whether the mental health clinician did not fully 

appreciate the suicide risk or did not ensure that an 

adequate intervention was used. The commander 

could also be questioned concerning the competence 

of the unit to perform a unit watch. Another issue is 

that soldiers performing the watch may have little or 

no experience with the procedures involved in a unit 

watch, and they may not fully appreciate that serious adverse outcomes might result if the procedures 

are not strictly followed. Although lawsuits are often 

barred through the Feres doctrine, the military may 

nonetheless take disciplinary action against physicians or commanders if an internal investigation uncovers fault or negligence. Monetary payments may 

be given out for compensable events. Department of 
437

Suicide and Homicide Risk Management

Defense Directive 6025.13 outlines the procedures for 

investigation of potential provider malpractice.22 If 

the surgeon general for the specific military branch 

makes a determination that an adverse privileging 

action should be placed against a physician, then that 

finding will be entered into the National Practitioner 

Data Bank (NPDB).22,23(pA-3) The NPDB is a database that 

provides information concerning specific areas of a 

practitioner’s licensure, including professional society 

memberships, medical malpractice payment history, 

record of clinical privileges, adverse licensure actions, 

withdrawal of clinical privileges, and other negative 

actions taken against an individual healthcare practitioner. Such information is provided through legally 

authorized queries to assist state licensing boards, 

hospitals, and other healthcare entities in establishing the qualifications of the healthcare practitioners 

they seek to license, hire, or privilege. These actions 

are representative of the military’s ongoing efforts to 

ensure that military healthcare is comparable to civilian 

standards. A survey of all military malpractice cases 

from 1978 to 1987 revealed that of 14 cases involving 

attempted or completed suicide, six cases resulted in 

monetary settlements totaling $754,000.24

The use of unit watch for management of homicide 

risk is perhaps the easier case to make. The landmark 

Tarasoff decision, although binding only within the state 

of California, gave clinicians the responsibility to take 

measures to protect the potential victim if the clinician 

believes there is a probability that the patient will commit murder.25,26 In the Tarasoff case, a patient told his 

psychiatrist that he planned to kill a female love interest. The murder was carried out, and the psychiatrist 

was found liable for not taking action such as alerting 

the victim and committing the patient. Many states 

now require Tarasoff-like duties to protect potential 

victims, either through case or statutory law. However, 

there is no federal law regarding this issue (federal law 

applies to the military). Some states have ruled that 

psychiatrists are liable for violent acts by their patients 

even when no specific victim can be identified, when 

no specific threat was made, or when homicides occur 

several months after a risk assessment.27–29

The military psychiatric community commonly 

assumes that a duty to protect exists, despite the lack 

of clear statutory guidance. The Feres doctrine would 

not exempt a military clinician from potential liability 

if an active duty patient hurt or killed an individual 

not on active duty; in such a case, relevant state law 

would be applicable. Unless one is familiar with the 

laws of each state, the best practice in the military is 

to adhere to a Tarasoff-like standard of care. The use 

of unit watch to prevent an individual from carrying 

out an act of homicide would be an added medicolegal 

(and ethical) safeguard when a clinician is assessing 

a soldier’s threats. 

In the authors’ experience, a large proportion of 

soldiers presenting with homicidal ideation toward 

their chains of command have diagnoses of adjustment disorder, personality disorder, or, sometimes, 

alcohol-abuse disorder. In the absence of a severe 

mental disorder, these service members do not meet 

criteria for hospitalization, but are often hospitalized 

because the clinician believes that it is necessary to 

protect the potential victim. As an alternative measure, 

unit watch helps protect potential victims by limiting 

access to lethal means and providing an observer to 

notify the chain of command or authorities if the potential perpetrator takes any confrontational action. 

As an adjunct to the unit watch, additional clinical 

actions in the case of a potential homicide sometimes 

include a recommendation that the commander move 

the soldier to another section of the unit (in the case of 

homicidal ideation toward an immediate supervisor), 

that the commander warn the potential victim about 

the homicide threat, and that the commander give 

both parties a direct order to avoid all contact except 

as necessary in the performance of their daily duties. In 

many cases, these interventions may actually be more 

effective in minimizing risk than simply notifying the 

local police and the potential victim, in keeping with 

the civilian standard of care when the patient does 

not meet commitment criteria because of the lack of 

evidence of a severe mental disorder. 

SUMMARY

Although there are no simple answers in the assessment and management of suicide and homicide risk 

in any setting, military clinicians practice in a unique 

community that necessitates a uniquely military approach to the issue. The recommendations and information presented in this chapter may help validate and 

standardize a military approach, and will hopefully 

stimulate research in this area. For example, publication of a case series of soldiers successfully managed 

with unit watch according to the guidelines discussed 

above would further validate this technique. A retrospective or prospective study comparing various outcome measures for soldiers at a post where unit watch 

is commonly used with outcomes for a control group 

of soldiers at a post where unit watch is not commonly 

used might also be possible. Optimization, validation, 

and eventually incorporation of this chapter’s recommendations into the curricula in military behavioral 
438

Combat and Operational Behavioral Health

health training programs, combat operational stress 

control doctrine, and other military publications will 

contribute to a wealth of resources available to military 

mental health professionals to support and guide the 

successful management of suicide and homicide risk 

in the active duty population.

Acknowledgment

The authors would like to express their sincere thanks to Colonel Sally Harvey for developing an earlier 

version of the example unit watch forms used in this paper. These forms have been modified and utilized 

in two major conflicts, Operation Iraqi Freedom and Operation Enduring Freedom; in peacekeeping operations in the Balkans; and in garrison settings throughout the United States, Europe, and Asia.

REFERENCES

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2. Hassinger AD. Mentoring and monitoring: the use of unit watch in the 4th Infantry Division. Mil Med. 2003;168(3):234–

238.

3. Pincus SH, Benedek DM. Operational stress control in the former Yugoslavia: a joint endeavor. Mil Med. 1998;163(6):358–

362.

4. Ritchie EC, Owens M. Military issues. Psychiatr Clin North Am. 2004;27:459–471.

5. US Department of the Army. Combat and Operational Stress Control. Washington, DC: DA; 2006. Field Manual 4-02.51 

(formerly Field Manual 8-51).

6. Jones FD. Psychiatric lessons of war. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes J, eds. War Psychiatry. 

In: Zajtchuk R, Bellamy R, eds. Textbooks of Military Medicine. Washington, DC: Office of The Surgeon General, United 

States Army and Borden Institute; 1995: 9–25.

7. Solomon Z, Benbenishty R. The role of proximity, immediacy, and expectancy in frontline treatment of combat stress 

reaction among Israelis in the Lebanon War. Am J Psychiatry. 1986;143:613–617.

8. Jones DR. US Air Force combat psychiatry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes J, eds. War 

Psychiatry. In: Zajtchuk R, Bellamy R, eds. The Textbooks of Military Medicine. Washington, DC: Office of The Surgeon 

General, United States Army and Borden Institute; 1995: 202.

9. Greene-Shortridge TM, Britt TW, Castro CA. The stigma of mental health problems in the military. Mil Med. 

2007;172(2):157–161.

10. Gal R, Jones FD. A psychiatric model of combat stress. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes J, 

eds. War Psychiatry. In: Zajtchuk R, Bellamy R, eds. The Textbooks of Military Medicine. Washington, DC: Office of The 

Surgeon General, United States Army and Borden Institute; 1995: 139.

11. Hill JV, Johnson RC, Barton RA. Suicidal and homicidal soldiers in deployment environments. Mil Med. 2006;171(3):228–

232. 

12. Alaimo CJ, Parker BL. Social support: an undervalued and underused clinical resource. Fed Pract. 2004;21(6):27–

28,31.

13. Gahm GA, Lucenko BA. Suicide Risk Management and Surveillance Office, Army Behavioral Health Technology Office. 

Army Suicide Event Report (ASER) Calendar Year 2004. Tacoma, Wash: Madigan Army Medical Center; 2005: 16–17.

14. Gahm GA, Lucenko BA. Suicide Risk Management and Surveillance Office, Army Behavioral Health Technology Office. 

Army Suicide Event Report (ASER) Calendar Year 2005. Tacoma, Wash: Madigan Army Medical Center; 2006: 11–17.
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15. Sadock BJ, Sadock VA. Somatoform disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Synopsis of Psychiatry: 

Behavioral Sciences/Clinical Psychiatry. 10th ed. Philadelphia, Penn: Lippincott, Williams & Wilkins; 2007: 640.

16. Rothberg JM, Jones FD. Suicide in the US Army: epidemiological and periodic aspects. Suicide Life Threat Behav. 

1987;17(2):119–132.

17. Helmkamp JC. Occupation and suicide among males in the US armed forces. Ann Epidemiol. 1996;6(1):83–88.

18. Sadock BJ, Sadock VA. Emergency psychiatric medicine. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Synopsis of 

Psychiatry: Behavioral Sciences/Clinical Psychiatry. 10th ed. Philadelphia, Penn: Lippincott, Williams & Wilkins; 2007: 

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19. Adam KS. Attempted suicide. Psychiatr Clin North Am. 1985;8(2):183–201.

20. Robertson JD. Psychiatric Malpractice: Liability of Mental Health Professionals. New York, NY: Wiley Law Publications; 

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22. US Department of Defense. Medical Quality Assurance (MQA) in the Military Health System (MHS). Washington, 

DC: DoD; 2004. DoD Directive 6025.13. 

23. National Practitioner Data Bank Guidebook. Available at: http://www.npdb-hipdb.hrsa.gov/npdbguidebook.html. 

Accessed November 2, 2009.

24. Lande RG, Armitage DT, eds. Principles and Practice of Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas; 

1997: 387.

25. Tarasoff v Regents of the University of California, 551 P2d 334, 131 Cal Rpt 14 (1976).

26. Sadock BJ, Sadock VA. Clinical-legal issues in psychiatry. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Synopsis 

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441

Severe Psychiatric Illness in the Military Healthcare System

Chapter 27

SEVERE PSYCHIATRIC ILLNESS IN THE 

MILITARY HEALTHCARE SYSTEm

GEOFFREY GRAMMER, MD*

INTRODUCTION

BRIEF PSYCHOTIC DISORDER, SCHIZOPHRENIFORM, AND SCHIZOPHRENIA

SUBSTANCE-INDUCED PSYCHOSIS

BIPOLAR DISORDER

MAJOR DEPRESSIVE DISORDER

POSTTRAUMATIC STRESS DISORDER

REMOTE SITE TREATMENT CONSIDERATIONS

AIR EVACUATION

SUMMARY

*Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia 

Avenue NW, Washington, DC 20307 
442

Combat and Operational Behavioral Health

INTRODUCTION

New military recruits with psychiatric illness often will have their first contact with mental health 

professionals within the military healthcare system. 

Demographics, personal development, and life circumstances contribute to first-presentation illness 

that manifests only after active duty entry. Medical 

standards for enlistment or commission and retention 

effectively select out service members with recurrent or 

chronic mental illness. Providers who care for military 

service members are thus afforded a unique opportunity to set the tone for therapeutic alliances with patients 

unfamiliar with mental healthcare. Providers must also 

contend with patients struggling with insight and acceptance of newly diagnosed mental illness.

Several assumptions are made in this discussion 

of severe psychiatric illness in the military. Diagnoses 

elaborated in this chapter are based on the 4th edition 

of the Diagnostic and Statistical Manual (DSM-IV-TR) of 

the American Psychiatric Association. Combat zones 

are considered to be outside the continental United 

States. Severe mental illnesses include, but are not 

limited to, the diagnoses of brief psychotic disorder, 

schizophreniform disorder, schizophrenia, schizoaffective disorder, delusional disorder, major depressive 

disorder–severe, and bipolar disorder types I and II. 

And finally, the use of antidepressants and neuroleptics requires 4 to 6 weeks before efficacy can be fully 

realized.

Almost 90% of new recruits enlist in the Army 

before the age of 25, thus falling within the window 

of the average age of onset for many psychiatric illnesses.1

 Schizophrenia will begin earlier in men than 

women, but excepting less distinct prodomes, the 

average age of onset falls well within this window. 

Bipolar disorder is considered to have a bimodal peak 

onset, both in early adulthood and again later in life 

(around age 50), a time when many are ending their 

military careers. Depression can begin at any age, but 

the average age of onset is 25, falling well within the 

new-recruit age range. 

Entering into military service is not a decision that 

most take lightly. It requires geographic separation 

from friends and family, changes in daily activities, 

loss of some flexibility enjoyed by civilians, and the 

potential for hazardous deployments. A decision to join 

can challenge one’s existential and phase-of-life development and presents service members with stressors rarely found in the civilian workforce. Drastic life 

changes can be accompanied by destabilizing anxiety, 

a precipitate of psychiatric illness.

Some new recruits enter military service to bring a 

change of direction to their lives. Although most often 

this is a personal developmental milestone followed 

by a successful career, it can sometimes be the result of 

premilitary failings resulting from subclinical or fully 

developed mental illnesses. Obligations required of 

soldiers and the stringent fitness for duty requirements 

may be unknown to those who see military service as 

a chance to bring about a change in their lives. At its 

extreme, recruits may join the military with preexisting 

severe mental illness, often stopping pharmacologic 

treatment shortly before entering basic training to 

facilitate acceptance into service. 

The military operates in environments ranging from 

remote locales with few to no medical facilities through 

major academic medical centers. Soldiers may find 

themselves in garrison, peacetime missions, training 

exercises, or combat zones. Each of these environments 

presents its own unique challenges to new onset or 

recurrence of major psychiatric symptoms. Resources 

at each locale are utilized to control symptoms and 

agitation until definitive care can be administered, 

often within the confines of continental United States 

military medical facilities.

Military mental health professionals provide care 

within the context of the physical disability system 

and military regulations. Providers must often comply with the actions of the physical evaluation board 

(which will determine fitness for duty and potential 

disability ratings), while simultaneously attempting 

to maximize clinical improvement. These competing 

agendas and potential conflicting interests can add 

an unwelcome complexity to patient management. 

Patients undergoing fitness-for-duty and disability 

determination may have a financial or administrative 

disincentive for improvement or accurate reporting of 

decline in their clinical status due to varying degrees 

of conscious and unconscious secondary gain. 

BRIEF PSYCHOTIC DISORDER, SCHIZOPHRENIFORM, AND SCHIZOPHRENIA

The spectrum of primary thought disorders described in the DSM-IV-TR may present uniquely in 

a military community. Though predominately distinguished by length of symptoms, brief psychotic 

disorder may terminate in non-thought-disorder 

diagnoses such as adjustment disorders.2

 Differentiating true schizophreniform disorder (as defined by 

complete resolution of symptoms within 6 months 

of onset) from first-break schizophrenia (which has 

the same symptoms as schizophreniform disorder 
443

Severe Psychiatric Illness in the Military Healthcare System

but lasts for a lifetime) may be possible only after 

clinical observation. Often the clinician will need 

to wait to see if the symptoms persist over time; it 

is estimated that 25% of these cases will resolve.3

Unfortunately for many patients, both brief psychotic disorder and schizophreniform disorder may 

serve only as place markers in the timeline of new 

onset schizophrenia, most commonly a chronic and 

disabling disease. 

A detriment to clinical accuracy can occur with such 

early presentation of primary thought disorders. It is 

common for psychotic symptoms to not be fully developed leading to ambiguous perceptual disturbances, 

delusional beliefs, or executive functioning that may 

make diagnosis more difficult. Premature diagnoses 

of delusional disorder and psychosis not otherwise 

specified may underestimate the severity of illness and 

long-term functional implications if the true disorder is 

schizophrenia. Military providers should consider this 

phenomenon when applying diagnoses and determining treatments and disposition management.

Presentation of psychotic illness is different than 

that seen in the general community. Closer scrutiny 

and command oversight can result in a greater interpersonal immersion than in the civilian workplace. 

Command-directed evaluations can require service 

members to undergo evaluation with a level of dysfunction that may not have reached threshold criteria 

in a civilian healthcare system. Early referral may be 

beneficial, as symptoms may be present for shorter 

periods before presentation to mental healthcare and 

thus offer an opportunity to positively effect long-term 

outcome through early treatment.4,5 Ensuring compliance during initial treatment may enhance outcomes 

and slow declines in function seen in naturalistic studies.6

 Service members undergoing a medical evaluation 

board often wait for months, if not more than a year, 

before adjudication, which offers an opportune time 

for close monitoring of compliance and subsequent 

clinical status.

Pharmacologic management of primary thought 

disorder extends beyond the scope of this chapter. 

Long-term metabolic and extrapyramidal side effects 

should be weighed against proven efficacy for positive 

and negative symptoms and receptor profiles.7 When 

psychosis arises in remote locations, choice of an antipsychotic agent is often more dictated by availability 

than the previously described variables. This may be 

problematic if efficacy is achieved despite long-term 

issues of toxicity.

SUBSTANCE-INDUCED PSYCHOSIS

Intentional and unintentional ingestions of supplements, medications, or illicit substances can result in 

mental status changes that may mimic severe thought 

disorders. History, physical examination, and laboratory testing sometimes detect a particular agent, but 

history may be difficult to obtain from an acutely 

agitated patient. Furthermore, not all substances are 

readily detected in drug screens or routine laboratory 

tests, or laboratory testing may not be possible in some 

field environments. 

Illicit substances and novel ways of utilizing 

items not intended for consumption have their own 

usage trends in the community. Illicit substance use 

has its own variations in popularity depending on 

street costs, accessibility, and cultural acceptance. 

Knowing which items are “in style” can assist with 

more rapid diagnosis of sudden changes in mental 

status. In addition, novel ways of ingesting or inhaling routine items, such as pressurized air, solvents, 

or even brake fluid, can alter mental status. Familiarity with these substances may allow for more 

rapid detection of their use and intervention for 

the potentially life-threatening complications that 

may develop. Collateral history from fellow service 

members, barracks health and welfare inspections, 

and prior substance abuse history may help providers determine if a particular agent is associated with 

behavioral change. 

Withdrawal from substance dependence can not 

only result in an acute change in mental status indistinguishable from primary mental illness, but it may 

also be associated with life-threatening complications. 

Military service with controlled environments—weekend drills, field exercises, combat deployments, and 

military training schools—can interrupt accessibility to 

drugs or alcohol for a chronic substance-using service 

member. Healthcare providers should remain vigilant 

for, and be prepared to treat, such events.

BIPOLAR DISORDER

Bipolar disorder presents diagnostic and management considerations for service members presenting 

with current or past histories of mania. With a bimodal 

onset, it can affect new recruits in their second decade 

or those getting ready to retire in their fifth decade.8

Both are associated with significant adjustments, as 

younger patients will have to contend with management of an indefinite mental illness, and those in 
444

Combat and Operational Behavioral Health

mid-life have retirement and generational phase-of-life 

development potentially derailed with a new-onset 

mental illness. 

Bipolar disorder type I can present with frank 

psychosis, making diagnosis more difficult. Acutely 

agitated patients with grandiose delusions may be indistinguishable from those with agitated schizophrenia 

without collateral history to suggest prior and current 

mood criteria. Misdiagnosis may be more common in 

certain ethnic groups and thus caution should be taken 

when suggesting diagnoses in minority populations.9

Bipolar type II can be less dramatic in its presentations with hypomania. A decreased need for sleep, 

narcissism, and increased goal-directed activity can 

be adaptive for noncommissioned and commissioned 

officers. Presentation for care can commonly occur under times of marked duress, such as a combat deployment, when defenses used in a hypomanic state are 

overwhelmed (leading to decompensation) or during 

depressed mood episodes. Traditional antidepressant 

medications can cause destabilization and thus a careful collateral history is needed for any service member 

presenting with depression, to ensure there have not 

been prior manic symptoms.

Bipolar disorder has a high likelihood of recurrent 

mood episodes and providers should give strong consideration for initiation of a medical evaluation board.10

Environmental changes, lack of access to laboratory 

monitoring, and sleep-cycle changes can destabilize 

this condition, and conversely, early treatment, avoidance of illicit drug and alcohol use, and lifestyle management can improve long-term prognosis.11 Military 

mental healthcare providers are in a unique position 

to affect the course of this illness long after patients 

have separated from the service.

Choice of pharmacologic agents should account 

for likely indefinite treatment and potential long-term 

side effects, such as metabolic impact and tolerance. 

Practice guidelines continue to push the envelope of 

evidenced-based treatments and extend beyond the 

scope of this chapter. Providers, however, should seek 

these resources to remain abreast of agents with the 

most evidence-based efficacy while mitigating potential side effects.12

MAJOR DEPRESSIVE DISORDER

Depression is a common disorder affecting service members of all ages.13 The effect of this illness 

on performance can be more variable than seen 

with primary thought disorders or bipolar disorder, 

ranging between little to no impact on performance 

to marked decrement with potential harm to self or 

others. Remote locales, variable pharmacologic and 

psychotherapeutic resources, command support, and 

psychosocial stressors all can affect treatment decisions 

and disposition.

The DSM-IV-TR does not distinguish between exogenous or endogenous depression. Although many 

cases have some components of external influences 

and endogenous predispositions, unique military 

environments can bring about extraordinary levels of 

environmental stress that challenge the most resilient 

of personalities. Geographic separation from friends 

and family, combat exposure, obligated tours of duty, 

scrutiny from command, loss of privacy, and physical 

demands are some of the unique military stressors 

than can help precipitate a depressed mood. Because 

service members are often unable to change their 

occupations or duty assignments and thus avoid an 

unpleasant stressor, hopelessness may ensue, leading 

to suicidal and/or homicidal thoughts. Even though 

meeting criteria for major depressive disorder, many 

of these service members will have rapid resolution 

of symptoms if medically removed from the situation, 

such as through evacuation, more fitting the intent of 

the diagnosis of adjustment disorder despite being 

incorrect by criteria.14

Whereas overt behavior associated with mania 

and psychosis will garner the attention of peers and 

commanders, isolation associated with a worsening 

depression may go unnoticed. Deployment to areas far 

from mental health resources, stigma associated with 

accessing care, and unwarranted fear of career damage 

if treated may delay entry into care. Ongoing military 

efforts to raise awareness and ease access cannot completely negate these effects. Unfortunately, ready access 

to firearms and heavy machinery make self-injurious 

behavior lethal in a military with a predominately 

younger male population, which has tended to prefer 

this mechanism for suicide.

Fortunately, mild to moderate depression can be 

treated with relative ease using both therapy and psychopharmacology, with medical assets allowing care 

in almost all austere locations. Providers who choose 

to use medications in their treatment of mild to moderate depression should consider agents less likely to 

cause sedation, ataxia, weight gain, or anticholinergic 

side effects because all of these can impair a soldier’s 

performance. Antidepressants with shorter half-lives 

and associated withdrawal phenomenon should also 

be avoided because compliance is not always accommodated by operational tempos. 

Severe depression may be associated with marked 

performance decrement, reality testing impairment, 
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Severe Psychiatric Illness in the Military Healthcare System

or injurious behavior, and should be managed at fixed 

facilities removed from active military operations. 

Diagnostic clarity often requires inpatient observation 

to rule out a depressive episode of bipolar disorder, 

or the presence of a primary thought disorder such as 

schizoaffective disorder, especially if there are comorbid psychotic symptoms. Treatments will likely require 

antidepressant and antipsychotic administration, with 

electroconvulsant therapy (ECT) as an option for those 

refractory to medication, unable to tolerate medication, 

or those with life-threatening severity, such as imminent suicidality or catatonia. Single episode severe 

depression with psychosis warrants strong consideration for a medical board.

POSTTRAUMATIC STRESS DISORDER

Combat-related posttraumatic stress disorder 

(PTSD) may account for up to 20% of inpatient admission to CONUS medical facilities through the 

aeromedical evacuation system.15 Often the symptoms 

of PTSD alone do not lead to inpatient treatment, but 

rather comorbid psychiatric conditions (with or without illicit substance use) manifest potentially dangerous clinic states that necessitate inpatient psychiatric 

treatment. With increased awareness of the phenomenon of PTSD and possible financial disability compensation, patients may find PTSD symptoms easier to 

discuss with providers, thereby masking another major 

psychiatric illness. Providers should remain vigilant 

for confounding illness present in patients who arrive 

with severe disability or safety concerns and insist on 

a sole diagnosis of PTSD. Further discussion of PTSD 

is covered elsewhere and readers are referred to those 

relevant sections of this book.

REMOTE SITE TREATMENT CONSIDERATIONS

Any mental health facility must be prepared to 

handle agitated and violent patients no matter how 

remote the location. Treatment teams need to construct 

contingency plans utilizing whatever resources they 

have available to secure a violent or agitated patient, 

including using restraint and emergency pharmacologic management. For smaller teams, other personnel 

may need to be enlisted to train and potentially assist 

with a restraint. Potential personnel resources may 

include medics, other unit members, military police, 

and battalion aid station staff. Soft-point restraints are 

a Joint Commission standard, but not always available 

on site. Providers may have to use locking ties typically 

reserved for detainees until appropriate restraint can 

be obtained. Pharmacologic treatment of agitation may 

require intramuscular injections that do not require 

refrigeration. 

Pharmacologic options may be limited, particularly 

in immature operational areas. Providers should be 

aware of what medications are available to them and, 

when possible, assist with deciding which medications 

to pack at the start of a mission. Availability of medical 

supplies and utilizing surrounding medical facilities 

can help expand medication options.

If troop movements are ongoing, medical facilities may find themselves occupied with tasks of unit 

relocation and thereby have less capability to provide 

resource intensive care. The threshold for evacuation 

will need to change to accommodate operational 

tempo in these situations. Skill sets of providers may 

also dictate what is feasible, as does patient availability. Expectations of patients to follow up weekly in an 

active combat environment may not be appropriate 

if traveling to and from the medical site is a hazard 

itself. Attending line unit battle update briefings will 

help with accurate intelligence acquisition for ongoing 

operations as well as foster a collaborative relationship 

with commands. 

While awaiting air evacuation, patients should be 

kept in a quiet room with minimal distractions. Patients who suffer from psychosis can misunderstand 

the most basic voice inflection, so providers should interact with these patients in a neutral tone and focus on 

factual information, such as current location, plan for 

evacuation, dosing of medications, and formal names 

of the people who are involved in the patient’s care. A 

patient who is psychotic at a combat stress center can 

be disruptive to soldiers recovering from mood and 

anxiety conditions. Providers should educate other 

patients at the facility about differing disease presentations in an effort to minimize pathologic identification 

for those for whom this would be a concern.

AIR EVACUATION

The international deployment of military forces 

creates a unique situation where patients may be 

evacuated across continents at the beginning of their 

mental healthcare. Although hospitalization alone can 

be an adjustment, time-zone changes, layover in medical facilities, and long evacuation flights may affect 
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Combat and Operational Behavioral Health

the presentation of patients as they move through the 

system.16 Exposing patients to this process is justified 

by the need to get them to a fixed medical facility for 

definitive treatment and fitness-for-duty determination.17 Given the risks of symptom exacerbation and 

subsequent agitation, a low threshold for pharmacologic treatment and possible physical restraint should 

be considered. 

Another consequence of medical evacuation is 

evolution of clinical state when service members reach 

rear-echelon medical facilities. There may be numerous 

reasons for such an occurrence. Once removed from 

whatever stressor may have precipitated or aggravated 

their condition, some service members will reconstitute quickly en route. Other patients may have time to 

reflect on consequences of admitting to delusional belief systems or to the presence of hallucinatory events, 

and thus began to recant their stories given the reaction 

of those to whom they had confided. Some service 

members may admit to severe psychiatric symptoms 

with secondary gain as a motivator and, upon seemingly realizing their objective, begin to report a rapid 

recovery to escape the mental healthcare system. Treatments instituted at the lower echelon of care may have 

a rapid effect leading to genuine symptom improvement. The end result is that patients diagnosed with 

severe psychiatric disorders at lower echelons of care 

may look different and much less ill when arriving at 

a tertiary treatment facility. 

Providers should not dismiss collateral and observed behavior noted downrange. Underestimation 

of severity of illness can have consequences to both 

patient care and unit readiness. Upon arrival at the 

definitive care facility, medical records should be 

reviewed and collateral contacts made with medical 

personnel involved in the care of the patient prior 

to that point. Existence of electronic record systems 

should facilitate continuity of care, but austere environments may not allow for such a convenience and 

physical records may not survive extensive evacuation routes. Providers should make concerted efforts 

at overcoming inherent obstacles to continuity that 

military operations may create.

Command should be notified of the patient’s arrival at each step along an evacuation route. It is 

not uncommon for patients to be evacuated from an 

operational area with such efficiency as to outpace 

command notification. In addition, commands can 

provide invaluable collateral data on history of presentation, premorbid functioning, known interpersonal 

and social stressors, environmental exposures, and 

actions that may be subject to the Uniform Code of 

Military Justice. 

Patients should receive a thorough medicalpsychiatric assessment upon arrival at definitive 

treatment facilities. Lower echelons of care may not 

have resources available to meet practice guideline 

recommendations for medical workup of the psychiatric patient. The receiving facility should ensure 

that psychiatric symptoms do not have a medical or 

substance-induced cause. Operational environments 

downrange may also have competing priorities, such 

as ongoing combat operations, that prevent providers 

from completing a thorough assessment. In some cases, 

an expeditious evaluation may have been formed to 

determine appropriateness for evacuation and initial 

management. Some patients may require tests, such 

as a positron emission tomography scan, magnetic 

resonance imaging, or electroencephalography, that can 

only be performed at higher echelon facilities. Finally, 

case load downrange may not lend itself to a thorough 

psychiatric assessment that can be performed at a major 

medical facility with subspecialty consultations and 

graduate medical education programs.

SUMMARY

Severe psychiatric illness represents an important 

component of military mental healthcare. Unique 

aspects of military service and operations may impact presentation and disease processes. Military 

mental health providers should be familiar with 

the management of severe psychiatric illness and 

the nuances of its treatment in an operational environment. 

REFERENCES

1. Civilian data from Bureau of Labor Statistics Current Population Survey File; 2004. Available at: http://www.defenselink.mil/prhome/poprep2004/enlisted_accessions/age.html. Accessed May 28, 2008.

2. Beighley PS, Brown GR, Thompson JW Jr. DSM-III-R brief reactive psychosis among Air Force recruits. J Clin Psychiatry. 

1992;53:283–288.

3. Zhang-Wong J, Beiser M, Bean G, Iacono WG. Five-year course of schizophreniform disorder. Psychiatry Res. 1995;59(1–

2):109–117.
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Severe Psychiatric Illness in the Military Healthcare System

4. Jarskog LF, Lieberman JA. Neuroprotection in schizophrenia. J Clin Psychiatry. 2006;67(9):e09.

5. Wyatt RJ, Henter I. Rationale for the study of early intervention. Schizophr Res. 2001;51(1):69–76.

6. McGlashan TH. A selective review of recent North American long-term followup studies of schizophrenia. Schizophr 

Bull. 1988;14:515–542.

7. Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. 

N Engl J Med. 2005;353(12):1209–1223.

8. Hale RE, Yudofsky SC, eds. The American Psychiatric Publishing Textbook of Clinical Psychiatry. 4th ed. Washington, DC: 

American Psychiatric Publishing; 2003: 490. 

9. Mukherjee S, Shukla S, Woodle J, Rosen AM, Olarte S. Misdiagnosis of schizophrenia in bipolar patients: a multiethnic 

comparison. Am J Psychiatry. 1983;140(12):1571–1574.

10. Tohen M, Zarate CA Jr, Hennen J, et al. The McLean-Harvard First-Episode Mania Study: prediction of recovery and 

first recurrence. Am J Psychiatry. 2003;160(12):2099–2107.

11. Post RM. Kindling and sensitization as models for affective episode recurrence, cyclicity, and tolerance phenomena. 

Neurosci Biobehav Rev. 2007;31(6):858–873.

12. Suppes T, Dennehy EB, Hirschfeld RM, et al. The Texas implementation of medication algorithms: update to the 

algorithms for treatment of bipolar I disorder. J Clin Psychiatry. 2005;66(7):870–886.

13. Grammer GG, Cooper M. National Collaborative Study of Early Psychosis and Suicide: New Onset Psychosis in New Military 

Service Members. Bailey K Ashford Research Award. Washington, DC: Walter Reed Army Medical Center; 2001.

14. American Psychiatric Association. Quick Reference to the Diagnostic Criteria From DSM-IV-TR. Washington, DC: American 

Psychiatric Association; 2005.

15. Data on file at Department of Psychiatry, Walter Reed Army Medical Center, Washington, DC; 2004.

16. Ritchie EC. Psychiatric patients. In: Hurd WW, Jernigan JG, eds. Aeromedical Evacuation: Management of Acute and 

Stabilized Patients. New York, NY: Springer-Verlag; 2003: Chap 26.

17. Ritchie EC, Morse JH, Brewer PG. Surviving the “air evac”: medical and logistical issues of evacuating psychiatric 

patients by air from Korea to the United States. Mil Med. 1996;161(5):298–302.
448

Combat and Operational Behavioral Health
449

Eating Disorders

Chapter 28

EATING DISORDERS

GAIL H. MANOS, MD*; JANIS CARLTON, MD, PhD†; and AILEEN KIM, MD‡

INTRODUCTION

OVERVIEW OF EATING DISORDERS

ETIOLOGY

CLINICAL FEATURES

DIFFERENTIAL DIAGNOSIS

COURSE AND PROGNOSIS

ABNORMAL EATING IN MILITARY POPULATIONS

MEDICAL AND PSYCHIATRIC TREATMENT OF EATING DISORDERS

TREATMENT OF EATING DISORDER ISSUES IN THE COMBAT ENVIRONMENT

AREAS FOR FURTHER RESEARCH

SUMMARY

*Captain, Medical Corps, US Navy; Navy Psychiatry Specialty Leader and Senior Medical Officer, Director of Mental Health, Naval Medical Center 

Portsmouth, 620 John Paul Jones Road, Portsmouth, Virginia 23708; formerly, Psychiatry Residency Training Director, Department of Psychiatry, 

Naval Medical Center Portsmouth, Portsmouth, Virginia

†

Commander, Medical Corps, US Navy; Department Head, Psychological Health and Traumatic Brain Injury, Building 7, Room 600, National Naval 

Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889; formerly, Department Head, Mental Health, Naval Hospital, Camp Lejeune, 

North Carolina 

‡

Lieutenant Commander, Medical Corps, US Navy; Staff Psychiatrist, Department of Behavioral Health, Building 7, 3rd Floor, National Naval Medical 

Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889; formerly, Chief Resident, Department of Psychiatry, Naval Medical Center Portsmouth, 

Portsmouth, Virginia
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Combat and Operational Behavioral Health

INTRODUCTION

Over the past decade, the growing obesity epidemic 

in the United States has received increased attention. 

Like the general population, the US military is experiencing an increase in those classified as overweight 

(54%) despite high physical activity levels.1 Although 

the majority of Americans are overweight or even 

obese by Centers for Disease Control and Prevention 

standards,2 the ideal body image as portrayed by 

television, movie, and fashion mediums appears to be 

underweight. This ideal may drive some individuals 

to abnormal eating behaviors, such as food restriction 

or bingeing with compensatory behaviors. Military 

service members may be particularly at risk because 

of the expectation that they conform to specific weight 

standards, with adverse career consequences for 

those who fail to live up to those standards. Under 

the stress of deployment to a combat zone, service 

members with an eating disorder may experience an 

exacerbation of their illness. Even those without a history of an eating disorder may develop poor eating 

habits as a reaction to stress, or, ironically, due to the 

ready availability of fast food in some locations. On 

the other hand, for some individuals, eating behaviors 

and overall fitness may improve in the military, with 

nutritional counseling and time for physical exercise 

more available.

The rates of eating disorders in the military parallel 

those reported in high-risk groups such as athletes and 

dancers, who place an emphasis on thinness.3,4 Abnormal eating and dieting behaviors are reported in 25% 

to 76% of female service members, with a significant 

increase around the time of personal fitness assessments (PFAs).5

 Because deployed service members 

are not subject to PFAs, they may feel less pressured to 

engage in the abnormal eating and dieting behaviors. 

Also, with meals eaten community style and public 

bathrooms, binge and purge behaviors may be more 

difficult to enact.

The diagnosis of an established eating disorder does 

not necessarily preclude deployment if the service 

member’s condition is in remission. For example, a 

physician deployed several years ago soon became 

overwhelmed with the stress of her duties and separation from family, leading to repetitive bingeing and 

intentional vomiting several times a day. She had 

previously avoided mental health treatment due to 

concerns about an adverse impact on her career. She 

was subsequently medically evacuated and treated 

for her bulimic behaviors and depression by one of 

the authors. Three years later, both her depressive 

symptoms and bulimia were in remission, allowing 

her to successfully deploy to a combat zone. Unlike 

the outcome in this case, other service members with 

eating disorders have experienced recurrence of their 

symptoms under the stress of deployment, resulting 

in early returns. 

This chapter presents information on the identification and recognition of eating disorders, medical 

complications, treatment, and prognoses. The authors 

also review available literature on eating disorder behaviors in military populations and potential risks of 

deploying individuals with an eating disorder.

OVERVIEW OF EATING DISORDERS

Eating disorders consist of a group of increasingly common psychiatric and medical conditions 

that have been studied extensively in women and 

in certain groups of men. The risks of both bulimia 

nervosa (BN) and binge eating disorder (BED) in 

the general population have increased with successive birth cohorts.6

 Anorexia nervosa (AN) was 

described in the scientific literature by Sir William 

Gull (in 1873) as a “mental state [that] destroys the 

appetite.”7 BN, marked by episodes of bingeing and 

purging, was first described in 1979.8 The lifetime 

prevalence for women in the general population is 

estimated as 0.5% to 1% for AN and 1% to 3% for BN. 

Rates for men were previously estimated to be about 

one tenth as high as those for women.9

 However, in 

2007, the National Comorbidity Survey Replication6

found that the estimated point prevalence of BN in 

men is significantly higher than previously thought, 

approximately one fifth that in women. Eating disorder not otherwise specified (EDNOS) is a residual 

category for conditions that do not meet the full 

criteria for AN or BN. It is difficult to determine 

the prevalence of EDNOS, but estimates range from 

1% to 30% in men and women.10 As many as 60% of 

treated eating disorder cases fall into the EDNOS 

category.11 It is estimated that only about one third 

of individuals with AN and 6% of those with BN 

receive mental healthcare,12 although the majority 

of persons with eating disorders receive treatment 

for another mental health complaint.6 Because physicians infrequently assess for eating disorders, and 

patients rarely spontaneously disclose them, these 

disorders may be underdiagnosed.6

 Healthcare providers should routinely ask patients about eating 

disorder symptoms even when these symptoms are 

not the presenting complaint.
451

Eating Disorders

Anorexia Nervosa

AN is a psychiatric disorder characterized by extreme weight loss in the absence of a medical cause, 

refusal to regain weight, and intense determination to 

continue or maintain weight loss. Patients with AN 

may deny that they are underweight and take measures to conceal their emaciation with bulky clothes 

to avoid being “ordered” to gain weight by family 

members or doctors. Typically, onset is between the 

ages of 13 and 20, peaking at 17 to 18 years of age.10

AN is defined by the Diagnostic and Statistical Manual 

of Mental Disorders, 4th edition (DSM-IV),9 as including 

the following conditions: 

1. the refusal to maintain body weight at or 

above a minimally normal weight (approximately 85% of those with the AN are below 

ideal body weight);

2. an intense fear of gaining weight or becoming 

fat, even though underweight;

3. a disturbance in the way in which one’s 

body weight or shape is experienced, undue 

influence of body weight or shape on selfevaluation, or denial of the seriousness of 

current low body weight; and

4. in postmenarcheal females, amenorrhea (ie, 

the absence of at least three consecutive menstrual cycles).

AN can be divided into (a) the restricting type, in 

which the individual does not engage regularly in 

bingeing or purging behaviors, but severely restricts 

calories intake, and (b) the bingeing/purging type, 

in which the individual meets criteria for AN and 

engages regularly in binge/purge behaviors such as 

self-induced vomiting and laxative or diuretic misuse. 

Exhibit 28-1 lists the warning signs and symptoms of 

AN. 

Bulimia Nervosa

BN is defined according to the DSM-IV9

 as consisting of the following conditions:

1. recurrent episodes of binge eating, with the 

binge episode characterized by eating within 

a certain time period more food than most 

people would eat in the same time period 

and under the same circumstances, including 

a sense of lack of control over eating during 

the episode;

2. recurrent inappropriate compensatory behavior to prevent weight gain;

3. binge eating and inappropriate behaviors occurring at least twice weekly for 3 months;

4. self-evaluation unduly influenced by body 

shape and weight; and

5. episodes not occurring exclusively during 

episodes of AN.

BN can be divided into purging and nonpurging 

types; during the latter, individuals use inappropriate 

compensatory behaviors such as fasting or excessive 

exercise rather than engaging regularly in vomiting, 

laxative use, diuretics, or enemas. Purging-type BN 

differs from purging-type AN in that patients with 

the latter are significantly underweight. The onset 

of BN is usually late adolescence to early adulthood. 

EXHIBIT 28-1

WARNING SIGNS OF ANOREXIA 

NERVOSA

	 •	 Abnormal weight loss without a medical 

cause

	 •	 Severe restriction of food intake

	 •	 Denial of hunger and/or a problem with low

weight

	 •	 Strict food preferences, such as complete

avoidance of foods containing fat or strict 

vegetarianism

	 •	 Intense fear of gaining weight and determination to continue weight loss

	 •	 Abnormal reproductive functioning (loss of

interest in sex, amenorrhea in females, low 

testosterone in males)

	 •	 Excessive exercise despite fatigue and weakness

	 •	 Unusual behaviors or rituals with meal

preparation and eating

	 •	 Distorted perception of weight or body

shape

	 •	 Inability to stop losing weight or decrease

exercise

	 •	 Unrealistically high self-expectations; perfectionism with a sense of ineffectiveness

	 •	 Use of dangerous methods to lose weight

	 •	 Belief that body weight and shape are extremely important to self-esteem and selfdefinition

	 •	 Psychological symptoms of starvation (eg,

depression, difficulty concentrating, social 

withdrawal)

	 •	 Physical signs of starvation (eg, sensitivity to

cold, fine hair on the face or body, emaciation)
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Combat and Operational Behavioral Health

Warning signs and symptoms of BN are shown in 

Exhibit 28-2.

Eating Disorder Not Otherwise Specified

The EDNOS category is considered by some to be 

overly broad, whereas the criteria for BN or AN may be 

too rigid. Examples of EDNOS include meeting all the 

criteria of AN except for amenorrhea or being underweight, meeting criteria for BN except for frequency 

of episodes, or engaging in purging behaviors without 

binge episodes. BED, bingeing without compensatory 

behaviors, is a category proposed in the DSM-IV for 

further study. Although only 1% of the general population is felt to meet strict DSM-IV diagnostic criteria for 

BED,11 the prevalence of binge behaviors is thought to 

be significantly higher. Night-eating syndrome (NES) 

is characterized by continual eating during evening 

hours between dinner and breakfast, accompanied by 

negative feelings about the eating behavior, insomnia, 

and nocturnal awakenings followed by food intake. 

Prevalence for this condition is estimated at 1.5% of 

the general population.13 Like BED, the prevalence of 

NES is significantly higher in overweight and obese 

individuals. NES is also a category proposed in the 

DSM-IV for further study. 

Obesity

Increasing media attention has focused on overeating and obesity. According to the World Health 

Organization, a body mass index (BMI) of 18.5 to 24.9 

is normal, a BMI of 25 to 29.9 is overweight, and a 

BMI greater than 30 is obese. The Centers for Disease 

Control and Prevention report that 51% of American 

women are overweight and 34% are obese.2 Although 

obesity is not itself considered an eating disorder, up 

to 50% of obese individuals, particularly those seeking bariatric surgery, have BED or NES.11,13 A crosssectional analysis from the US Department of Defense 

Survey of Health-Related Behaviors found that 10% of 

active duty men and 4% of active duty women were 

obese.14 Based on data from the general population, it 

is likely that many of these individuals have an eating 

disorder contributing to their obesity; thus, recognition 

of eating disorders directly impacts fitness for duty 

and deployability. 

EXHIBIT 28-2

WARNING SIGNS OF BULIMIA NERVOSA

•	 Fluctuations in weight, usually within about

15 lb of normal weight

	 •	 Fear of gaining weight

	 •	 Uncontrollable, secretive episodes of binge

eating followed by attempts to purge by 

vomiting, laxatives, etc

	 •	 Excessive exercise for weight control

	 •	 Physical problems with the throat, stomach,

and colon; swelling of the parotid glands

	 •	 Dental problems, tooth decay

	 •	 Psychological problems such as depression,

mood swings, impulsivity

	 •	 Dissatisfaction with body shape and preoccupation with weight loss

	 •	 Belief that body weight and shape are extremely important to self-esteem and selfdefinition

•	 Unrealistically high self-expectations; perfectionism with a sense of ineffectiveness

ETIOLOGY

The etiology of eating disorders includes genetic, 

biological, sociocultural, psychological, familial, developmental, and comorbid factors.15 Although all eating 

disorders are characterized by an abnormal relationship with food, and usually a disturbance in body 

image, the underlying factors vary with the type of 

eating disorder. Although it is important to understand 

etiological factors commonly found in the different 

eating disorders, it is also necessary to remember that 

each person is an individual with a complex history 

and a unique set of characteristics.

Biological Factors

Brain serotonin, norepinephrine, dopamine, endogenous opioids, and a variety of neuropeptides 

(eg, leptin, neuropeptide Y) have been implicated in 

appetite, food intake, satiety, and the development of 

eating disorders.16 Traditionally, the catecholamines, 

particularly norepinephrine and dopamine, have been 

associated with appetite or onset of eating. Serotonin 

has been associated with satiety or cessation of an 

eating episode as well as specific carbohydrate cravings sometimes associated with binges. Disorders of 

appetite, satiety, or both, underlie abnormal eating 

behaviors. This may be relevant to the mechanism of 

action for medications, particularly antidepressants 

that modulate brain serotonin and catecholamine 

activity in the treatment of eating disorders.

Eating disorders co-occur more frequently in 
453

Eating Disorders

monozygotic twins (50% concordance rate) than in 

dizygotic twins (10% concordance) and are more 

likely to occur in first-degree relatives of patients 

with eating disorders than in the general population. 

Genetic factors account for 58% to 76% of the variance 

in AN and for 54% to 83% of the variance in BN, with 

a 7- to 12-fold increase in prevalence among relatives.17 Some studies have found a link between the 

serotonin receptor 5-HT2A gene polymorphism in 

the promoter region and eating disorders.18 Enhanced 

5-HT2A receptor binding suggestive of serotonergic 

dysfunction has been found in AN and BN patients.19

Polymorphism of the 5-HT1B receptor gene has also 

been linked to minimum lifetime BMI in women with 

BN.20 These findings suggest that some individuals are 

more at risk genetically than others to developing an 

eating disorder. The increasing incidence of these disorders in society may be the result of the sociocultural 

importance placed on body image and thinness that 

has allowed more people with a genetic predisposition 

for AN or BN to develop an eating disorder.

Although all the complex peripheral and central 

mechanisms that regulate appetite, food intake, and 

body weight are not yet understood, most people 

maintain a body weight around a relatively stable 

“set point” or “settling point,” which changes across 

the age span in a predictable manner. In individuals 

with an eating disorder, regulation of appetite—and 

in many cases body weight—is thrown out of balance. People who engage in periods of excessive food 

restriction that may be followed by binges ignore the 

biological signals of hunger and satiation. Binge behaviors may be a natural holdover from a time when 

humans foraged or hunted for food and needed to eat 

as much as possible before food was lost to competitors or spoilage.

Sociocultural Factors

Social and cultural factors are important in the 

development of both AN and BN. Although the stereotype persists that these disorders, particularly AN, 

are more common in higher socioeconomic groups, 

most of this evidence is based on small, uncontrolled 

case series.7

 These eating disorders are most common 

in Western cultures, where tasty, high-calorie food is 

abundant. Evidence suggests that, as other cultures 

have become richer and more Westernized, body 

dissatisfaction has grown and eating disorders have 

increased.21

Obesity is considered a socioculturally driven eating 

disorder. Individuals and families dine more often in 

restaurants, where the food served is often high in fat 

and in large portions. The media present conflicting 

signals: on one hand, images show thin, happy families eating at fast food restaurants; on the other hand, 

magazines present not only the latest fad diet, but 

also recipes for beautiful, high-calorie dishes. Eating 

is a social or family event. From an early age, many 

people learn to see tasty foods as a reward for good 

behavior or accomplishment. As individuals struggle 

to lose or maintain weight by severely restricting intake 

or skipping meals, they may trigger the urge to binge 

or impulsively overeat, followed by guilt, and in the 

case of bulimics, purging or using other compensatory 

behaviors. In an effort to demonstrate control, patients 

with AN may simply refuse to indulge.

Psychological and Family Factors

Families or first-degree relatives of individuals 

with eating disorders have a higher rate of eating 

disorders (approximately 10% vs 1%–3% in the general population). Although these rates may indicate a 

genetic component, there is also evidence for learning 

and modeling within the family and from peers.22

Patients with eating disorders frequently report that 

their parents or siblings were overly concerned with 

body weight and external appearances. Often, their 

first diet was started in response to criticism from a 

family member or friend.

Families of patients with AN are often described as 

perfectionistic, with one or both parents described as 

authoritarian and having high expectations for their 

children. Psychological factors in the development of 

AN include a drive to perfection, unrealistic self-expectations, and perhaps a misdirected search for autonomy 

and self-control through control of food intake and 

weight. The primary comorbid psychiatric condition 

associated with AN is depression, although it is not clear 

if this is a preceding condition or a result of AN.

Families of patients with BN are more often described as chaotic, with a higher rate of mood disorders, substance abuse, and eating disorders. A history 

of sexual abuse during childhood has been reported in 

one third to nearly one half of women with BN.23,24 A 

review of 53 controlled studies that examined the link 

between sexual abuse and eating disorders found that 

childhood sexual abuse was a risk factor for eating disorders, particularly BN, with psychiatric comorbidity.25

Furthermore, women who had experienced both childhood sexual abuse and rape in adulthood had even 

higher rates of eating disorder behavior and marked 

impulsivity.25 Conditions associated comorbidly with 

BN—including borderline personality disorder, substance abuse, and mood instability—have also been 

found to be more prevalent in people with a history of 

childhood abuse.26 Childhood sexual abuse may lead 

to diminished self-esteem, development of maladaptive behaviors (including eating disorders), and place-
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Combat and Operational Behavioral Health

ment of individuals at risk for further trauma.

A study of 1,887 female Navy recruits found that 

57% had a history of childhood physical or sexual 

abuse or both, and 35% had been sexually assaulted 

as adults.27 In addition, women who were raped as 

adults were 4.8-fold more likely to have experienced 

childhood sexual abuse. Trauma may also result in 

psychobiological changes that increase vulnerability 

to developing an eating disorder. These findings suggest that healthcare providers should ask about eating 

patterns, purging behaviors, and body image in female 

service members with a history of abuse.

CLINICAL FEATURES

Eating disorders are often hidden.28 The individual 

may consider these behaviors to be shameful or may 

lack insight into their pathological nature. Patients 

with restricting-type AN may move food around on 

their plates or otherwise disguise their lack of food 

consumption. Individuals with BN may eat normally 

but subsequently purge in secret. Those with AN may 

be easier to identify based on height and weight measurements and their emaciated appearance. A BMI of 

less than 17.5 in an individual from Western cultures, 

where food is abundant, should raise suspicion among 

healthcare workers and prompt further evaluation. It 

may be more difficult to spot BN or EDNOS among 

normal-weight individuals. 

In an operational environment, service members 

with BN may find it more difficult to binge and purge 

because of lack of privacy for these behaviors. One 

of the authors treated a female service member who 

carried a plastic bag into which she vomited in secret 

due to lack of privacy in the latrine area. She would 

then wait to dispose of the bag into a trash receptacle 

when no one was looking. On the other hand, excessive exercise as a compensatory behavior may easily be overlooked as adaptive rather than disguising 

pathological behavior.

Medical Findings

Anorexia Nervosa

In addition to an emaciated appearance with 

sunken cheeks, prominent bone structure, low body 

fat, and muscle wasting, patients with AN may have 

dry skin, hypercarotenemia (manifested by a yelloworange discoloration of the skin); lanugo (fine, downy 

hair covering the body to compensate for lower 

body temperature resulting from loss of body fat); 

acrocyanosis (digits of the hands and feet become 

blue and sweaty from decreased circulation); and 

atrophy of the breasts.28–30 Symptoms of concomitant 

hypothyroidism include hair loss, peripheral edema, 

and sensitivity to cold. Tachypnea and shortness of 

breath may result from metabolic alkalosis caused 

by vomiting. Conversely, metabolic acidosis may occur from laxative abuse.31 Gastrointestinal symptoms 

include pain, bloating, and severe constipation (from 

starvation, chronic laxative abuse, or both) that may 

result in obstruction and megacolon. Exercise-induced 

disorders (eg, hernias, shin splints, and other injuries) 

are also common.

Cardiac problems include mitral valve prolapse, 

prolongation of the corrected QT interval, sinus bradycardia, and arrhythmias from electrolyte imbalance 

(particularly hypokalemia).27 Pneumomediastinum 

induced by vomiting32 or cardiomyopathy (from ipecac poisoning)28 may be seen on a radiograph. The 

heart is often strophic due to chronic hypovolemia.33

The second leading cause of death in AN is cardiac 

arrhythmia. Central nervous system changes include 

nonspecific electroencephalogram changes and generalized reversible atrophy associated with starvation 

and dehydration.

Osteoporosis occurs in half of women with AN and 

can lead to compression fractures and kyphosis.34,35

Patients with AN have a 3-fold higher risk of fracture 

than those who do not. Bone loss may develop in as 

short a time as 6 months after onset of the illness and 

persist even after recovery, leading to a long-term risk 

of fractures. Fractures were found in 57% of women 

with AN in the ensuing 20-year period after onset.36

Although most studies of osteoporosis in AN have 

focused on women, one study37 found that 50% of men 

with eating disorders had lumbar spine and femoral 

neck bone densities more than two standard deviations below those of age-matched controls. Compared 

with women with eating disorders, this group of men 

had more severe bone loss. Andersen, Watson, and 

Schlechte37 suggested that the correlation between 

reduced body weight in men and lowered testosterone 

led to more bone loss. Given the increased physical 

demands in an operational environment, those with 

AN may be at even higher risk for fractures. 

Bulimia Nervosa

Patients with BN and other binge/purge conditions 

usually have normal weight without the concomitant 

features of starvation. Even patients with bingeing/

purging-type AN do not achieve as low a body weight 

as restrictive-type AN patients. External examination 
455

Eating Disorders

may reveal damage to teeth and gums from acidic 

vomit. Russell sign is the calloused posterior surface 

of one or more fingers used to induce vomiting. Physical findings include gastrointestinal disorders (eg, 

sequelae of laxative abuse, esophageal tearing from 

excessive vomiting, and complications of electrolyte 

imbalance, including metabolic alkalosis and cardiac 

arrhythmias).28,31

Laboratory Studies

Serum chemistry may show electrolyte disturbances. Patients who purge may develop hypokalemia, 

hypochloremia, and elevated serum bicarbonate.38

Hypokalemia appears to be particularly common, occurring in up to one half of those who purge; however, 

the ratio of urinary sodium to urinary chloride may be 

a better predictor of purging behavior than serum hypokalemia.39 Metabolic acidosis with low serum bicarbonate may occur in laxative abusers.38 Hyponatremia 

may result from water intoxication or a syndrome of 

inappropriate antidiuretic hormone.28

Other laboratory abnormalities include anemia; 

leucopenia, neutropenia, and thrombocytopenia40; 

hypercholesterolemia41; and euthyroid sick syndrome 

with normal thyroid-stimulating hormone and low 

triiodothyronine and thyroxine.28,42 Hypercarotenemia has been proposed as a laboratory marker for 

restricting-type AN, with a sensitivity of 62% and a 

specificity of 83% when a cutoff marker of 200 μg/mL 

is used.30 In one study of patients with AN, high serum 

creatinine and uric acid levels were associated with a 

chronic disease course, whereas low serum albumin 

and low body weight predicted lethality.38

DIFFERENTIAL DIAGNOSIS

Medical conditions that must be considered in the 

differential diagnosis include inflammatory bowel 

disease, thyroid disease, abdominal malignancy, central nervous system disease or tumor, and new-onset 

diabetes mellitus. The psychiatric differential includes 

depression, substance abuse, psychosis, and obsessivecompulsive disorder. Comorbidity with psychiatric 

conditions (including depression, psychosis, anxiety, 

personality disorder, and substance abuse) must also 

be addressed.

COURSE AND PROGNOSIS

Anorexia Nervosa

AN is associated with significant morbidity and 

mortality. It is usually a chronic, sometimes life-long 

disease with low full recovery rates. In a review of 

studies43 conducted with patients at least 4 years after 

onset of illness, approximately 24% had what was 

considered a poor outcome (eg, never reached target 

weight gain within 15% of normal, had not established 

regular menses). Another 44% were considered to have 

a good outcome (eg, achieved and maintained weight 

within 15% of normal, had regular menses). About 28% 

had outcomes that fell between poor and good. The 

mortality rate was 5%. Even among those judged to 

be recovered based on body weight and menses, two 

thirds continued to struggle with body image, obsessive preoccupation with weight and appearance, and 

disordered eating habits.

Crude 10-year mortality rates for patients receiving 

treatment for AN has been cited at 3.3% to 5.6%.44,45

Twenty-year mortality rates are 15% to 20%, with suicide and cardiac arrest the leading causes of death.46–49

The annual mortality rate associated with AN is 12-

fold higher than the annual death rate as a result of all 

causes of death for women in the general population 

15 to 24 years of age.46 AN is associated with social and 

functional impairments,41 as well as with medical and 

psychiatric morbidities.47 

Bulimia Nervosa

There is limited evidence that some untreated 

patients with BN have modest rates of improvement 

or recovery. For patients treated with either psychotherapy or medication, the short-term improvement 

rates are 50% to 70%; however, relapse rates are high 

(30%–50% in 6 months to 6 years follow-up).50,51 Longer-term prognosis may be somewhat better. Patients 

with milder symptoms and fewer medical and psychiatric comorbidities who do not require hospitalization 

have a better course and prognosis. The mortality rate 

for BN has been cited at 0.3% per year.52 A metaanalysis of standardized mortality rates in BN 5 to 11 years 

after diagnosis found a 7-fold greater mortality rate 

than expected.51 

Eating Disorder Not Otherwise Specified

The only study to date that reported mortality information on EDNOS found that 4 of 28 subjects had 

died in an 11-year follow-up.53 The risk of dying may 

be greater in the first few years after diagnosis of an 
456

Combat and Operational Behavioral Health

eating disorder. A review of 10 eating disorder populations found a 2% risk of dying for women in the first year after presentation and a 5% risk of dying for men 

in the first and second years.53

ABNORMAL EATING IN MILITARY POPULATIONS

Research on eating disorders in military populations 

primarily consists of case reports54–56 and surveys of 

military populations within gender or service. These 

surveys generally rely on self-reporting, which in civilian populations has been shown to underestimate 

pathological weight-control behaviors.57 A summary of 

the published literature assessing eating disorders in 

military populations is provided in Table 28-1. There 

are no studies of eating disorders in military populations in combat operational environments.

McNulty5 surveyed prevalence and contributing 

factors of abnormal eating behaviors in 3,000 active 

duty women in the US Army, Navy, Air Force, and 

Marine Corps. The rate of AN was highest in the 

Marine Corps, at 4.9%. Rates across the other services 

were Army, 1.3%; Navy, 1.1%; and Air Force, 0.8%. 

The rate of BN was again highest among marines at 

15.9%. Rates in other services were Army, 4.3%; Navy, 

5.2%; and Air Force, 9.3%. Rates of EDNOS were far 

higher: 62.8% of the total population met the criteria 

for this diagnosis. Again, the Marine Corps reported 

a significantly higher rate: 76.7%. The rates for the 

other services were Army, 57.4%; Navy, 61.2%; and Air 

Force, 58.6%. Notably, more than 60% of respondents 

had some type of eating disorder, and nearly every 

Marine Corps respondent (97.5%) met criteria for an 

eating disorder. Of those with an eating disorder at the 

time of the survey, the overwhelming majority had no 

history of previous eating disorder and negative family histories. Fasting or purging increased during PFA 

periods, suggesting that the military environment may 

put women at risk for eating disorders and increased 

use of unhealthy strategies of weight reduction to 

meet standards.

In a survey of 423 active duty Army women (officers and enlisted personnel) from medical and field 

commands, Lauder and colleagues58 found that 142 

women (33.6%) were at risk for abnormal eating behaviors. These at-risk women admitted to abnormal 

eating or purging behaviors more than once a month 

for 3 months, or had high scores of body dissatisfaction and a drive for thinness associated with a BMI 

of less than 21. Of the 142 women deemed at risk 

by the survey, 108 completed a structured interview 

with a board-certified psychiatrist. Of this number, 

33 were diagnosed with an eating disorder. The other 

women had specific stressors, such as PFA periods, that 

prompted their abnormal eating behaviors. Therefore, 

8% of the total sample was diagnosed with an eating 

disorder, and 3.1% met criteria for an eating disorder 

situational to the military environment. In a follow-up 

study of this same population, Lauder et al59 evaluated 

their subjects for the prevalence of the female athlete 

triad, defined by the presence of an eating disorder, 

amenorrhea, and osteoporosis. They found no subjects who met the full triad, although, as they pointed 

out, the military physical activities that the subjects 

participated in may have had a protective effect on 

bone mass density.

McNulty60 surveyed 1,425 Navy men from medical and line communities. She reported prevalence 

for AN (2.5%), BN (6.8%), and EDNOS (40.8%) in this 

population. Purging behaviors increased dramatically 

(up to 15%) during PFA periods. Fasting during these 

times occurred in nearly one third of respondents. 

Stressors of military life significant for AN, BN, or 

EDNOS included failing to be selected for advanced 

training schools, fear of being involuntarily separated, 

mandatory physical fitness, nonsupport of a supervisor, height/weight requirements, and rotating shifts. 

McNulty further reported that some sailors spoke of 

anger and discouragement over the PFA and their personal struggles with weight. One soldier even reported 

past suicidal ideation associated with the issue.

In a similar survey of 1,323 female Navy nurses, 

McNulty61 reported the prevalence of AN (1.1%), BN 

(12.5%), and EDNOS (36%). To lose weight rapidly, 

these respondents reported skipping meals (44.4%), 

binge eating (19.2%), exercising excessively (16.9%), 

using diet pills (8.5%), using laxatives (7.1%), and 

vomiting (3%). Poor body image and satisfaction 

were predictors of eating disorders, as were height 

(in AN) and weight (in BN). Work-related stressors 

that adversely impacted eating disorder behaviors 

included working in an undesired area or in the intensive care unit, rotating shifts, and being a staff nurse. 

It is unclear if the high rates of BN and EDNOS in the 

survey personnel, compared with the general population, were related to their status as military officers 

or their occupation as nurses. Other studies of eating 

behaviors in nursing students have found conflicting results. A study of female medical students and 

nursing students found abnormal eating behaviors 

in one fifth of the respondents, with a higher rate in 

the nursing students.62 Another study found a similar 

rate of overall abnormal eating behaviors in nursing, 

medical, and art students (~20%), but no difference 

among the three groups.63
457

Eating Disorders

TABLE 28-1 

SUMMARY OF ABNORMAL EATING BEHAVIOR STUDIES IN MILITARY POPULATIONS

Subjects N Findings Study

Army ROTC 310 20% subjects with increased bulimic 

behaviors, body dissatisfaction, drive for 

thinness

Lauder TD. Abnormal eating behaviors in 

female Reserve Officer Training Corps cadets. 

Mil Med. 2001;166:264–268.

Women in the 

Army, Navy, 

Air Force, and 

Marines

3,000 AN (%) BN (%) EDNOS (%)

Marines 4.9 15.9 76.7

Navy 1.1 5.2 61.2

Air Force 0.8 9.3 58.6

Army 1.3 4.3 57.4

McNulty P. Prevalence and contributing factors 

of eating disorder behaviors in active duty 

service women in the Army, Navy, Air Force, 

and Marines. Mil Med. 2001;166:53–58.

Army women 423 33.6% abnormal eating or purging behaviors and increased body dissatisfaction; 

8% diagnosed with eating disorder; 3.1% 

situational eating disorder

Lauder T, Williams MV, Campbell CS, Davis 

GD, Sherman RA. Abnormal eating behaviors in military women. Med Sci Sports Exerc.

1999;31:1265–1271.

Army women 

with “at- risk” 

eating behaviors

108 None with female athlete triad (osteoporosis, amenorrhea, eating disorder)Lauder T, Williams M, Campbell C, Davis 

G, Sherman R. The female athlete triad: 

prevalence in military women. Mil Med. 

1999;164:630–635.

Navy men

Navy women 

(nurses)

1,425

1,323

AN (%) BN (%) EDNOS (%)

Men 2.5 6.8 40.8

Women 1.1 12.5 36.0

McNulty P. Prevalence and contributing factors 

of eating disorder behaviors in active duty 

Navy men. Mil Med. 1997;162:753–758.

McNulty P. Prevalence and contributing 

factors of eating disorder behaviors in a 

population of female Navy nurses. Mil Med. 

1997;162:703–706.

Air Force weightmanagement 

patients 

+

Civilian weightmanagement 

patients

+

Military control 

population

155 Air Force group: 4 times more purging 

behaviors than civilian group, 2–5 times 

more purging behaviors than military 

control group; great fluctuations in weight

Peterson AL, Talcott GW. Bulimic weightloss behaviors in military versus civilian 

weight-management programs. Mil Med. 

1995;160:616–620.

Israeli Army 

women diagnosed with 

anorexia

16 6/1,000 had AN; 16 treated with CBT and 

clomipramine; 12 returned to full duty; 3 

returned to limited duty; 1 discharged

Mark M, Rabinowitz J, Rabinowitz S, Gaoni B, 

Babur I, Danon Y. Brief treatment of anorexia 

nervosa in military personnel. Hosp Community Psychiatry. 1993;44:69–71.

Male Hungarian 

military college 

students

Male Hungarian 

general college 

students

480

752

No anorexic or bulimic subjects but general 

college students more likely to have behavioral and psychological characteristics 

of eating disorders. Body builders in both 

groups more likely to be perfectionistic

Lukacs L, Muranyi I, Tury F. Eating and 

body attitudes related to noncompetitive 

bodybuilding in military and general Hungarian male student populations. Mil Med. 

2007;172:152–156.

Army women 

and men in 

advanced individual training

1,090 40% overweight; 10.8% with prior psychiatric history; 25.4% with history of verbal 

abuse; 9.8% reported disordered eating. 

Females, overweight, and those with previous psychiatric treatment and history of 

verbal abuse most at risk

Warner C, Warner C, Matuszak T, Rachal J, 

Flynn J, Grieger TA. Disordered eating in 

entry-level military personnel. Mil Med. 

2007;172:147–151.

AN: anorexia nervosa

BN: bulimia nervosa

CBT: cognitive-behavioral therapy

EDNOS: eating disorder not otherwise specified

ROTC: Reserve Officer Training Corps
458

Combat and Operational Behavioral Health

Peterson and colleagues64 compared the prevalence 

of bulimic weight-loss behaviors in patients enrolled 

in an Air Force weight-management program with 

civilians enrolled in a weight-management program 

and with normal military controls. The Air Force members in the weight-management program vomited, 

engaged in strenuous exercise, or used the sauna/

steam room four times more often than the civilian 

group. They were 2- to 5-fold more likely than the 

military comparison group to engage in bulimic 

weight-loss behaviors. They also lost more weight than 

the other two groups: 53% of the Air Force members 

in the weight-management program, but only 10% of 

the other two groups, reported a weight loss of more 

than 10 pounds in 1 month. The Air Force members 

in the weight-management group also showed more 

variability, with 41% gaining more than 5 pounds in 

1 week, compared with 27% in the civilian group and 

14% in the military control group. Fixed-interval reinforcement operant conditioning may have affected 

the fluctuations in weight and heightened weight-loss 

behaviors seen in the Air Force weight-management 

group, because participants were required to weigh 

in every month on a specified date. Thus, they may 

have continued with their routine eating habits until 

just a few days before the weigh-in and made drastic, 

last-minute attempts to drop weight, similar to the 

behaviors seen in the 6-month PFA cycles.

Warner et al65 assessed prevalence and risks factors 

for disordered eating in a cross-sectional survey of over 

1,000 advanced individual training soldiers. Even in 

this entry-level population, 40% were overweight and 

9.8% endorsed disordered eating (7.0% of the men, 

29.6 % of the women). Risk factors for abnormal eating 

behaviors included being a woman, being overweight, 

having a history of previous psychiatric treatment, and 

having a history of verbal abuse.

Carlton et al66 surveyed eating disorders in a mixed 

military population at a large Navy medical center. A 

relatively high percentage of respondents were men, 

officers, or both, which reflected the general makeup 

of the population studied. The average BMI reported 

by the respondents—both men and women—would 

put them in the overweight category. More than 50% 

of respondents reported a BMI of 25 or greater. 

Overall, the findings were consistent with those of 

other studies on eating and dieting behavior in the 

military, with high rates of body image dissatisfaction, abnormal patterns of eating and dieting, and a 

high correlation between these behaviors and the PFA 

cycle. Nearly 40% of respondents reported bingeing 

or binge-like behaviors, 18% or more reported some 

type of purging behavior, and 25% reported fasting. 

These behaviors were associated with worrying about 

the PFA and were more likely to occur in those with 

higher BMI, poor body image, or both. A high percentage of the study population reported dissatisfaction 

with body appearance and self-esteem dependent on 

body image. Women scored higher; however, data 

indicated that a significant proportion of men in the 

Navy are also dissatisfied with their bodies and engage in abnormal eating behaviors. These unhealthy 

attitudes and behaviors were common even though the 

sample was from a medical command; however, other 

studies in Navy personnel have found lower rates of 

abnormal eating behaviors in healthcare workers (30%) 

and medical doctors (6%), compared with the rate in 

shipboard service members (65%).60

Although the data indicate that one third or more 

of the population sample exhibited abnormal eating 

and weight-loss behaviors, only 2% had actually been 

clinically diagnosed.66 This finding is consistent with 

other indications that eating disorders are underreported in the military, even at a medical command. It 

is not surprising that service members are reluctant 

to come forward. In addition to the stigma, the diagnosis may be grounds for disqualification from many 

assignments, mandatory enrollment in weight-loss 

programs, denial of promotion, and involuntary 

separation from service. McNulty5 reported that in 

fiscal year 1995 approximately 5,000 people were 

discharged from military service for failure to meet 

weight standards. Military providers may be reluctant 

to diagnose eating disorders because they are traditionally considered difficult to treat and may end a service 

member’s career.

MEDICAL AND PSYCHIATRIC TREATMENT OF EATING DISORDERS

Anorexia Nervosa

Medical Assessment and Treatment

Patients with AN have poor insight into their conditions. They may perceive their low body weight as 

an accomplishment and have limited motivation to 

change their behaviors.67 The American Psychiatric Association guidelines recommend that patients weighing less than 75% of ideal body weight be treated on an 

inpatient basis.68 Other indications for hospitalization 

are shown in Exhibit 28-3. The hospital utilization 

rate for individuals with AN is higher than that for 

any other psychiatric disorder except schizophrenia 

and organic mental disorders.69 The cost of treatment 

is substantial and is estimated to be even higher than 
459

Eating Disorders

that for schizophrenia.70 Some patients may refuse 

treatment out of dread of weight gain and limited insight. In these cases, involuntary hospitalization may 

be necessary. Patients involuntarily committed for AN 

may show short-term benefit as manifested by weight 

gain, but have a higher mortality rate than those who 

undergo treatment voluntarily.71 With changes in managed care, treatment for AN is increasingly moving 

toward partial-day programs or outpatient treatment. 

Hospitalization is often reserved for patients with serious life-threatening medical complications or those 

who can afford to pay privately.

Once diagnosed with AN, an individual’s general 

medical condition should be assessed. Medical comorbidities, if they exist, must be addressed, although 

many (such as electrolyte imbalance) may resolve or 

improve once malnutrition and purging behaviors are 

rectified. Patients who require hospitalization need 

careful management because rapid refeeding can lead 

to gastric bloating, edema, arrhythmia, tachycardia, 

congestive heart failure, and sudden cardiac death.33,72

Vitamin supplementation, with calcium at doses of 

1,000 to 1,500 mg in addition to a multivitamin, is recommended.73 Alendronate74 and etidronate75 have been 

found helpful in promoting bone formation in patients 

with anorexia; however, bone restoration appears to 

be most determined by weight restoration. 

Psychotherapy

There are fewer controlled trials in the psychotherapeutic management of AN compared to BN.76 Family 

therapy for adolescent patients may be one of the 

more effective treatments77,78; however, this approach 

is impractical in the military setting. Although better 

studied in BN, cognitive-behaviorial therapy (CBT)—

in which cognitive distortions of body image and feelings of self-worth are addressed—has been applied 

with some success to patients with AN.79

Mark et al80 reported on a treatment protocol 

implemented by the Israeli Defence Forces to treat 

AN in their armed forces. They surveyed, weighed, 

and measured all female soldiers over a 6-month 

period. In this sample, 6 of every 1,000 (0.6%) female 

soldiers were anorexic. Requirements for enrollment 

in the treatment program were an identifiable trigger for the disorder, motivation for treatment and 

military service, a social support system, and selfacknowledgment of the eating disorder. As part of 

the treatment program, the soldiers were educated 

on the serious medical nature of AN and instructed 

that they could be discharged if they failed or refused 

treatment. Service members were hospitalized for 4 

to 6 weeks. During this time, each underwent a thorough medical workup, was placed on a high-calorie 

diet, and set goals for weekly weight gain. Therapy 

was based on a CBT model. All patients were initially 

given clomipramine to decrease obsessional ruminations; this drug was tapered off over several months.

Of the 16 patients followed in the study for 1 year 

after discharge from the program, 12 were returned 

to full duty, three were returned to limited duty, and 

one was discharged.

In one study,81 interpersonal therapy (IPT), CBT, 

and “nonspecific supportive clinical management”—

defined as supportive therapy techniques, education, 

and nutritional advice—were compared in a randomized trial. Surprisingly, nonspecific supportive clinical 

management was found superior to both CBT and IPT, 

with CBT yielding superior results to IPT. Therapists 

administering the treatments investigated in the study 

were not eating-disorder specialists. Results of this 

study have yet to be replicated, but may have implications for the feasibility of treating AN in the military 

healthcare setting.

In general, the treatment plan for AN patients 

should involve a multidisciplinary team, including experts in mental health, nutrition, and internal medicine 

or primary care. The therapeutic approach should be to 

treat the whole patient. It is often better to focus away 

from food and toward resolving underlying issues of 

self-esteem and perfectionism.

EXHIBIT 28-3

INDICATIONS FOR HOSPITALIZATION IN 

ANOREXIA NERVOSA*

•	 Limited motivation to change abnormal eating behaviors

	 •	 Intractable (or rapid) weight loss despite

treatment

	 •	 Refusal to eat

	 •	 Prolonged QT interval

	 •	 Bradycardia < 40 beats per minute

	 •	 Arrhythmia

	 •	 Hypothermia

	 •	 Symptomatic hypotension

	 •	 Less than 75% ideal body weight

	 •	 Persistent suicidal ideation

	 •	 Need for withdrawal/detoxification from

laxatives, diet pills, or diuretics

*This list is not all-inclusive, and a decision to admit a 

patient to a hospital should always be based on a clinical 

assessment of the patient’s psychiatric and general medical 

conditions.
460

Combat and Operational Behavioral Health

Medications

Controlled trials of medications in the treatment of 

AN are summarized in Exhibit 28-4. Restoring weight 

and subsequent metabolic stabilization are treatment 

priorities for patients with AN. Cyproheptadine 

(32 mg/day) was found to improve weight gain in 

patients with restricting-type AN but not those with 

bingeing/purging-type AN.78 Because zinc deficiency 

has been linked to AN through inhibition of release of 

neuropeptide Y,82 supplementation with this mineral 

may be beneficial in promoting recovery from AN and 

improving these patients’ levels of anxiety and depression.83 In a controlled trial of 35 female inpatients with 

AN, supplementation with zinc promoted a rate of 

increase of BMI twice that of placebo.84 Birmingham 

and Gritzner85 recommend oral administration of 14 

mg daily of elemental zinc for 2 months. A doubleblind trial86 of cisapride (10 mg tid) found reduction 

EXHIBIT 28-4

MEDICATIONS EFFECTIVE* AS MONOTHERAPY IN PLACEBO-CONTROLLED 

TRIALS FOR ANOREXIA NERVOSA

	 •	 Zinc1

	 •	 Cyproheptadine2

	 •	 Fluoxetine (after weight restoration, bingeing/purging subtype) 3,4

	 •	 Naltrexone (bulimic subtype)5

	 •	 Olanzapine6

*Defined as fewer days to reach healthy BMI or reduction 

in binge/purge behavior for bulimia nervosa subtype of 

anorexia nervosa.

BMI: body mass index

(1) Birmingham CL, Goldner FM, Bakan R. Controlled trial 

of zinc supplementation in anorexia nervosa. Int J Eat Disord. 

1994;15:251–255. (2) Halmi KA, Eckert E, LaDu TJ, Cohen 

J. Anorexia nervosa. Treatment efficacy of cyproheptadine 

and amitriptyline. Arch Gen Psychiatry. 1986;43:177–181. (3) 

Kaye WH, Nagata T, Weltzin TE, et al. Double-blind placebocontrolled administration of fluoxetine in restricting- and 

restricting-purging-type anorexia nervosa. Biol Psychiatry. 

2001;49:644–652. (4) Walsh BT, Kaplan AS, Attia E, et al. 

Fluoxetine after weight restoration in anorexia nervosa: a 

randomized controlled trial. JAMA. 2006;295:2605–2612. (5) 

Marrazzi MA, Bacon JP, Kinzie J, Luby ED. Naltrexone use 

in the treatment of anorexia nervosa and bulimia nervosa. Int 

Clin Psychopharmacol. 1995;10:163–172. (6) Bissada H, Tasca 

GA, Barber AM, Bradwejn J. Olanzapine in the treatment 

of low body weight and obsessive thinking in women with 

anorexia nervosa: a randomized, double-blind, placebocontrolled trial. Am J Psychiatry. 2008;165:1281–1288.

in subjective distress during meals in a small group 

of AN patients, but did not find a difference in gastric 

emptying or weight gain. 

To date, no antidepressant or antipsychotic has been 

demonstrated to improve the long-term recovery rate 

from anorexia.87,88 Tricyclic antidepressants (TCAs) 

have not only been shown ineffective, but also given 

their potential lethality, may be risky in this patient 

population.89,90 Selective serotonin reuptake inhibitors (SSRIs) have not been found useful in low-weight 

patients.91 This may be because of the general state of 

malnutrition of low-weight patients with AN, resulting 

in deficiency of tryptophan, the amino acid required 

for serotonin synthesis.92 One SSRI, fluoxetine, was 

shown to be useful at higher doses in preventing relapse in those who have regained weight93; however, 

a larger study reported negative results.94

Antipsychotic drugs may have an augmenting role, 

particularly in patients with AN who have poor insight 

into their conditions.95–98 However, not all studies 

have demonstrated the efficacy of antipsychotics,99,100

and their use may have serious adverse effects in this 

population.73 In a small, randomized trial, olanzapine was superior in reducing ego-syntonic anorexic 

ruminations compared to chlorpromazine, although 

there was no difference in weight gain.101 Theoretically 

opiate antagonists may be helpful for subgroups of 

eating-disorder patients who fit an addiction model. 

Marrazzi et al102 reported reduction in binge/purge 

EXHIBIT 28-5

INDICATIONS FOR HOSPITALIZATION IN 

BULIMIA NERVOSA*

	 •	 Changes in vital signs (pulse, blood pressure)

	 •	 Syncope

	 •	 Hypothermia

	 •	 Suicide risk

	 •	 Alcohol or drug abuse

	 •	 Uncontrolled vomiting

	 •	 Hematemesis (vomiting of blood)

	 •	 Arrhythmia

	 •	 Electrolyte imbalance

	 •	 Need for withdrawal from laxatives, diet

pills, and diuretics

*This list is not all-inclusive, and a decision to admit a patient to the hospital should always be based on a clinical 

assessment of the patient’s psychiatric and general medical 

conditions.
461

Eating Disorders

behaviors in a mixed population of BN and AN (bulimic subtype) patients treated with naltrexone in a 

randomized trial of 37 patients.

Bulimia Nervosa

Literature to guide treatment of BN is fairly extensive; hospitalization is seldom necessary unless there 

are medical complications (Exhibit 28-5). Compared 

to AN, evidence shows that BN can be treated more 

effectively with medication, although psychotherapy 

remains the cornerstone of treatment. The most established treatment for BN is CBT; in one study,103

however, fewer than 10% of patients with bulimia who 

received psychotherapy were treated with this type 

of therapy. Guided self-help manuals that use CBT 

principles have also been found effective.92,104 Even 

with CBT, it is estimated that only 50% of patients 

with BN recover.105

Patients with BN who fail to respond to psychotherapeutic techniques may benefit from pharmacotherapy. Medications that have been shown effective in 

randomized, placebo-controlled trials in the treatment 

of BN are listed in Exhibit 28-6. Controlled trial data 

have shown efficacy for TCAs106–110 and monoamine 

oxidase inhibitors,111,112 with the latter demonstrating some superiority.113 Both TCAs and monoamine 

oxidase inhibitors may have lethal adverse effects in 

EXHIBIT 28-6

MEDICATIONS EFFECTIVE IN PLACEBO-CONTROLLED TRIALS FOR BULIMIA NERVOSA

*Contraindicated in treatment of bulimia because of increased risk of seizure.

(1) Pope HG Jr, Hudson JI, Jonas JM, Yurgelun-Todd D. Bulimia treated with imipramine: a placebo-controlled, double-blind study. 

Am J Psychiatry. 1983;140:554–558. (2) Agras WS, Dorian B, Kirkley BG, Arnow B, Bachman J. Imipramine in the treatment of bulimia: 

a double-blind controlled study. Int J Eat Disord. 1987;6:29–38. (3) Barlow J, Blouin J, Blouin A, Perez E. Treatment of bulimia with 

desipramine: a double-blind crossover study. Can J Psychiatry. 1988;33:129–133. (4) Hughes PL, Wells LA, Cunningham CJ, Ilstrup 

DM. Treating bulimia with desipramine. A double-blind, placebo-controlled study. Arch Gen Psychiatry. 1986;43:182–186. (5) Walsh 

BT, Gladis M, Roose SP, Stewart JW, Stetner F, Glassman AH. Phenelzine vs placebo in 50 patients with bulimia. Arch Gen Psychiatry.

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NP, Koke SC, Lee JS. A placebo-controlled study of fluoxetine in continued treatment of bulimia nervosa after successful acute 

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bupropion: a multicenter controlled trial. J Clin Psychiatry. 1988;49:262–266. (13) Pope HG Jr, Keck PE Jr, McElroy SL, Hudson JI. A 

placebo-contolled study of trazodone in bulimia nervosa. J Clin Psychopharmacol. 1989;9:254–259. (14) Marrazzi MA, Bacon JP, Kinzie 

J, Luby ED. Naltrexone use in the treatment of anorexia nervosa and bulimia nervosa. Int Clin Psychopharmacol. 1995;10:163–172. (15) 

Faris PL, Kim SW, Meller WH, et al. Effect of decreasing afferent vagal activity with ondansetron on symptoms of bulimia nervosa: 

a randomised, double-blind trial. Lancet. 2000;355:792–797. (16) Hoopes SP, Reimherr FW, Hedges DW, et al. Treatment of bulimia 

nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: improvement in binge and purge measures. 

J Clin Psychiatry. 2003;64:1335–1341. (17) Nickel C, Tritt K, Muehlbacher M, et al. Topiramate treatment in bulimia nervosa patients: a 

randomized, double-blind, placebo-controlled trial. Int J Eat Disord. 2005;38:295–300. (18) Sundblad C, Landén M, Eriksson T, Bergman L, Eriksson E. Effects of the androgen antagonist flutamide and the serotonin reuptake inhibitor citalopram in bulimia nervosa: 

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	 •	 Tricyclic antidepressants (desipramine, imipramine)1–4

	 •	 Monoamine oxidase inhibitors (phenelzine,

isocarboxazid)5,6

	 •	 Fenfluramine7

	 •	 Fluoxetine8–11

	 •	 Buproprion*,12

	 •	 Trazodone13

	 •	 Naltrexone (high dose)14

	 •	 Ondansetron15

	 •	 Topiramate16,17

	 •	 Flutamide18

	 •	 Citalopram19

	 •	 Sertraline2o

	 •	 Fluvoxamine11
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this patient population (potentially made worse by 

underlying electrolyte imbalance) and are not currently 

recommended as first-line treatment. Fenfluramine, 

a serotonergic agonist withdrawn from the market, 

was shown to be superior to both placebo and desipramine (a TCA).110 The SSRI antidepressants are, 

similarly, serotonergic agonists and theoretically may 

work through a similar mechanism. Fluoxetine at high 

doses (60 mg/day) was superior to placebo in two 

8-week trials114,115 and one 16-week trial.116 Fluoxetine’s 

efficacy in BN, as with the TCAs,117 is not a secondary 

effect of its antidepressant properties.118 As many as 

one third of initial responders may relapse by the end 

of 1 year despite continued treatment,119 suggesting 

that, whereas continued treatment may afford some 

protective effect, additional treatments may be needed 

for sustained effectiveness.

Although fluoxetine is the only antidepressant 

currently approved for BN, other SSRIs may also be 

effective. In a randomized, placebo-controlled trial, 

sertraline 100 (mg/d for 12 weeks) was found to be 

significantly more effective than placebo in reducing 

binge/purge behaviors in 20 female outpatients.120

Fluvoxamine has been found effective in preventing 

relapse in patients with BN who had responded to 

inpatient behavioral psychotherapy.121 In a singleblind trial comparing citalopram to fluoxetine, both 

agents resulted in significant improvement in eating 

psychopathology. Patients on fluoxetine displayed 

greater reduction in introjected anger, whereas those 

on citalopram demonstrated greater improvement in 

depressive feelings.122 In comparison, another study 

found that use of the androgen receptor antagonist 

flutamide reduced craving and binge behaviors but 

not purging, whereas citalopram did not separate 

from placebo on these measures.123 Among the newer, 

non-SSRI antidepressants, only bupropion has been 

studied in a controlled trial. Although bupropion was 

highly effective in reducing bingeing, there was a 5.8% 

incidence of seizure among study participants.124 As a 

result, this agent is contraindicated in BN. As a class, 

antidepressants reduce binge eating by 61.4% (remission rate: 22%) and reduce purging by 58.9% (remission 

rate: 34%).125 Unfortunately, up to 45% of patients who 

respond to pharmacotherapy may relapse in the first 

6 months.126

Topiramate is becoming increasingly popular for 

treating BN after two randomized, double-blind, 

placebo-controlled trials established efficacy.127,128

Other agents that have been found effective in at least 

one double-blind trial include the 5-HT3 antagonist 

ondansetron,129 the opioid antagonist naltrexone,102

and trazodone.130

Several studies have compared psychotherapy to 

pharmacotherapy and failed to find any advantage 

of combining medication with therapy versus therapy 

alone.131–133 Results from two metaanalyses found 

that combination approaches were associated with 

higher remission rates, although adding medication to 

therapy increased the dropout rate.134,135 In summary, 

the preference is to treat BN with psychotherapy, primarily CBT, or a combination of psychotherapy and 

medication.

Eating Disorder Not Otherwise Specified

Because EDNOS is a nonspecific diagnostic category, treatment approaches depend on symptoms. The 

one category of EDNOS for which there appears to be a 

growing body of literature is BED. In general, the treatment resembles that for BN, with outcome measures 

defined by reduction in bingeing. The best-studied 

psychotropic agents used to treat BED and obesity are 

antidepressants and anticonvulsants. SSRIs have been 

found effective in double-blind trials for treatment of 

BED.136–138 The anticonvulsant topiramate has also been 

found effective in double-blind trials for BED associated with obesity,139 and a similar agent, zonisamide, 

was also associated with significant weight loss in 

a double-blind trial of obese adults.140 Alternatively, 

agents specifically marketed for weight loss (including phentermine, sibutramine, and orlistat)141,142 have 

been used to treat weight gain in overweight or obese 

patients with BED. Although several agents have been 

found effective for short-term weight loss, there are 

relatively few data on long-term efficacy with these 

agents. A review of the Cochrane database system 

found that, compared with placebo, the number of 

patients achieving 10% or more weight loss was 12% 

higher with orlistat and 15% higher with sibutramine 

in double-blind trials that lasted more than 1 year.143

However, there was significant attrition in these studies, with an average of 33% of those on orlistat and 43% 

of those on sibutramine dropping out.

TREATMENT OF EATING DISORDER ISSUES IN THE COMBAT ENVIRONMENT

No formal studies have been conducted of disorders of eating behavior among military personnel in 

a combat environment. Operation Enduring Freedom 

and Operation Iraqi Freedom are the first US military 

actions in which women play a major part in combat; 

given their higher incidence in this group, eating disorders may become an increasingly important issue. 

Although significant evidence shows that abnormal 
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Eating Disorders

eating and weight-loss behaviors are more prevalent 

in the military than in the general population, the actual rates of eating-disorder diagnoses in the military 

are at or below the civilian rates. This discrepancy 

may be due to a variety of reasons, including the 

pronounced situational component in the military 

(such as the PFA) producing abnormal eating and 

dieting patterns, the fear of adverse career actions 

probably leading to underreporting, and the fact 

that those with severe eating disorders are screened 

out prior to enlistment or are discharged when their 

eating disorders become evident. Additionally, service members with an eating disorder may try to 

conceal it in order to deploy, because operational 

and combat experience can be an important step 

toward promotion. 

It is likely that few service members with a recognized eating disorder will be deployed to a combat 

zone. Individuals who meet criteria for AN clearly 

should not deploy, and probably should not be on active duty, due to the high rates of morbidity and mortality in AN as well as specialized treatment requirements. Those with a history of BN or EDNOS whose 

symptoms are well controlled should be considered 

on a case-by-case basis. 

A careful history and evaluation should be conducted prior to the decision allowing affected service 

members to deploy. Given the chronicity of eating, only 

those who display good insight, treatment compliance, 

adequate symptom control, and a general high function should be considered for deployment. Potential 

side effects and availability of the prescribed medication should be considered. If multiple psychotropic 

agents, antipsychotics, or anticonvulsants are required 

for symptom stabilization, the service member should 

not be deployed. In particular, it should be noted that 

topiramate is becoming increasingly popular for bulimia but carries a warning for anhidrosis and hyperthermia,144 which would be particularly problematic 

in a desert environment. Additional factors to consider 

include assessment of strengths and weaknesses, support systems, past aggravating factors, comorbidity 

with substance abuse or depression, motivation for 

deployment, anticipated job while deployed, the 

deployment site, and anticipated access to mental 

healthcare. 

It is more likely that a service member with a previously concealed or controlled eating disorder will 

present in theater when symptoms become obvious 

to coworkers or impact the individual’s ability to 

perform. Once again a careful assessment is needed to 

determine if the service member can remain in theater 

or should be returned. Factors to consider are similar 

to those above and include the severity of current 

symptoms, prior history, comorbidity, the individual’s 

job, the location, access to care, and impact on the mission. Metabolic abnormalities and dehydration are of 

particular concern in strenuous or hot climates; thus, 

bulimic patients with such abnormalities should be 

medically evacuated.

Both positive and negative situational factors are 

associated with deployment, and their effects may 

vary on an individual basis. During deployment PFAs 

are suspended, so the pressure of the weigh-in and 

measurements are removed. In most deployment situations personnel have more time to exercise. Also, a hot 

climate affects appetite and food intake. Most dining 

facilities offer a variety of foods so that an individual 

can make healthy choices; however, some may find 

that the buffet style (usually including a dessert and 

ice cream bar) leads to overeating. The communal 

eating and living environment may make bingeing 

and purging less likely (although not impossible). 

Laxatives and diuretics are more difficult to obtain 

in the combat environment, thus further reducing 

purging options. Structured meal times can also either 

decrease the likelihood of overeating or increase the 

urge to binge. There are clearly fewer environmental 

cues such as food commercials and restaurants, although many areas have fast food restaurants that are 

open for extended hours. The separation from home 

environment and family may have either a positive or 

negative impact and should be individually assessed 

for each patient. 

AREAS FOR FURTHER RESEARCH

Further research is necessary to improve the understanding of eating disorders in several areas. It is 

likely that the global war on terror will continue for 

some time, either as continued combat or with a US operational presence at widespread locations around the 

world. Given the known high incidence of abnormal 

eating behaviors in military personnel across services, 

military medical providers must understand how or 

if these conditions impact operational readiness and 

performance. Anecdotally, it appears that most service 

members who deploy lose weight during the deployment, most likely in healthy ways from increased 

exercise and decreased food intake. Deployment may 

somehow be protective for eating disorders due to 

decreases in certain types of stress. Additionally, a primary symptom in eating disorders is an overconcern 

about physical appearance and self-esteem tied to appearance. It may be that in a combat zone these issues 
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Combat and Operational Behavioral Health

are less important, and that personal satisfaction and 

feelings of reward derive from sources other than food 

or physical appearance. Other valuable research would 

be measuring the actual amount of weight loss during 

deployment, identifying any difference in weight loss 

among those who are and are not overweight prior to 

deployment, and determining whether the incidence 

of eating disorder behaviors is increased or decreased 

with deployment. 

Another area of research interest is the potential 

for comorbid development of posttraumatic stress 

disorder (PTSD) in patients with eating disorders. 

Both eating disorders23–27 and adult PTSD145,146 have 

been linked independently to a history of childhood 

trauma and sexual abuse. It is not known if there is 

an independent link between eating disorders and 

the development of PTSD. An additional area for 

further research is the effect, currently unknown, of 

combat trauma on the risk of developing an eating 

disorder.

SUMMARY

Eating disorders are common among service members, and the military environment includes stressors 

that may contribute to unhealthy behaviors. Healthcare providers must be aware of the signs and symptoms of each disorder, capable of accurate diagnoses, 

and proactive in offering the available treatments, 

both medial and psychiatric. Vigilance is especially 

important with troops preparing for deployment, for 

these disorders may be exacerbated in theater, with 

negative consequences for individuals, their units, and 

their missions. Despite significant long-term morbidity and mortality associated with these conditions, 

eating disorders are treatable. The military may be 

an advantageous environment to provide deterrents 

to unhealthy behaviors, structured support and treatment for affected individuals, and opportunities for 

further research to increase the understanding of these 

disorders. 

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Long-term fluoxetine treatment of bulimia nervosa. Br J Psychiatry. 1995;166:660–666.
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bulimia nervosa: a randomised, double-blind trial. Lancet. 2000;355:792–797.

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therapy in binge eating disorder: a one-year follow-up study. Psychother Psychosom. 2001;70:298–306.

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obesity: a placebo-controlled monotherapy trial. Hum Psychopharmacol. 2008;23:1–11.

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controlled trial. JAMA. 2003;289:1820–1825.

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multicenter placebo-controlled double-blind study. Am J Psychiatry. 2008;165:51–58. Epub December 3, 2007.

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473

Substance Use and Abuse in the Military

Chapter 29

substance use and abuse in the 

military

R. GREGORY LANDE, DO*; BARBARA A. MARIN, PhD†; JAMES J. STAUDENMEIER, MD, MPH‡; and

DARYL HAWKINS, PhD§

INTRODUCTION

EFFECTS OF ALCOHOL ABUSE ON PERFORMANCE

Cognitive Impairment

Memory Impairment

Sleep Impairment

SCREENING FOR ALCOHOL ABUSE

TOBACCO USE

OTHER DRUGS OF ABUSE

THE ROLE OF THE MILITARY MEDICAL REVIEW OFFICER

THE ARMY SUBSTANCE ABUSE PROGRAM

SUMMARY

*Chief, Psychiatry Continuity Service, Department of Psychiatry, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Building 2, Room 5343, 

Washington, DC 20307; Clinical Consultant, Walter Reed Army Medical Center Substance Abuse Program, Washington, DC

†

Integrated Chief, Department of Addictions Treatment and Clinical Director, Army Substance Abuse Program, Walter Reed Army Medical Center, 6900 

Georgia Avenue NW, Washington, DC 20307-5001

‡

Colonel, Medical Corps, US Army; Consultant, Army Substance Abuse Program, Department of Psychiatry, USAMEDDAC, 11050 Mount Belvedere 

Boulevard, BMD (Wilcox), Fort Drum, New York 13602; formerly, Fellow in Geriatric Psychiatry, Walter Reed Army Medical Center, Washington, 

DC 

§

Alcohol and Drug Control Officer, Army Substance Abuse Program, Building 6, Room 2066, Walter Reed Army Medical Center, 6900 Georgia Avenue 

NW, Washington, DC 20307-5001
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Combat and Operational Behavioral Health

INTRODUCTION

Through the centuries of armed conflict, soldiers 

have sought to immunize themselves from the fear 

and uncertainty of combat. The principle shield that 

protects these combatants is training. Endless training 

breeds confidence in military skills and weapons. A 

strong group milieu firmly centered around camaraderie, mutual support, and confidence further strengthens emotional resilience. These are the positive factors 

reinforcing a sense of “invulnerability.”

The emotional shield protecting soldiers from the 

stress of combat is further strengthened by training 

and group cohesion, but weakened by other hidden, 

pernicious factors. Chief among the factors battering 

the emotional shield are individually experienced 

traumas. Although substance use may be perceived 

by soldiers as a way of reducing the stress of these 

traumas, the corrosive influence of substance abuse 

is substantial.

Modern militaries are dominated by complex machinery, precision weaponry, advanced information 

technologies, and a structural agility necessary for 

rapid adaptation to a wide range of threats. In a similar 

fashion, today’s soldier is more sophisticated, relying 

more than ever on “brain over brawn.” Nonetheless, 

physical stamina is important, given the grinding 

endurance required of combat operations. As a consequence, all military personnel must maintain a level 

of physical fitness. Despite the obvious importance 

of physical training, cognitive stamina may be even 

more important. A successful military career requires 

persistent honing of the basic cognitive tasks involving 

information processing and psychomotor skills. 

EFFECTS OF ALCOHOL ABUSE ON PERFORMANCE

Cognitive Impairment

The use of alcohol promotes a wide range of 

biobehavioral impairments, many of which have 

particular significance to military activities. Alcohol 

impairs cognitive function in ways both subtle and 

severe. The nature and intensity of alcohol-related 

impairments vary according to consumption patterns, 

physiologic response, social acceptance, and the presence of co-occurring medical or psychiatric problems. 

Despite these intraindividual variations, at least for the 

purposes of comparison, the average man weighing 

150 pounds can reliably achieve a blood alcohol concentration (BAC) of 0.04% following the consumption 

of two standard alcohol drinks in 1 hour.1

 Thus, even 

low levels of alcohol consumption impair cognition. 

Complex tasks are even more sensitive to the intoxicating influence of alcohol.

Mental activities that require divided attention, such 

as managing a weapon and scanning the environment, 

can suffer when blood alcohol levels hover as low as 

0.02%.2

 The brain’s information processing system 

attempts to compensate by focusing mental acuity 

in one area. This can lead to a devastating outcome 

when mental agility and survival are closely linked. 

The average man can achieve a BAC of 0.02% with 

as little as one standard drink in 1 hour, or be on the 

downward alcohol concentration slope after a bout of 

heavier drinking.2

One psychomotor task with special significance 

in military operations involves the ability to visually 

track objects. Whether sighting a weapon or driving a 

vehicle, the smooth and accurate control of eye motion 

is critical to mission success. Military personnel can 

experience impaired visual acuity, mostly in terms of 

difficulty focusing, with BAC as low as 0.03%.2

Clearly, the “blurred” vision associated with alcohol use is common. A less recognized, but potentially more hazardous, consequence of consumption 

involves a visual–spatial impairment. Visual–spatial 

exercises require the proper placement of objects in 

space. To effectively respond to an enemy sniper firing from multiple areas requires recognition of the 

sniper’s relative positions and possible extrapolation 

to the next location. This sort of analysis relies on 

accurate perception and the application of abstract 

thinking.

Alcohol interferes with visual–spatial processing 

in two broad ways: intoxication makes multitasking 

more difficult or it simply renders the vision less accurate. The long-term use of alcohol, where duration 

and quantity are not fully defined, seems to produce a 

fixed change in cognition. The change is expressed in a 

loss of mental agility, inhibiting the ability to confront 

a novel problem with a creative solution. Clues to this 

condition emerge when an otherwise adequately performing individual is thrust into a new environment 

and cannot adapt old skills to the current reality.2

The greatest degree of impairment in the ability to 

apply abstract reasoning occurs in the weeks following 

reduction or cessation of significant alcohol consumption. Military personnel accustomed to substantial 

levels of alcohol use may be forced into an unwelcome 

abstinence when deployed, which can be accompanied 

by the emergence of worrisome symptoms of cognitive decline.
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Substance Use and Abuse in the Military

Memory Impairment

Chronic alcohol use disrupts the communication 

paths between areas of the brain responsible for 

processing memories, specifically the frontal lobes 

and the hippocampus.3 In fact, long-term alcohol use 

structurally reduces brain volume.4 The resulting 

memory deficits profoundly influence the acquisition 

and retention of knowledge.

A more intriguing and potentially harmful effect of alcohol use arises from acute intoxication. It 

seems increasingly apparent that alcohol consumption interferes with memory formation. The risk of 

acute alcohol-related memory impairment correlates 

closely with quantity consumed and the speed of 

absorption. Bolus, or binge, drinking among men is 

defined as five or more drinks in 2 hours. For women, 

four or more drinks in 2 hours constitutes bolus 

drinking. A much higher probability of memory 

impairment exists if bolus drinking occurs on an 

empty stomach. 

Blackouts—the complete failure to transcribe events 

into memory—are not a rare phenomenon. Indeed, 

surveys among college students, a cohort closely agematched with the largest military contingent, would 

suggest that blackouts are common. Based on these 

surveys, an estimated 40% to 50% of college students 

report a prior blackout. Fragmented memory loss 

is more common than a total blackout.3

 Just a few 

drinks, ambiguously regarded as “social drinking,” 

can produce lapses in attention and word finding. 

Neither condition benefits military personnel engaged 

in fast-paced military operations.

Sleep Impairment

Alcohol’s negative impact on cognition and memory is amplified by another side effect of consumption. Even small amounts of alcohol can profoundly 

affect the sleep cycle.5 Although alcohol consumption 

reduces the amount of time necessary to fall asleep, 

it disturbs the late parts of the sleep cycle. The night 

is spent with frequent awakenings, many of which 

occur during rapid eye movement (REM) sleep. Disruption of REM sleep may have particular relevance 

in exacerbating fatigue, irritability, and the recall of 

disturbing dreams.

The sleep-inducing benefits of alcohol fade with 

repeated use, while at the same time the sleep cycle becomes ever more fragmented. It seems natural enough 

to use alcohol as a soporific during periods of stress 

and trauma. However, shift work and deployment 

across time zones may synergistically combine with 

an alcohol-induced sleep disorder to further impair 

the individual.

Alcohol withdrawal, perhaps induced by the forced 

abstinence of rapid mobilization, characteristically 

produces marked insomnia, disturbing dreams, and 

even hallucinations.5

 This can be an especially troublesome development when a service member deploys 

to an area of combat operations. The normal anxiety 

associated with deployment fuses with the symptoms 

of withdrawal and may produce substantial incapacitation. 

SCREENING FOR ALCOHOL ABUSE

The detection of alcohol abuse begins with an understanding of its prevalence. Epidemiologic studies categorize alcohol use as light, moderate, and heavy.6

 Light 

drinking consists of three or fewer beverages per week. 

Light drinking is common. Nearly 43% of Americans 

meet the consumption criteria for light drinking.

Gender influences the values associated with moderate and heavy drinking. Moderate drinking among 

women consists of more than three but less than eight 

drinks per week; for men, no more than 14 drinks per 

week. Heavy drinking among women consists of more 

than one daily drink per week; for men it is more than 

two daily drinks per week. Based on these criteria, 14% 

of Americans are moderate drinkers and almost 4.5% 

meet the definition of heavy drinking.6

Epidemiologic consumption patterns contributed 

to the development of a simple screening tool referred 

to as the “Quantity Frequency Questionnaire.”7 The 

first set of questions queries quantity by asking, “On 

average, how many days a week do you drink alcohol?” and “On a typical day when you do drink, how 

many do you have?” If the multiplied sum of the two 

responses exceeds 14 for men (or seven for women) 

this can be considered “at-risk” drinking.

Bolus drinking is another “at-risk” drinking behavior. This pattern of drinking is the other half of the 

Quantity Frequency Questionnaire. The individual 

is asked, “What is the maximum number of drinks 

you had on any given day in the past month?” “At 

risk” bolus drinking occurs when men exceed four 

(and women three) drinks at one time. If the person 

is deemed “at-risk” based on the Quantity Frequency 

Questionnaire, then the CAGE questions should be 

asked.8

 The CAGE questionnaire inquires about alcohol use over the past year by asking:

C: Have you ever felt that you should CUT 

down on your drinking?
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Combat and Operational Behavioral Health

 A: Have people ANNOYED you by criticizing 

your drinking? 

G: Have you ever felt bad or GUILTY about your 

drinking?

 E: Have you ever tried a drink first thing in the 

morning? (EYE opener) 

If the person answers yes to any of the CAGE 

questions, this should trigger a more comprehensive 

assessment of substance use.

Alcohol screening questionnaires can be combined 

with certain laboratory tests. (Most biochemical markers require a blood sample.) The accuracy of these tests 

in detecting alcohol use depends on the tests’ sensitivity and specificity. By itself, no single test conclusively 

identifies alcohol use. Multiple tests, combined with an 

“at risk” history, provide better evidence of problem 

drinking.9 Perhaps the best single biochemical marker 

of alcohol use is gamma glutamyl transferase, or GGT. 

Elevated GGT occurs in a range of 30% to 50% among 

problem drinkers.

Problem drinking may also elevate aspartate aminotransferase and mean corpuscular volume, but both 

are less sensitive than GGT. Carbohydrate deficient 

transferrin is elevated among heavy drinkers and has 

sensitivity levels approaching GGT. Ethyl glucuronide 

can be detected in a urine specimen up to 5 days after 

heavy alcohol use. Ethyl glucuronide might play a 

clinically useful role in detecting alcohol use after bolus 

drinking on weekends. 

TOBACCO USE

Although alcohol remains the most commonly used 

substance, tobacco use is almost as frequent. Approximately 29% of Americans use tobacco, with nearly 24% 

of that figure accounted for by cigarettes. Another 

3% of the population uses smokeless tobacco.10 Thus, 

healthcare practitioners should inquire about all forms 

of tobacco, including smokeless products.

 During periods of major upheaval, such as natural 

or manmade disasters, an increase in the use of tobacco 

occurs. Several studies explored tobacco use among 

individuals exposed to the Oklahoma City bombing in 

1995, in the aftermath of the 2001 terrorist attack on the 

twin towers of the World Trade Center in New York, 

and during other stressful events.11–13 The findings from 

these collective studies provide evidence of increased 

smoking among traumatized individuals. Individuals 

who increase their smoking during periods of stress 

subsequently develop the symptoms of posttraumatic 

stress disorder (PTSD) at rates exceeding nonsmokers. 

The problem is further compounded when traumatized individuals report an inability to quit smoking. 

In a more quantifiable way, smoking appears to double 

the risk of developing PTSD.14

Tobacco use appears to play a key role in amplifying 

anxiety, inhibiting more effective coping strategies, and 

possibly contributing to heightened irritability. Military planners and healthcare practitioners can monitor 

tobacco use as a potential risk factor for emotional 

distress. For example, the predeployment phase begins 

with official notification of a pending assignment. 

Some military personnel may respond by initiating or 

markedly increasing their use of tobacco.

The Fagerström Test for Nicotine Dependence15 is a 

screening tool used to assess cigarette use and can be 

administered at any phase of the deployment cycle, 

be it pre-, during, or postdeployment, to assess the 

degree of nicotine use. The test has a total of six questions, covering the following areas for an individual 

smoker:

1. time of day first cigarette is smoked;

2. whether the subject has difficulty refraining 

from smoking in places where it is not allowed;

3. time of day it would be most difficult to go 

without a cigarette;

4. total number of cigarettes smoked each 

day;

5. time of day, if any, when the subject smokes 

more frequently; and

6. whether or not the subject smokes even when 

ill enough to be home in bed.15

Points are assigned to the responses, ranging from 

0 to 3 points, depending on the particular question. 

The test has a maximum total of 16 points; any score 

above 7 points is considered a very high addiction.15

Military personnel scoring at the higher levels may 

be at increased risk of emotional deterioration. The 

increased use of tobacco may be an effort to selfmedicate. Healthcare practitioners should take the 

opportunity to explore this possibility.

OTHER DRUGS OF ABUSE

A sizable minority of the American public regularly 

skirts potentially severe legal penalties to use, abuse, 

or sell a wide range of illegal drugs. A person’s drug 

of choice is a complex judgment based on personality 
477

Substance Use and Abuse in the Military

dynamics, cost, availability, and the drug’s effects. In 

some situations, such as deployment to foreign locations, the new environment can either restrict options 

or provide new opportunities.

The National Survey on Drug Use examined patterns among individuals 18 to 25 years old, the age 

range that correlates well with the majority of the 

military population. Among this group, the survey 

reported 16.4% used marijuana, 6% used prescription 

drugs for recreational purposes, 1.7% used cocaine, 

and 1.5% used a hallucinogen.10

Marijuana is the most commonly used illegal drug, 

with 5.8% of Americans 12 years and older reporting 

use in the month proceeding the administration of the 

National Survey on Drug Use.16 During the same time 

period, 2.1% reported the nonmedical use of prescription pain relievers, 0.8% of Americans reported the use 

of cocaine, and 0.4% used a hallucinogen. “Ecstasy” 

accounts for half of the reported hallucinogen use.10

The nonmedical use of prescription pain-relieving 

drugs is an area of special concern. The most likely 

source of these prescription drugs was a friend or 

family member.

The extent to which military use of illegal drugs 

bears some similarity to the National Survey on Drug 

Use is not precisely known. It seems reasonable to 

conclude that social trends are reflected in the military 

population. Following this line of reasoning, marijuana, cocaine, and the nonmedical use of prescription 

drugs would be the most likely problem areas.

The abuse of prescription pain relieving medications is particularly vexing. Traditional medical tests 

designed to detect opiate use will not identify the most 

likely offenders. Medications derived naturally from 

the poppy plant include morphine and codeine. These 

naturally occurring compounds are referred to as 

opiates and are included in most standard urine drug 

screens. Opioids are semisynthetic or fully synthetic 

opiates. Heroin, hydromorphone, hydrocodone, oxycodone, and fentanyl are examples of opioids. Opioids 

are not included in most standard medical urine drug 

tests and must be specifically ordered by name. If a 

clinician suspects the nonmedical use of oxycodone, 

for example, then oxycodone must be ordered by name 

from the testing laboratory. Clinicians should consult 

their laboratories for guidance. 

Military planners and healthcare professionals 

should recognize the difficulty identifying opioid 

abuse and the ease in obtaining these medications. 

Detection of the nonmedical use of prescription drugs 

begins with an increasing index of suspicion triggered 

by certain behaviors. Routine screening should be 

part of every health encounter, which should include 

several questions aimed at understanding the person’s use of addicting medications. Greater concern 

is occasioned by frequent medical visits rewarded 

with overlapping prescriptions. Some of the excess 

medications may be destined for diversion. The truly 

resourceful individual will seek prescription medications from multiple healthcare providers, both military 

and civilian, as well as the Internet.

The US government, through the Controlled 

Substances Act, classifies drugs into five schedules 

based on abuse potential. Drugs in schedule I or 

II are considered “illegal drugs” for purposes of 

prosecution. The Controlled Substances Act applies 

in all settings, be it a tertiary care medical facility in 

the United States, a regional military hospital in a 

foreign country, or mobile medical assets in support 

of combat operations.

The US military fields a robust drug-testing program. Today’s modern drug-testing programs are direct descendants of embryonic military efforts initiated 

in the 1970s. Roughly a decade later, President Ronald 

Reagan signed Executive Order 12564,17 mandating 

federal drug testing. Federal regulators understood 

the importance of clinical oversight and by the mid1980s created the position of a medical review officer 

(MRO). The MRO plays a critical role in the fair and 

effective administration of the Federal Drug Testing 

Program. The US Department of Transportation and 

the Substance Abuse and Mental Health Services 

Administration both have extensive print and online 

documentation outlining the exact responsibilities of 

the MRO. US Army policies and procedures are found 

in Medical Command Regulation 40-51.18

THE ROLE OF THE MILITARY MEDICAL REVIEW OFFICER

For the sake of brevity, and in light of the changing 

rules and variances among the services, this chapter 

will not cover all the responsibilities and regulations 

pertaining to the military MRO. The official definition 

of the MRO is “a licensed physician responsible for 

receiving laboratory results generated by an agency’s 

drug testing program who has knowledge of substance 

abuse disorders and has appropriate medical training 

to interpret and evaluate an individual’s positive test 

result together with his or her medical history and any 

other relevant biomedical information.”19(p5)

The military treatment commander appoints the 

MRO (always a physician) specifically to function in 

that capacity. The MRO must be familiar with laboratory procedures, which include screening immunoassay, gas chromatography, and mass spectrometry. The 
478

Combat and Operational Behavioral Health

Figure 29-1. Standard Form 513, Medical Record Consultation Sheet.
479

Substance Use and Abuse in the Military

testing procedures are consistent among the services. 

For purposes of illustration, the Army’s procedures are 

set forth in Army Regulation (AR) 600-85,20 Chapter 8, 

which places the responsibility of test result reporting 

in the hands of the alcohol and drug control officer 

(ADCO). The ADCO is a member of the garrison or 

administrative section of Army Substance Abuse 

Program (ASAP). The installation biochemical testing 

coordinator (IBTC) works for the ADCO and coordinates the testing and review of the urinalysis. The 

IBTC and ADCO do not have a direct affiliation with 

the military treatment facility. The IBTC or ADCO 

sends the MRO a consult or request (using an SF513, shown in Figure 29-1) requesting a review of the 

positive urinalysis. The SF-513 request should include 

the military person’s identifying data, specific drugs 

in question, and the date the biochemical test was 

conducted. The MRO should also review DD Form 

2624 (Figure 29-2), otherwise known as the Specimen 

Custody Document: Drug Testing. 

The MRO will review the military person’s medical records seeking a legitimate medical prescription 

that would account for the biochemical test result. 

If such evidence is lacking, the MRO will document 

this finding on the consult and forward the response 

to the ADCO or IBTC. The MRO’s response triggers 

one of the important safeguards of the biochemical 

testing program. Up to this point, the MRO’s opinion 

rested solely on medical documentation. To ensure 

that a comprehensive medical review occurs before 

a drug test is deemed “positive,” the military person 

will have the opportunity to meet with the MRO and 

present medical evidence that might account for the 

test result. Normally, the ADCO or IBTC will arrange 

the interview with the MRO. 

If the service member agrees to proceed, the MRO 

reviews the purpose of the interview and reviews 

the test results. Most importantly, the service member is afforded the opportunity to present evidence, 

such as a valid prescription, that might account for 

Figure 29-2. DD Form 2624, Specimen Custody Document: Drug Testing, page 1. (Figure 29-2 continues)
480

Combat and Operational Behavioral Health

Figure 29-2 continued. DD Form 2624, Specimen Custody Document: Drug Testing, page 2. 

the drug test. If satisfied that the evidence confirms 

legitimate drug use, the MRO will annotate “legitimate drug use” on the SF-513 and return the form to 

the ADCO.

THE ARMY SUBSTANCE ABUSE PROGRAM

Biochemical testing is only one of several methods 

through which referrals are made to the ASAP, or its 

counterparts in the other military services. Referrals 

can also be initiated by commanders and supervisors in response to observed changes in occupational 

performance, interpersonal relations, and physical fitness or health problems suspected to be secondary to 

substance use. These referrals are made by physicians 

and other healthcare providers in the context of routine 

or emergency medical treatment, as a consequence 

of military or civilian law enforcement investigation 

or apprehension identifications, or through the individual’s voluntary self-identification to the clinic. 

In fiscal year 2008, the Army’s Drug and Alcohol 

Management Information System reported that 10,407 

soldiers were enrolled in the ASAP Army-wide. An 

additional 10,310 soldiers were evaluated, though not 

enrolled. Of those evaluated and subsequently enrolled 

for outpatient treatment, 22% were referred through 

biochemical identification, 27% through commander 

or supervisory intervention, 11% as a result of a driving under the influence/driving while intoxicated 

arrest, 5% through other investigation or apprehension identification, 10% as medical referrals, 24% as a 

result of self-identification, and the remainder through 

a variety of other channels (ie, security clearances, 

family members).21

 Regardless of the method of identification, all of the 

military substance abuse treatment programs function 

in large measure within the conceptual model of an 

employee assistance program, focusing on personnel 

conservation and military readiness. Optimizing the 
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Substance Use and Abuse in the Military

advantages of coercive treatment through effective 

leveraging of command oversight, the ASAP benefits 

from a well-articulated team approach in the service of 

behavior change. The relationship between the ASAP 

and the command is clearly defined in AR 600-85,20

with parallel guidance in Air Force Instruction 44-121,22

and Operational Navy Instruction 5350.4C.23 AR 600-

85 differentiates the responsibilities of the command 

from that of the clinical staff, placing clinical decision 

making in the hands of the ASAP’s professional staff. 

All of the clinical staff is required, per AR 40-68,24 to be 

licensed to practice independently and to be certified 

in substance abuse rehabilitation. The clinical consultant, an addictions-trained physician, assists the ASAP 

staff, providing medical consultation and adjunctive 

medication management. It is the ASAP clinical staff’s 

responsibility to advise command of all referrals and to 

secure command input into their assessments. 

Although only the clinical staff may define treatment recommendations, unit commanders retain authority for all administrative decisions, ranging from 

deployments to retention or separation from service, 

extensions on active duty to permit reenlistment, or 

bars to reenlistment.20(p9) When retention decisions are 

required, commanders must assess the service members’ rehabilitation efforts in the context of their occupational specialties, prior service records, the needs 

of the military, and their potential for future military 

service. In general, each of the military services will 

tend to separate drug- or alcohol-dependent service 

members who do not respond to treatment. 

The Secretary of Defense is required to identify 

and treat all active duty service members who are 

drug and alcohol dependent.25 Regardless of service 

designation, referral for evaluation is mandatory and 

early intervention is key. All of the military services 

have procedures and policies to identify and offer 

treatment to those active duty members who have 

drug and alcohol problems. The unique challenges to 

deployed commanders in managing substance abuse 

issues are addressed in an information paper produced 

by the Army Center for Substance Abuse Programs.26

It provides guidance to deployed unit commanders 

regarding accessing ASAP services prior to deployment, in theater, and upon return. 

Once identified and referred, a comprehensive 

biopsychosocial and substance use assessment is completed by the ASAP staff. The assessment explores the 

extent of substance use; intervention is recommended 

according to the degree of impairment. Such treatment 

recommendations are based upon careful consideration of the criteria for substance use disorders, per 

the current Diagnostic and Statistical Manual of Mental 

Disorders.

27 Diagnoses of abuse and dependence generally require enrollment in treatment for periods of 3 

months to 1 year. The intensity of response can range 

from a 12-hour instructional program called ADAPT 

(Alcohol and other Drug Abuse Prevention Training) 

to outpatient treatment activities in the ASAP. Referrals to higher levels of care for detoxification, intensive 

outpatient programs, partial hospitalization programs, 

or residential treatment are often incorporated into the 

treatment plan. 

Per Health Affairs Policy 9700029,28 a continuum 

of substance abuse care must be considered for active 

duty service members, consistent with the patient 

placement criteria of the American Society of Addiction Medicine. “These criteria reflect the philosophy 

of placing patients in the least intensive/restrictive 

treatment environment, appropriate to their therapeutic needs.”29(p2) In addition to defining a crosswalk for 

level-of-care determinations, the American Society of 

Addiction Medicine posits a multidimensional analysis to enhance treatment decision making. Acute intoxication or withdrawal potential (Dimension 1) and 

the patient’s biomedical conditions and complications 

(Dimension 2) must receive primary consideration 

in the stabilization process, after which the patient’s 

emotional, behavioral, and cognitive conditions and 

complications (Dimension 3); readiness for change 

(Dimension 4); relapse, continued use, or continued 

problem potential (Dimension 5); and recovery/living environment (Dimension 6) are considered in the 

formulation of a dynamic and individualized treatment plan.30(p4) Treatment emphasizes motivational 

enhancement over confrontational drama, supported 

by a multidisciplinary team approach to facilitate 

change. 

Although the clinical role of the ASAP providers 

and the administrative domain of the command are 

clearly differentiated, a collaborative thread is woven between the command and clinical staff through 

implementation of the “rehabilitation team.” The rehabilitation team concept is developed in AR 600-85,20(p17)

and is a core ingredient of an effective program. With 

the ASAP clinician serving as chair, the rehabilitation 

team is composed of the soldier, the unit commander 

or first sergeant, and others as needed. In its most effective implementation, the rehabilitation team meeting 

provides the soldier with a positive outlook to start 

treatment. It offers a forum to clearly define program 

expectations and to explain the benefits for successful 

completion, while also articulating the consequences 

of failure to comply with treatment guidelines. It also 

offers a setting in which to provide assurances of support to mitigate a soldier’s fears, to explain patient 

rights, and to discredit some of the myths that pervade 

early beliefs and undermine success. Careers are more 

often enhanced than lost through the rehabilitation 

process. Therefore, it is imperative that soldiers experi-
482

Combat and Operational Behavioral Health

ence the ASAP staff and command group as a unified 

team whose primary mission is to conserve personnel 

and promote health and well-being. Career retention 

goals and personnel conservation thus are married to 

rehabilitation efforts through the close collaboration 

with command. 

SUMMARY

Today’s military requires sophisticated knowledge 

and advanced technical skills to successfully navigate 

lethal battlefields. Even modest amounts of alcohol can 

impair crucial decision-making abilities and negatively 

affect military operations. Military personnel are not 

immune to the larger social problem of tobacco, illicit 

drugs, and the misuse of prescription and over-thecounter medications. The military maintains an active 

biochemical testing program to constantly assess the use 

of these substances and their impact on military readiness. In addition, each service offers specific administrative rules and clinical support to address the misuse of 

substances. The best outcome for the individual and the 

organization results from a collaborative effort involving clinicians, commanders, and a motivated patient to 

resolve issues of substance abuse.

REFERENCES

1. National Institute on Alcohol Abuse and Alcoholism. Alcohol-related impairment. Alcohol Alert. July 1994; No. 25 PH 

351. Available at: http://pubs.niaaa.nih.gov/publications/aa25.htm. Accessed September 10, 2008.

2. National Institute on Alcohol Abuse and Alcoholism. Cognitive impairment and recovery from alcoholism. Alcohol 

Alert. July 2001; No. 53. Available at: http://pubs.niaaa.nih.gov/publications/aa53.htm. Accessed September 10, 

2008.

3. White AM. What happened? Alcohol, memory blackouts, and the brain. Alcohol Research Health. 2004;2:186–196.

4. National Institute on Alcohol Abuse and Alcoholism. Alcohol’s damaging effects on the brain. Alcohol Alert. October 

2004; No. 63. Available at: http://pubs.niaaa.nih.gov/publications/aa63/aa63.htm. Accessed September 10, 2008.

5. National Institute on Alcohol Abuse and Alcoholism. Alcohol and sleep. Alcohol Alert. July 1998; No. 41. Available at: 

http://pubs.niaaa.nih.gov/publications/aa41.htm. Accessed September 10, 2008.

6. National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health. Percent distribution of current drinking status, drinking levels, and heavy drinking days by sex for persons 18 years of age and older: United 

States, NHIS, 1997–2006. Available at: http://www.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/

AlcoholConsumption. Accessed September 10, 2008.

7. Cherpitel CJ. Brief screening instruments for alcoholism. Alcohol Health Res World. 1997;21(4):348–351.

8. National Institute on Alcohol Abuse and Alcoholism. Screening for alcoholism. Alcohol Alert. April 1990; No. 8 PH 

285. Available at: http://pubs.niaaa.nih.gov/publications/aa08.htm. Accessed September 10, 2008.

9. Peterson K. Biomarkers for alcohol use and abuse. Alcohol Res Health. 2004/2005;28(1):30–37.

10. Results from the 2007 National Survey on Drug Use and Health: National Findings. Department of Health and Human 

Services. Substance Abuse and Mental Health Services Administration. Available at: http://www.oas.samhsa.gov/

nhsda.htm. Accessed April 21, 2009.

11. Pfefferbaum B, Vinekar SS, Trautman RP, et al. The effect of loss and trauma on substance use behavior in individuals 

seeking support services after the 1995 Oklahoma City bombing. Ann Clin Psychiatry. 2002;14(2):89–95.

12. Vlahov D, Galea S, Resnick H, et al. Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, 

residents after the September 11th terrorist attacks. Am J Epidemiol. 2002;155(11):988–996.

13. Hapke U, Schumann A, Rumpf HJ, John U, Konerding U, Meyer C. Association of smoking and nicotine dependence with 

trauma and posttraumatic stress disorder in a general population sample. J Nerv Ment Dis. 2005;193(12):843–846.
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14. Koenen KC, Hitsman B, Lyons MJ, et al. A twin registry study of the relationship between posttraumatic stress disorder 

and nicotine dependence in men. Arch Gen Psychiatry. 2005;62(11):1258–1265.

15. Fagerström K, Schneider NG. Measuring nicotine dependence: a review of the Fagerström Tolerance Questionnaire. 

J Behav Med. 1989;12:159–182.

16. Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Department of Health and 

Human Services. Results From the 2005 National Survey on Drug Use and Health: National Findings. September 2006. 

Available at: http://oas.samhsa.gov/NSDUH/2k5NSDUH/2k5results.htm. Accessed September 10, 2008.

17. Ronald Reagan, President. Drug-Free Federal Workplace. September 15, 1986. Executive Order 12564. Available at: http://

www.archives.gov/federal-register/codification/executive-order/12564.html. Accessed December 18, 2008.

18. US Department of the Army, Medical Command. Medical Review Officers and Positive Urinalysis Drug Testing Results. 

Washington, DC: DA; 2005. MEDCOM Regulation 40-51.

19. Shults TF. Medical Review Officer Handbook. 8th ed. Research Triangle Park, NC: Quadrangle Research, LLC; 2005.

20. US Department of the Army. Army Substance Abuse Program. Washington, DC: HQDA; 2006. Army Regulation 600-

85.

21. Army Center for Substance Abuse Programs 2008 data. Available at: https://ssob.acsap.hqda.pentagon.mil/sso/

pages/index.jsp. Accessed April 10, 2009.

22. US Department of the Air Force. Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program. Washington, DC: 

HQUSAF September 26, 2001. Air Force Instruction 44-121. Available at: http://www.e-publishing.af.mil/shared/

media/epubs/AFI44-121.pdf. Accessed December 18, 2008.

23. US Department of the Navy. Drug and Alcohol Abuse Prevention and Control. Washington, DC: Department of the Navy, 

Office of the Chief of Naval Operations; October 15, 2003. OPNAV Instruction 5350.4C. Available at: http://www.

navyfitrep.com/inst_files/OPNAVINST_5350.4C_-_DAPA.pdf. Accessed December 18, 2008.

24. US Department of the Army. Clinical Quality Management. Washington, DC: HQDA; 2004. Army Regulation 40-68. 

Available at: http://www.army.mil/USAPA/epubs/pdf/r40_68.pdf. Accessed December 18, 2008.

25. Medical and Dental Care, Identifying and Treating Drug and Alcohol Dependence. 10 USC §1090 (2010).

26. Army Center for Substance Abuse Programs. Army Substance Abuse Program Guidance for Deployed Commanders. Washington, DC: DA; 2004.

27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. (DSM-IV-TR).

Washington, DC: APA; 2000.

28. US Department of Defense. Curbing Alcohol Abuse. Posted by Casscells SW, August 21, 2008. Health Affairs Policy 

Memo 9700029. Available at: http://www.health.mil/MHSBlog/Article.aspx?ID=336. Accessed December 18, 2008. 

29. American Society of Addiction Medicine. Patient Placement Criteria. Available at: http://www.asam.org/PatientPlacementCriteria.html. Accessed December 18, 2008.

30. American Society of Addiction Medicine. Patient Placement Criteria for the Treatment of Substance-Related Disorders: 

ASAM PPC-2R. 2nd rev ed. Chevy Chase, Md: ASAM; 2001.
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487

The Impact of Deployment on Military Families and Children

Chapter 30

THE IMPACT OF DEPLOYMENT ON 

MILITARY FAMILIES AND CHILDREN

SIMON PINCUS, MD*; BARBARA LEINER, MSW, LCSW-C†; NANCY BLACK, MD‡; and TANGENEARE 

WARD SINGH, MD§

INTRODUCTION

THE DEPLOYMENT CYCLE

Predeployment

Deployment

Sustainment

Late Deployment

Postdeployment

EFFECTS OF DEPLOYMENT ON SPOUSES

CHILDREN’S DEVELOPMENTAL RESPONSES DURING DEPLOYMENT

Infants

Toddlers

Preschoolers

School-Age Children

Adolescents

INTERGENERATIONAL TRANSMISSION OF THE EFFECTS OF WAR AND 

COMBAT TRAUMA

SUMMARY

ATTACHMENT: RESOURCES FOR MILITARY FAMILIES

*Colonel (Retired), US Army; Clinical Director, Department of Mental Health, McChord Medical Clinic, 690 Barnes Boulevard, Joint Base Lewis-McChord 

(McChord Field), Washington 98438; formerly, Chief, Inpatient Psychiatry, Madigan Army Medical Center, Tacoma, Washington 

†

Psychiatric Social Worker, Department of Child Psychiatry, Walter Reed Army Medical Center, Borden Pavilion, 6900 Georgia Avenue NW, Washington, 

DC 20307-5001; formerly, Clinical Case Manager, Department of Child Psychiatry, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland

‡

Colonel, Medical Corps, US Army; Training and Program Director, National Capital Consortium of Child and Adolescent Psychiatry Fellowships, 

Department of Psychiatry, Walter Reed Army Medical Center, Borden Pavilion, 6900 Georgia Avenue NW, Washington, DC 20307-5001

§

Major, Medical Corps, US Army; Department of Behavioral Health, Blanchfield Army Community Hospital, 650 Joel Drive, Fort Campbell, Kentucky 

42223 
488

Combat and Operational Behavioral Health

“Deployment” is the term used when military personnel leave their usual daily workstations to train 

for or to perform a mission. Missions vary in length 

and range from training to humanitarian assistance 

to combat. Deployment has an effect on the service 

member, the member’s unit, the units that remain to 

carry on with existing tasks, and the affiliated support 

systems in the community as well as the member’s 

family. With an increased number of married military 

service members, deployment affects a growing community of spouses and children, both on and off base. 

Whether service members are single or married, their 

parents, siblings, and other relatives are frequently 

part of an extended family network that is affected by 

deployment and its outcome. This chapter addresses 

the complex issues faced by the military family when 

a service member leaves the home base to perform 

the mission of war. It also provides a list of resources 

available to military service members and their families 

(see Attachment).

In 1994, Peebles-Kleiger and Kleiger1

 wrote about 

reintegration stress in families with members returning 

from Operations Desert Shield/Storm (ODS/S). They 

described two versions of this stress: (1) Logan’s seven 

phases of adjustment and (2) a four-stage version of 

emotional adjustment based on the Kubler-Ross model 

of grief.1(pp176–177) In a report on the emotional cycle of 

deployment following the Gulf War and during the 

rotations to Bosnia and Kosovo, Pincus et al2 utilized 

these models to identify five stages: (1) predeployment, 

(2) deployment, (3) sustainment, (4) late deployment 

(referred to as “redeployment” in the original online article), and (5) postdeployment. Simon Pincus, MD, is an 

Army psychiatrist at McChord Medical Clinic (Madigan 

Army Medical Center) in Tacoma, Washington. He and 

his colleagues have continued using this approach as 

they educate families and communities during Operation Enduring Freedom (OEF), Operation Iraqi Freedom 

(OIF), and Operation Noble Eagle (ONE) engagements. 

Their goal is to sustain health and function in all family 

members during the stress of deployment.

In ODS/S (1990–1991), 645,000 troops were deployed to the war zone, including 228,000 National 

Guard and reserve forces that were brought onto 

active duty.3(p273) OIF and OEF have included an even 

wider variety and greater number of military service 

members4(p233): activated reserve and National Guard 

units and personnel, as well as individual augmentees and ready reserve personnel. During the Balkans 

engagements service members were occasionally sent 

on second deployments and multiple tours (some 

units have had three or four deployments). Longer 

tours (particularly for the Army) to a combat theater 

have become common during OIF and OEF. Soldiers 

who have already endured physical and psychological injuries—including posttraumatic stress disorder 

(PTSD)—are being returned to combat conditions. The 

broader involvement of service personnel, who are 

deployed more frequently and for longer tours of duty, 

likely increases the impact of the mission on military 

as well as civilian families and communities. 

In many cases during ODS/S, families were less 

prepared for mobilization and war5(p442) than families 

in today’s readiness climate. Many families of ODS/S 

military personnel were unfamiliar with the larger 

military system of demands, benefits, and supports 

that exists for the active duty member and beneficiary. Foreign-born or non-English–speaking spouses, 

another subset of military families facing unique circumstances, may be less capable or willing to access 

available resources.6(p78)

School enrollment records provide one example of 

the size of deployment impact on military children. In 

2004, Lamberg7 reported in the Journal of the American 

Medical Association that 191,000 children of soldiers 

were enrolled in public schools in approximately 35 

school districts near military posts around the United 

States. In addition to this number, the Department of 

Defense reported approximately 104,000 children enrolled in preschool through 12th grade at DoD schools 

in seven US states, Guam, and Puerto Rico, and in 13 

foreign countries.7

To date, national and local community support of 

troops has been consistently positive in OIF, OEF, and 

ONE. Although there are differing political views and 

increasing criticism about the execution of the war in 

Iraq, the nation as a whole has been able to separate 

these issues from the role of military service members 

and to convey support for them and their families. This 

broad community support creates a positive environment for military families, which in turn results in less 

isolation and greater overall family resiliency.8(p1285)

The Deployment Cycle

Each stage of deployment involves emotional and 

organizational elements that affect both individual 

service members and their families (Figure 30-1). Any 

impending deployment introduces uncertainty, even 

for previously deployed and experienced service members. Despite ongoing training, ambiguity likely exists 

INTRODUCTION
489

The Impact of Deployment on Military Families and Children

• Anticipation of loss vs denial

• Train up; long hours away

• Getting affairs in order

• Mental and physical distance

• Arguments

Stage 1: Predeployment

Time frame: variable

• Mixed emotions/relief

• Disoriented/overwhelmed

• Numb, sad, alone

• Sleep difficulty

• Security issues

Stage 2: Deployment

Time frame: first month, time through 

staging, embarkation, and settling in to 

mission

• New routines established

• New sources of support

• Feeling more in control

• Independence

• Confidence (“I can do this”)

Stage 3: Sustainment

Time frame: month 2 through near end

• Anticipation of homecoming

• Excitement

• Apprehension

• Burst of energy/”nesting”

• Difficulty making decisions

Stage 4: Late Deployment

Time frame: penultimate month to end

• Honeymoon period

• Loss of independence

• Need for “own” space

• Renegotiating routines

• Reintegrating into family

Stage 5: Postdeployment

Time frame: 3 to 6 months after return 

home

Figure 30-1. Common emotional rections to each stage of 

deployment.

TABLE 30-1

NEGATIVE EMOTIONAL AND BEHAVIORAL 

CHANGES IN CHILDREN DURING DEPLOYMENT

Age Behaviors Emotions Remedies

Infants: 

< 1 y

Refusing to 

eat

Listlessness Support from 

parent, pediatrician

Toddlers: 

1–3 y

Crying, tantrumsIrritability, 

sadness

Increased attention, holding, 

hugs

Preschoolers: 3–6 yPotty accidents, 

clinginess

Irritability, 

sadness

Increased attention, holding, 

hugs

School-age 

children: 

6–12 y

Whining, 

body aches

Irritability, 

sadness

Spending time, 

maintaining 

routines

Teenagers: 

12–18 y

Isolating, 

acting out, 

using drugs

Anger, 

apathy

Patience, 

limit-setting, 

counseling

about extent of the deployment, associated mission 

challenges, time commitment, the family’s capacity to 

manage the separation, and the ever-present risk of injury or death.3(p273),8(p1285) The stages of military deployment are listed in Table 30-1 and discussed below. The 

model developed by Pincus, revised to accommodate 

current deployment cycles during OIF, OEF, and ONE, 

is the source for the following section.9

Predeployment

The predeployment phase starts with the alert order 

for deployment and ends when the service members 

leave the home station. Its time frame can vary from 

several weeks to more than a year. The predeployment 

period often results in both denial and anticipation of 

separation. For many, the predominant feeling is loss 

of control.10(p632) As the departure date approaches, 

spouses often ask if the service members really must 

go. Increased field training, preparation, and long 

hours away from home mark the beginning of the 

pending extended separation.

As service members think and talk about the upcoming mission and their unit relationships, bonding 

with fellow unit members is essential to unit cohesion 

and safety during the mission, but it can create an 

increasing sense of emotional and physical distance 

for military spouses and children.9,11,12 Because of 

this psychological distancing, spouses often feel as 
490

Combat and Operational Behavioral Health

if their loved ones have already deployed. However, 

the change in focus from family to unit is a necessary 

part of the deployment process for active duty service 

members as they prepare for, and embrace, the mission. It can be especially demanding for the activated 

National Guard or Reserve service members who are 

transitioning from civilian to military life. By extension, 

spouses of National Guard and Reserve service members can have significant adjustment challenges during 

this transition. These complex issues can increase the 

individual service member’s negative feelings within 

the context of deployment.13(p633)

With deployment pending, families review their 

personal and family affairs to reorder their lives during 

the service member’s absence. Lists are generated to 

categorize a variety of expected needs: home repairs, 

home security, car maintenance, finances, insurance, 

tax preparation, childcare plans, and wills. Anxiety 

about financial and bill-paying responsibilities is often 

significant.14(p85) Couples may want increased intimacy 

and arrange for memorable holidays or anniversaries. 

Desire for sexual intimacy may be ambivalent, vacillating between wanting and not wanting to be close 

before the impending separation. Fears about marital 

fidelity may be raised or may go unspoken. Other 

frequently voiced concerns include anxiety about 

children’s ability to handle the separation, fears of 

functioning without the partner, and the survivability 

of the marriage. Completing the multitude of tasks 

and fulfilling high expectations before deployment can 

place tremendous strain on couples and families. 

It is not uncommon for military couples to argue 

before deployment.3,9 For well-established couples and 

those familiar with the deployment cycle, arguments 

may be accepted as part of the rhythm of marital life 

and adjustment to deployment. For less experienced 

couples, however, especially those facing an extended 

separation for the first time, such arguments can lead 

to fears that the relationship could be over. 

In 1980, Valentine cited the work of Evelyn Duvall, 

who identified “nine ever-changing family developmental tasks that span the life cycle.”15(p350) These tasks 

serve to establish and maintain (1) an independent 

home, (2) satisfactory ways of obtaining and spending 

money, (3) mutually acceptable patterns in the division 

of labor, (4) continuity of mutually satisfying sexual 

relationships, (5) an open system of emotional and 

intellectual communication, (6) workable relationships 

with relatives, (7) ways of interacting with associates 

and the community, (8) competency in bearing and 

rearing children, and (9) a workable philosophy of 

life.15(p350)

Unresolved family challenges have potentially 

devastating consequences. To a military commander, 

a worried, preoccupied service member is easily distracted and unable to focus on essential tasks during 

critical times. From a psychological perspective, it 

is easier to be angry than to confront the pain and 

loss of saying goodbye.2,16 In the worst-case scenario, 

unresolved emotional preoccupation can lead to serious accidents or the development of a combat stress 

disorder, which in turn can contribute to mission ineffectiveness.17–19 At home, significant spousal distress 

interferes with completing basic routines, concentrating at work, and attending to the children. This can 

exacerbate children’s fears that the parents are unable 

to adequately care for them or that the deployed parent 

will not return. Adverse child reactions include regressive behaviors such as inconsolable crying, apathy, or 

tantrums. A downward emotional spiral can result in 

which both service member and spouse become even 

more upset at the prospect of separating.

Kiser et al20(p90) outline seven characteristics of family 

resiliency: (1) a strong commitment to the family that 

involves a close bond and stable relationship with at 

least one person, (2) family organization with shared 

parental leadership and clear role boundaries, (3) belief 

in the family and its ability to succeed, (4) implementation of strategies to manage the demands created by 

stressors, (5) willingness to work to resolve issues, (6) 

maintenance of social connections, and (7) a coherent 

and positive understanding of stressors consistent with 

the family’s shared world view.20(p90) When military 

couples are able to explore and discuss their mutual 

expectations as they prepare for the deployment, they 

are more likely to successfully adjust throughout the 

phases of the deployment experience. Healthy couples 

will expect that nondeploying spouses will exercise 

their freedom to make independent decisions; maintain contact with same- and opposite-sex friends and 

neighbors (for assistance and socialization); budget 

effectively; care for children competently; and stay in 

touch through letters, care packages, e-mail messaging, 

and telephone calls. Failure to communicate these and 

other expectations is frequently a source of misperception, distortion, and hurt feelings during and after the 

deployment period. 

Deployment Phase

The deployment phase is the period from the service 

member’s departure from home through the first 

month of separation. Mixed emotions arise during 

this stage. Spouses may report feeling disoriented or 

overwhelmed, or they may feel relieved that they no 

longer have to appear brave and strong. There may be 

residual anger about tasks left undone by the deployed 

spouse. The departure creates a gap that can lead to 
491

The Impact of Deployment on Military Families and Children

feelings of numbness, sadness, loneliness, or abandonment. It is common for family members to have difficulty sleeping or coping with everyday challenges. 

Worries about home security and personal safety may 

come up again. Other concerns may involve pay problems, sick children, or car repairs. For many, the early 

part of the deployment stage can be an unpleasant, 

disorganizing experience. 

Although it is often assumed that only wives have 

such difficulties or concerns, these issues apply to 

spouses of either gender. Husbands may feel overwhelmed in taking responsibility for childcare, school 

attendance and homework, meals and shopping, 

medical and dental care, extracurricular activities, peer 

groups, friends, and social activities for their children. 

When new caregivers are brought in to assist families 

in the absence of the deployed parent, feelings of 

uncertainty can develop in children as they attempt 

to integrate another deployment-related change into 

their lives.

Sustainment Stage

The sustainment stage lasts from the end of the first 

month of the deployment to the month prior to return 

home. Sustainment is a time of establishing new sources 

of support and new routines. At home, many Army 

families rely on the local family readiness group (FRG), 

a garrison-based function that serves as a close network 

of community spouses and families. The FRG ideally 

meets on a regular basis to provide help with problems and disseminate information. The Army’s sister 

services have groups that perform similar functions. In 

addition, many military spouses are comfortable receiving support from their families, friends, churches, or 

other cultural, community, ethnic, or religious institutions as their primary means of emotional support. As 

challenges occur, most spouses find that they are able 

to cope with crises and make important decisions on 

their own. They report feeling more confident and in 

control. During the sustainment stage, most military 

spouses report that they can do what is needed to keep 

their families functioning successfully. 

Frequency, method, and content of communication 

between deployed service members and families are 

important factors at every stage of deployment, but 

especially during sustainment. The reality that phone 

contact is unscheduled and initiated by the service 

member can be frustrating. Spouses can feel tied to the 

house, not wanting to miss a call. Service members may 

feel forgotten if they call and no one is home, especially 

if they waited a long time to get to a phone. When expectations regarding the frequency of calls are unmet, 

resentment and anger may result. The Defense Satellite 

Network (DSN) offers time-limited calls home at no 

cost, depending upon location. Commercial phone 

lines are an option for some service members, but large 

phone bills can result, adding to family stress. More 

recently, some families are able to remain connected 

through video-teleconference capabilities via the Internet. For most military spouses, reconnecting with 

their loved ones is a stabilizing experience. For those 

who have difficult interactions during phone calls, the 

contact can exacerbate stress in the deployment stage 

and may result in the need for counseling.9

With e-mail now widely available, spouses and 

service members report feeling more in control; both 

are able to initiate communication, and they are not 

limited by the constraints of scheduling phone calls. 

Another advantage of e-mail is the ability to be more 

thoughtful about what is said and to monitor intense 

emotions that may be unnecessarily disturbing. However, e-mail security and restrictions can constrain 

some communication.

One disadvantage of the improved access to communication (phone calls or e-mail) is the immediacy 

of, and proximity to, unsettling news from either the 

family or the service member. It is virtually impossible 

to disguise negative feelings of hurt, anger, frustration and loss, especially on the phone. Inaccurate and 

disappointing news may travel quickly by personal 

cellular phones.

Unsubstantiated rumors can circulate unchecked 

within the FRG.9

 Rumors involving allegations of infidelity can be particularly damaging. Other troubling 

rumors may involve innuendo that a particular spouse 

or service member is handling the deployment poorly, 

combat accidents or injuries, unexpected changes in 

the date of return, or disciplinary actions. Rumors can 

be hurtful to service members, spouses, and the FRG. 

At its worst, unit cohesion and even mission success 

can suffer. Limiting the negative effect of rumors is a 

constant challenge for unit leaders and chaplains. The 

rapidity of crosscommunication of potentially inaccurate news can undermine the ability of the service 

member, unit, or family to focus and perform safely.

Late Deployment Stage 

The late deployment stage is defined as the month 

before the service member returns home. Deployments 

occurring during the OIF surge have been marked by 

unexpected and late announced extensions of combat 

tours. Deployment extensions typically lead to frustration and anxiety for all involved and can introduce 

unexpected strain at a time when everyone is looking 

forward to the service member’s return. The late deployment stage is generally one of great anticipation. 
492

Combat and Operational Behavioral Health

As in the deployment stage, there can be a rush of conflicting emotions: excitement that the soldier is coming 

home, apprehension, concern that spouses may not 

agree with how things have been managed, worry 

about whether independence will be lost or how roles 

will shift, and concern about whether family members 

will get along. With the separation almost over, there 

can be renewed difficulty making decisions. A spouse 

may wonder whether decisions should be deferred 

until the service member is home to make them. Many 

spouses also experience a burst of energy during this 

stage,9,16 a rush to complete tasks around the home. 

During late deployment, expectations of service members, spouses, and children all are high.

Postdeployment 

Postdeployment begins with the service member’s 

return from theater and arrival home, sometimes first 

to the clearing station or demobilization station. Like 

predeployment, the time frame can be variable. The 

actual homecoming is often ceremonial and can be a 

joyous occasion. Children rush to the returning parent 

and the reunited couple embrace. The unit commander 

calls the unit to attention, praises unit members for 

their service, and then dismisses them. Weapons and 

equipment are turned in, and further demobilization 

tasks (including health evaluations, mental health 

surveys, and family health surveys) are completed. 

Finally, the family goes home. Homecoming can also 

be a frustrating and upsetting experience. The date 

of return may change, or units may travel home in 

separate groups over several days. Spouses may be 

required to attend to other unexpected family obligations, such as sick children.

A “honeymoon” period usually follows the homecoming, during which families reunite; however, they 

may soon find themselves feeling emotionally distant. 

Some spouses describe awkwardness in addition to 

excitement, especially reestablishing intimacy after 

so many months of separation. Emotional reconnection may require time before sexual intimacy feels 

comfortable. Eventually, returning service members 

reassert their role as spouse or parent within the family.16 This is an essential task that can flow naturally 

or lead to tension within the family. Service members 

may feel pressure to make up for lost time and missed 

milestones. They may want to quickly reestablish the 

authority they had before. However, some things will 

have changed in their absence: spouses typically become more autonomous during deployments, children 

have grown, and individual personal priorities in life 

may be different. It is not realistic to expect everything 

to be the same as before the deployment. 

During the postdeployment period, spouses may 

report a lost sense of independence or resentment at 

having been left on their own. Spouses may consider 

themselves to be the true heroes, who managed things 

while service members were away. At least one study21

suggests that stay-at-home parents are more likely to 

report distress than the deployed service members. 

Like their military spouses, nondeployed spouses 

also have to adapt to changes that result from the 

homecoming, and may find they are more irritable 

with their mates around. They may desire to retain a 

sense of their own space. Basic household chores and 

routines need to be renegotiated. Roles played by each 

spouse in the marriage must be reestablished, perhaps 

in a new form. 

Reunions with children can be both joyful and 

challenging. Youngsters’ feelings tend to depend on 

their age and their understanding of the reason for the 

service member’s absence. Babies less than 1 year old 

may not know the returned parent and cry when held. 

Toddlers (1–3 years) may be slow to warm up. Preschoolers (3–6 years) may feel guilty or scared about 

future separations. School-age children (6–12 years) 

may want a lot of attention. Teenagers (13–18 years) 

may be moody and may not appear to care. Children 

are often loyal to the parent who remained behind 

and may not respond initially to discipline from the 

returning service member. Children may also fear 

the military parent’s return if a threat of discipline or 

consequences has been put forward. Some children 

may display ongoing anxiety triggered by the real possibility of future deployments. The returned service 

member may not agree with privileges granted to children by the nondeployed parent. Generally, reunited 

parents should not make immediate changes, instead 

taking time to renegotiate family rules and norms. 

Otherwise, the service member risks invalidating the 

efforts of the nondeployed parent and alienating the 

children. Returning service members may feel hurt in 

response to a perceived ambivalent reception. Clearly, 

making changes slowly and allowing children to set 

the pace for reintegration can lead to a successful 

reunion. 

Postdeployment is probably the most critical stage 

for service member, spouse, and children. Successful 

reintegration is aided by fostering patient communication, setting reasonable expectations, and taking 

time for family members to reacquaint.9,16 Counseling 

may be required if the soldier is injured, returns with 

unrelenting psychiatric symptoms, or engages in 

health-risk behaviors such as excessive alcohol use or 

physical displays of anger. Nevertheless, the separation experienced during the deployment offers service 

member and spouse a chance to evaluate changes 
493

The Impact of Deployment on Military Families and Children

within themselves and what direction they want their 

marriage to take. Postdeployment is both a difficult 

and joyful stage, and many military couples have reported that their relationship is stronger as a result.

Effects of Deployment on SPOUSES

Soon after the August 1990 announcement that the 

United States would send troops to the Persian Gulf, 

Rosen et al22(p47) were tasked to study the impact of 

deployment on service member and family well-being. 

They studied Army spouses to determine which group 

had the most difficulty coping during ODS/S. They 

identified three vulnerable groups: (1) enlisted spouses 

under 30 years of age, many of whom were Spanish 

speaking and many married to noncommissioned 

officers; (2) very young spouses of junior enlisted, especially those living off post; and (3) older, employed 

spouses who faced their own unique stresses.

In May 2003, Haas et al surveyed23 pregnant military and civilian women in the antenatal clinic at the 

Naval Hospital Camp Lejeune to measure stress levels. Almost predictably, women whose partners were 

deployed and who already had more than one child 

at home reported higher levels of stress (up to eight 

times greater than those with no children at home) 

than their peers who were married to nondeployed 

military members.23(p48)Another study conducted in 

a southeastern Virginia Navy community looked at 

families whose service members deployed to the Mediterranean between 1989 and 1991.24(p103) The authors 

found that deployment associated with combat had 

the strongest effect on spouses, predisposing them to 

depression. 

Not all military families are traditional in constellation; some are single-parent families and some are 

blended families. Although in past wars most deploying service members were men, this is no longer the 

case. In 1993, Birgenheier25 (quoting data from Magnusson and Payne) noted that women comprised more 

than 10% of the military, and that 14% of them, along 

with 4% of military service men, were single parents. 

With the onset of Operation Desert Storm on January 

15, 1991, mothers were assigned to combat settings for 

the first time.25(p471) 

Children’s Developmental Responses During Deployment

Forty percent of service members have children, 

approximately one third of whom are less than 5 years 

of age. Children of varying ages respond differently to 

deployment stress. Their strengths and vulnerabilities 

are determined by stages of psychosocial development. Parents or other caring adults must avoid burdening children of any age with matters that are more 

appropriate to adults. 

Some children may have greater difficulty adapting 

to the stress of a deployed parent. Signs or symptoms 

indicating an inability to return to normal routines 

or the presence of more serious problems require a 

visit to the family doctor or mental health counselor. 

Despite obstacles, the vast majority of spouses and 

children successfully negotiate the sustainment stage 

and look forward to their deployed family member 

coming home. Table 30-1 provides examples of negative behavioral and emotional changes in children of 

different ages that require further attention.

Infants

Infants (< 1 year; the Eriksonian psychosocial developmental stage of “trust versus mistrust”26) thrive 

when held and actively nurtured. The infant is at 

risk when a primary caregiver becomes significantly 

depressed or otherwise emotionally unavailable. 

Infantile depression may present with symptoms of 

apathy, irritability, eating refusal, or weight loss. Early 

intervention becomes critical to prevent undue harm 

or neglect. In particular, pediatricians should monitor 

growth. Personnel in community services, social work, 

pediatrics, and psychiatry must assist with parental 

support and treatment, parental skill development, 

and coordination of appropriate family services. 

Toddlers

Toddlers (1–3 years; the Eriksonian psychosocial 

developmental stage of “autonomy versus shame,”26) 

generally take their emotional and behavioral cues 

from their primary caregivers. If the home-based 

parent is coping well, the toddler tends to do well. 

The opposite is also true. If the primary caregiver is 

not coping well, then toddlers may become sullen or 

tearful, throw tantrums, or develop sleep or eating 

disturbances. Toddlers respond to increased attention such as playing together, hugs, or longer bedtime 

rituals. Given the challenges of caring for young, active children, home-based parents should balance the 

demands for caring for children alone with their own 

needs for time. Parents may also benefit from sharing 

their day-to-day experiences with other parents facing 

similar challenges.
494

Combat and Operational Behavioral Health

Preschoolers

Preschoolers (3–5/6 years; the Eriksonian psychosocial developmental stage of “initiative versus 

guilt,”26) may regress in acquired skills as a result 

of deployment stress. This regression may manifest 

itself as loss of toilet training, change in language 

use, thumb sucking, refusal to sleep alone, or increased neediness. Young children may become 

more irritable, depressed, or aggressive. They are 

prone to somatic complaints and can develop more 

pervasive fears of losing parents or other important 

adults. Caregivers need to reassure preschoolers 

with extra attention and physical closeness (hugs, 

holding hands). Adults should avoid changing family routines; they should support developmental 

accomplishments, such as encouraging youngsters 

to continue to sleep in their own bed. Answers to 

questions about the deployment should be brief, 

matter-of-fact, and to the point. Consistency of routines and expectations, although important for all 

age groups, provides greater comfort and security 

for younger children in particular. 

School-Age Children

School-age children (6–12 years; the Eriksonian 

psychosocial developmental stage of “industry versus inferiority,”26) may whine and complain, develop 

somatic complaints, become aggressive, or otherwise 

behaviorally demonstrate their feelings. They may focus on the military parent missing a key event such as 

a birthday, school play, or important game. Depressive 

symptoms may present as sleep disturbance, loss of interest in school, changes in eating habits, or decreased 

desire to play with friends. School-age children benefit 

from talking about their feelings and need more physical attention than usual. Although some reduction in 

school performance may occur, parental expectations 

and routines should largely remain the same.

Rosen et al27 studied children’s responses during 

ODS/S deployments, finding that sadness was fairly 

widespread in both boys and girls aged 3 to 12 years 

old. Children’s symptoms sometimes varied with birth 

order. Discipline problems and immature behaviors 

were more prominent in eldest children (mean age 7.2 

+/− 5.4 years). Academic problems and refusing to 

talk were noted more in second children. Both groups 

evidenced eating and sleeping problems as well as 

increased need for adult attention.27(p466) Kelley24 reported that the children of ODS/S combat-deployed 

service members demonstrated more internalizing 

and externalizing behaviors that took longer to resolve 

after the father’s return. The frequently quoted study 

by Jensen et al28 focused on children’s responses to parental separation during ODS/S. In this study, ODS/S 

combat deployments were related to elevated, but 

not pathological, depressive and anxiety symptoms 

for both the nondeployed spouse and the children, 

as measured by parental reports. Boys and younger 

children appeared especially vulnerable to deployment effects.28

Adolescents

Adolescents (13–18 years; the Eriksonian psychosocial developmental stage of “identity versus role confusion,”26) may be irritable or rebellious. Teens might 

argue or participate in other attention-getting behavior. 

Huebner and Mancini29 noted that adolescents face a 

number of normal developmental stressors, including 

puberty. These normal stressors combined with the 

multiple challenges of deployment can push teenagers’ coping capacities beyond their limits. With their 

developing cognitive capacity for abstract thought 

and more complex emotional lives, adolescents may 

experience ambivalent feelings, such as anger mixed 

with pride in the deployed parent. They can also experience a sense of loss and uncertainty about whether 

they will see the parent again. 

Changes in responsibilities and roles during deployment may be challenging, but also provide older 

children and teens with an opportunity for greater 

independence and growth. The return of the deployed 

parent can be more difficult due to the potential loss 

of these newly earned responsibilities. In Huebner’s 

study, teens were more aware of having become closer 

to their nondeployed parents (mothers) and struggled 

to return to their previous roles and relationships at 

the end of the deployment. These adolescents also 

reported being aware of more intense family relations 

and of their own fluctuating emotions.29(pp3,9,10) 

During parental deployments, adolescents may 

show a lack of interest in school, peers, and school 

activities. They are at greater risk for promiscuity, 

alcohol use, and drug use. Although teens may deny 

problems and worries, it is extremely important for 

caregivers to stay engaged and be available to talk 

about the teens’ concerns. Sports and peer or family social activities should be encouraged to give 

normal structure to teens’ lives. Academic tasks can 

add further order to a teenager’s life. Likewise, additional responsibility in the family, commensurate 

with their emotional maturity, helps teens feel important and needed. Monetary incentives can also 

contribute positively to the maintenance of grades 

and chores. Adolescents should not, however, be 

placed in roles of coparenting or serve as confidantes 
495

The Impact of Deployment on Military Families and Children

to the nondeployed spouse. Even the most capable 

adolescents need to know that competent adults 

remain in charge and will look after and care for the 

adolescents’ needs.

Intergenerational Transmission of the Effects of War and Combat Trauma

Newer research has identified elevated rates of 

PTSD and depression in service members returning 

from combat deployment in Iraq, with approximately 

20% of these personnel evidencing symptoms indicative of a mental disorder.30 It is essential to consider 

the impact of these postcombat conditions on families, 

particularly children. Intergenerational trauma transmission, sometimes referred to as secondary traumatization, is a phenomenon whereby children are affected 

by their parent’s posttraumatic sequelae.31 A body of 

literature in this field has emerged since the mid-1960s, 

when the subject was first considered in work with 

families of Holocaust survivors.32 Interest in the subject 

continued with the 1983 National Vietnam Veterans 

Readjustment Study (NVVRS), which was established 

in response to a congressional mandate for an investigation of PTSD and other postwar psychological problems among Vietnam veterans.33 Numerous studies 

were conducted with families of Vietnam veterans that 

examined the psychological, behavioral, and adaptive 

styles of children of veterans. Additional work in the 

field of intergenerational trauma studies has focused 

on the impact of multiple traumas (genocide, political 

violence, repressive regimes, domestic violence, crime, 

and life-threatening diseases)34 on survivor’s children. 

In such cases, the children did not experience the actual 

traumatic events, but were affected by their parents’ 

traumatic experiences.

The multigenerational repercussions of trauma 

are well documented in anecdotal data. Children of 

Holocaust survivors report feeling that they have 

absorbed their parents’ Holocaust experiences as if 

“through osmosis.”35 Many children of Holocaust 

survivors describe an unspoken presence of the Holocaust in the home that served as an organizing force 

underlying family communications and relationships. 

Many reported that their parents never spoke about 

the traumas they endured, giving rise to the term 

“conspiracy of silence.”35 This “conspiracy” refers to 

an avoidance of discussion within the family as well 

as within society at large of the horrors experienced 

by Holocaust survivors. This silence is regarded as a 

powerful means of transmission of the impact of the 

parental trauma.

Initial clinical observations in the 1960s noted 

significant anxiety, depression, and maladaptive behaviors in children of Holocaust survivors.36 The early 

literature was generally presumptive of significant 

psychopathology, given the severity and duration 

of the traumatic experiences of the parents who had 

little opportunity to integrate their massive losses and 

traumatic experiences. Over time, these results were 

questioned because of methodological weaknesses and 

lack of reliable data.37 Questions naturally arose about 

how to assess the meaning and impact of any parental 

trauma on a child. New interest developed in considering the strengths that parents confer to their children 

as a result of their histories of traumatization.32

Similarly, studies of children of Vietnam veterans 

present a range of findings and conclusions. Some 

reports indicate that children of veterans had difficulties in academic performance, peer relations, and 

affective coping, with general deficits in psychosocial 

functioning.38 The NVVRS determined that on over 

100 life-adjustment indices, the majority of Vietnam 

veterans successfully adjusted to postwar life with few 

symptoms of psychological disorders.33 Other studies 

raised concerns over the adverse impact on children related to their fathers’ combat-related PTSD, emotional 

numbing,39 or participation in acts of abusive violence 

during combat.40 Studies appearing in the literature by 

the mid-1980s suggested that children of fathers with 

PTSD were at increased risk for learning disabilities, 

aggression, depression, and hyperactivity.41

A significant factor in the emergence of intergenerational trauma transmission appears to be related 

to whether the veteran parent had, or did not have, 

symptoms of PTSD. NVVRS data indicate a relationship between PTSD and family disruption, as well as 

marital instability and child behavioral problems.40

Parental feelings of detachment or inability to feel 

and express emotions were noted to carry over into 

the parenting relationship, possibly leading to behavioral problems in children. Significantly, affective 

avoidance and emotional numbing are most highly 

correlated with behavioral difficulties in children of 

veterans.42 The literature also notes that veterans who 

have participated in abusive violence or atrocities see 

themselves as social outcasts and have difficulty trusting others. These views can contribute to increased 

family violence and difficulty with the formation of 

nurturing parenting bonds.40 

Intergenerational trauma transmission appears to 

occur most significantly when second-generation children experience trauma themselves. Vietnam veterans 

who were sons of World War II veterans and who were 

diagnosed with PTSD had more severe and persistent symptoms than veterans whose parents had not 
496

Combat and Operational Behavioral Health

been exposed to combat. Problems for these Vietnam 

veterans emerged at the time of homecoming, with 

clashes in ideology between fathers who fought the 

“good war” and sons who fought an unpopular war. 

The lack of support for returning Vietnam veterans 

may have impeded the resolution of PTSD symptoms 

and facilitated the intergenerational transmission of 

combat-related trauma for those with veteran fathers.43

Similarly, Israeli veterans of the 1982 Lebanon War 

who were sons of Holocaust survivors were also noted 

to have especially severe and persistent symptoms 

of PTSD compared with control groups, suggesting 

that intergenerational trauma transmission is more 

pronounced when the offspring experience personal 

traumas.44

A veteran’s PTSD can affect children in a number of 

ways. The parent’s reexperiencing of traumatic events 

can be sudden, intense, and vivid. These intrusions are 

very frightening to children, who do not understand 

what is happening. Children may worry about the parent’s well-being, or the parent’s ability to provide care 

for them. Parents with emotional numbing and who 

are “shut down” can seem remote and uninvolved to 

their children. The parent may seem uncaring, and the 

child may feel unloved. Symptoms of anxiety, hyperarousal, irritability, and low frustration tolerance can 

influence a child’s sense of safety and can cause the 

child to question the parent’s love.33

Children of combat veterans with PTSD have been 

observed to fall into three general response types: (1) 

the disengaged child, (2) the overidentified child, and 

(3) the rescuer child. While the disengaged child may 

become emotionally detached from family life, the 

overidentified child tries to become closer to the parent 

at the expense of age-appropriate activities and peer 

relationships. This child may experience flashbacks 

and nightmares that are similar to the veteran parent. 

The rescuer child, similar to the child of an alcoholic, 

tends to feel responsible for the parent’s problems and 

guilty when things do not go well. This child takes on 

parental roles and responsibilities.38

Trauma involves a disruption of emotions, beliefs, 

and cognitions. The parent may return from combat 

with altered thoughts, feelings, and behaviors in the 

aftermath of a single traumatic event, or as a result 

of prolonged exposure to the intensity of the combat 

experience. There may be change in parents’ fundamental sense of themselves as people, and in the way 

they view themselves within the context of society as 

well as within their interpersonal relationships. Issues 

of safety and trust can be deeply affected by trauma, 

reshaping an individual’s beliefs about relationships 

and about the world at large.37 Intergenerational 

transmission of the impact of parental trauma occurs 

when the parent’s disrupted beliefs and assumptions 

are communicated to a child who has not experienced 

the trauma but who comes to internalize a set of feelings or beliefs that parallel those of the traumatized 

parent. 

Mechanisms of intergenerational transmission 

of trauma described by Ancharoff and colleagues37

include silence, overdisclosure, identification, and 

reenactment. In an environment of silence, the child 

experiences the impact of the parent’s trauma affectively but in the absence of explanation or reassurance. The family sometimes colludes in avoiding 

difficult subjects or any trigger to the traumatized 

parent’s symptoms. The child can have frightening 

fantasies about the parent’s unspoken experience 

and feel anxious about provoking the parent’s symptoms. Overdisclosure occurs when the parent reveals 

frightening or horrific details that the child cannot 

tolerate and that may cause the child to develop PTSD 

symptoms. Identification may occur when a child 

tries to connect emotionally with a parent who is 

otherwise withdrawn and unavailable. Reenactment 

occurs when family members are involved in reliving some aspect of a traumatic memory as a result of 

the parent’s difficulty with separating the past from 

the present.37 

Not all children develop emotional problems in 

the aftermath of the parent’s combat experience or 

PTSD symptoms. However, when a child is expressing 

emotional problems at home or in school, a comprehensive assessment of the child’s social and academic 

status is indicated. This assessment should include an 

evaluation of overall family functioning and patterns 

of communication.

Because trauma involves betrayal of trust, all 

trauma-related work must occur within a safe and 

trusting therapeutic relationship. Individual treatment 

may be needed prior to participation in family therapy. 

The goal of intervention is to help the family recognize 

its patterns of communication, to develop beliefs and 

behaviors that distinguish the past from the present, 

and to have an expanded range of responses.37 The 

combat veteran or any survivor of trauma must find 

a way to integrate past experiences with the present 

reality in a way that feels meaningful and hopeful. 

If silence attests to an inability to integrate trauma,34

then the therapeutic dialogue must skillfully address 

this silence because it disrupts a sense of continuity 

of self and experience. The therapist does not seek to 

elicit detailed descriptions of the parent’s traumatic 

experiences. Rather, assisting the family to develop 

new interactive patterns through a more informed 

awareness of family communication patterns is an 

appropriate goal in addressing the intergenerational 
497

The Impact of Deployment on Military Families and Children

transmission of the effects of combat trauma.

The emerging body of anecdotal and empirical 

literature suggests that interpersonal relationships 

are affected by the profoundly disruptive nature of 

trauma. The issues are highly complex; over the past 

40 years researchers have sought to identify, qualify, 

and measure the impact of parental trauma on children. If trauma occurs, how does it occur and how 

does it affect future generations and manifest in these 

successive generations? However, over the years since 

ODS/S, service members and their families have had 

to adapt to a major shift in US foreign policy and in 

the role of the US military in extended multinational 

deployments. The Bosnian experience provided new 

insight into the different skills needed to minimize 

familial trauma. Research on ODS/S veterans has 

further added to knowledge of this subject. However, 

the multiple and lengthy combat deployments of 

OEF and OIF have posed new challenges for military 

service members, their families, and children. It is 

unclear to what degree the traumatic experiences of 

service members involved in OEF and OIF will impact 

their children. Family well-being is not only essential 

to mission success, but also to the future health of the 

military in its efforts to retain skilled military service 

members.45,46

SUMMARY

The military, Department of Veterans Affairs, and 

TRICARE civilian healthcare professionals must 

be prepared to support service members and their 

families through the five stages of deployment, and 

the sequelae that might result from service member 

combat exposure. Given the established 20% rate of 

mental illness in returning OIF veterans, the multigenerational effects of combat-related stress and trauma 

must be considered as a possible health effect of the 

current conflicts. Public and professional education 

efforts on these topics are essential for families to cope 

effectively with the deployment experience and seek 

help if problems develop. Additional research addressing the impact of deployment on service members and 

their families will better ensure that US military forces 

are prepared for the challenges of the next conflict.

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2. Pincus SH, House R, Christenson J, Adler LE. The emotional cycle of deployment: a military family perspective. 

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1/2/3:38–44.

10. Wynd CA, Dziedzicki RE. Heightened anxiety in Army Reserve nurses anticipating mobilization during Operation 

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11. Diedrich J. Deployment overseas can take toll on families. The Gazette. October 31,1999:A4.

12. MacIntosh H. Separation problems in military wives. Am J Psychiatr. 1968;125(2):260–265.

13. Samler JD. Reserve unit mobilization trauma. Mil Med. 1994;159(10):631–635.

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Care. 1993;19(2):81–98.

15. Valentine D. The developmental approach to the study of the family: implications for practice. Child Welfare. 

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16. Logan KL. The emotional cycle of deployment. US Naval Inst Proc. 1987;113:43–47.

17. Pincus SH, Benedek DM. Operational stress control in the former Yugoslavia: a joint endeavor. Mil Med. 1998;163:358–

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19. Neumann M, Levy A. A specific military installation for the treatment of combat reactions during the war in Lebanon. 

Mil Med. 1984;149:196–199.

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1998;7(1):87–103,viii–ix.

21. Zeff KN, Lewis SJ, Hirsch KA. Military family adaptation to United Nations Operations in Somalia. Mil Med. 

1997;162(6):384–387.

22. Rosen LN, Westhuis DJ, Teitelbaum JM. Patterns of adaptation among Army wives during Operations Desert Shield 

and Desert Storm. Mil Med. 1994;159(1):43–47.

23. Haas DM, Pazdernik LA, Olsen CH. A cross-sectional survey of the relationship between partner deployment and 

stress in pregnancy during wartime. Womens Health Issues. 2005;15(2):48–54.

24. Kelley ML. The effects of military-induced separation on family factors and child behavior. Am J Orthopsychiatry. 

1994;64(1):103–111.

25. Birgenheier PS. Parents and children, war and separation. Pediatr Nurs. 1993;19(5):471–476.

26. Erikson EH. Childhood and Society. New York, NY: WW Norton; 1950.

27. Rosen LN, Teitelbaum JM, Westhuis DJ. Children’s reactions to the Desert Storm deployment: initial findings from a 

survey of Army families. Mil Med. 1993;158(7):465–469.

28. Jensen PS, Martin D, Watanabe H. Children’s response to parental separation during Operation Desert Storm. J Am 

Acad Child Adolesc Psychiatry. 1996;35(4):433–441.

29. Huebner AJ, Mancini JA, Wilcox RM, Grass SR, Grass GA. Parental deployment and youth in military families: exploring uncertainty and ambiguous loss. Fam Relations. 2007;56(2):112–122.

30. 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.

31. Rosenheck R, Nathan P. Secondary traumatization in children of Vietnam veterans. Hosp Community Psychiatry. 

1985;36:538–539.
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32. Yehuda R, Schmeidler J, Elkin A, et al. Phenomenology and psychobiology of the intergenerational response to trauma. 

In: Danieli Y, ed. International Handbook of Multigenerational Legacies of Trauma. New York, NY: Plenum Press; 1998: 

639–656.

33. Price JL. Children of veterans and adults with PTSD. [National Center for PTSD Web site]. Available at: http://ncptsd.

va.gov/ncmain/ncdocs/fact_shts/fs_children_veterans.html?opm=1&rr=rr112&srt=d&echorr=true. Accessed February 24, 2010.

34. Danieli Y, ed. International Handbook of Multigenerational Legacies of Trauma. New York, NY: Plenum Press; 1998.

35. Danieli Y. The treatment and prevention of long-term effects and intergenerational transmission of victimization: a 

lesson from Holocaust survivors and their children. In: Figley CR, ed. Trauma and Its Wake. New York, NY: Brunner/

Mazel; 1985: 295–313.

36. Yehuda R, Schmeidler J, Giller EG Jr, Siever LJ, Binder-Byrnes, K. Relationship between posttraumatic stress disorder 

characteristics of Holocaust survivors and their adult offspring. Am J Psychiatry. 1998;155(6):841–844.

37. Ancharoff MR, Munroe JF, Fisher LM. The legacy of combat trauma: clinical implications of intergenerational transmission. In: Danieli Y, ed. International Handbook of Multigenerational Legacies of Trauma. New York, NY: Plenum Press; 

1998: 257–276.

38. Harkness L. The effect of combat-related PTSD on children. Natl Center PTSD Clin Q. 1991;2(1):12–15. Available at: 

http://ncptsd.va.gov/ncmain/nc_archives/clnc_qtly/V2N1.pdf?opm=1&rr=rr1046&srt=d&echorr=true. Accessed 

February 24, 2010.

39. Samper RE, Taft CT, King DW, King LA. Postraumatic stress disorder symptoms and parenting satisfaction among a 

national sample of male Vietnam veterans. J Trauma Stress. 2004;17(4):311–315.

40. Rosenheck R, Fontana A. Transgenerational effects of abusive violence on the children of Vietnam combat veterans. J 

Trauma Stress. 1998;11(4):731–742.

41. Dansby VS, Marinelli RP. Adolescent children of Vietnam combat veteran fathers: a population at risk. J Adolesc.

1999;22:329–340.

42. Ruscio AM, Weathers FW, King LA, King DW. Male war-zone veterans’ perceived relationships with their children: 

the importance of emotional numbing. J Trauma Stress. 2002;15(5):351–357.

43. Rosenheck R, Fontana A. Warrior fathers and warrior sons. In: Danieli Y, ed. International Handbook of Multigenerational 

Legacies of Trauma. New York, NY: Plenum Press; 1998: 225–242.

44. Solomon Z, Kotler M, Mikulincer M. Combat-related posttraumatic stress disorder among second-generation Holocaust 

survivors: preliminary findings. Am J Psychiatry. 1988;145:865–868.

45. Schneider RJ, Martin JA. Military families and combat readiness. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg 

JM, eds. Military Psychiatry: Preparing in Peace for War. In: Zajtchuk RM, Bellamy RF, eds. Textbooks of Military Medicine. 

Washington, DC: Office of The Surgeon General, US Department of the Army, Borden Institute; 1994: 19–30.

46. van Vranken EW, Jellen LK, Knudson KH, et al. Division of Neuropsychiatry. The Impact of Deployment Separation on 

Families. Washington, DC: Walter Reed Army Institute of Research; 1984. Report NP-84-6.
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ATTACHMENT: RESOURCES FOR MILITARY FAMILIES

An important endeavor for military members and their families is navigating through the many resources 

available to help them through the deployment cycle. Although not an exhaustive list, this attachment includes 

a number of these resources and a synopsis of their purposes.

Organizations Supporting the Service Member and Military Family

Military OneSource 

Military OneSource (available at: http://www.militaryonesource.com) is a service provided by the Department 

of Defense at no cost to active duty, National Guard, and reserve (regardless of activation status) soldiers and 

their families. The agency promotes multiple services such as help with childcare, personal finances, emotional 

support during deployments, relocation information, and resources needed for special circumstances. These 

services can be accessed by telephone, online, and face to face through private counseling with master’s level 

consultants in the local community.

Information on Helping Military Children 

The Department of Defense, in partnership with LIFELines organizations, provide a Web site as the department’s official source of education information (available at: www.militarystudent.org). Its purpose is to better 

enable the children of military personnel, their parents, special needs families, military leaders, and educators 

deal with the various issues that face the military child by providing each group with access to information, tools, 

and resources from a central location. Ultimately, the aim is to enhance the educational and social well-being of 

all military children by increasing the understanding and awareness of how to meet their unique needs.

Educational Resources Available to Aid Bereaved Children and Their Families

The New York University Child Study Center created a Web site (available at: www.aboutourkids.org) dedicated to advancing the field of child mental health through evidence-based practice, science, and education. Using 

the search engine on the site to look up information on bereavement, users can gain access to a list of books on 

bereavement, war, terrorism, and tolerance targeted at children of all ages, parents, and professionals.

National Child Traumatic Stress Network Guideline on Managing Childhood Traumatic Grief 

 The National Child Traumatic Stress Network, a consortium of treatment and research centers across the United 

States, provides an online guideline (available at: http://www.nctsnet.org/nccts/nav.do?pid=hom_main). The 

network comprises 70 member centers—45 current grantees and 25 previous grantees —funded by the Center for 

Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health 

and Human Services, through a congressional initiative—the Donald J Cohen National Child Traumatic Stress 

Initiative. This initiative recognizes the profound, destructive, and widespread impact of trauma on American 

children’s lives and seeks to improve the quality, effectiveness, provision, and availability of therapeutic services 

delivered to all children and adolescents experiencing traumatic events.

Department of Defense Military Assistance Program

The Military Assistance Program (available at: http://dod.mil/mapsite/) aims to provide information and 

interactive resources for assisting military families with relocation, money management, and job search at a 

new location.

Operation Special Delivery

 Operation Special Delivery (available at: http://www.operationspecialdelivery.com) provides trained volunteer doulas for pregnant women whose husbands or partners have been severely injured or who have lost 
501

The Impact of Deployment on Military Families and Children

their lives due to the current war on terror, or who will be deployed at the time they are due to give birth. The 

doulas are informational, emotional, and physical coaches, not medical providers.

SGT Mom’s 

SGT Mom’s (available at: http://www.family-networks.org/military. cfm) is an interactive Web site created in 

1996 and run by a military spouse who handles all e-mails, updates, and additions. It is not an official Department 

of Defense site and is not related to any official military organization. The Web site contains a communication 

forum, links to other sites, the latest news about military families, ways to support troops, and a question-andanswer section. SGT Mom’s is “military life explained by a military wife.”

The National Long Distance Relationship Building Institute (Dads at a Distance)

As stated on the homepage, the Dads at a Distance Web site (available at: http://www.daads.com) was created “to help fathers who are business travelers, military men, non-custodial fathers, airline pilots, travel guides, 

traveling salesmen, railroad workers, truckers, professional athletes, musicians, entertainers, actors, corporate 

executives, or any other fathers who have to be away from their children to maintain and strengthen their relationships with their children while they are away.” The Web site provides tips for long-distance fathers, links to 

related Web sites, information on relevant products and books, and stories of long-distance fathering.

The Tragedy Assistance Program for Survivors 

The Tragedy Assistance Program for Survivors, or TAPS (Available at: http://www.TAPS.org) was founded 

after the deaths of eight soldiers aboard an Army National Guard aircraft in November 1992. TAPS provides a 

support network for the surviving families of those who have died in service to America. To accomplish their 

mission, TAPS has experienced caseworkers who act as liaisons, assisting the family members in finding solutions to problems. TAPS’ small professional staff and a large national volunteer network work hand-in-hand 

with federal, state, and private agencies in finding solutions to problems of surviving military families.

The Building Strong and Ready Families Program 

This is a 2-day program that helps couples develop better communication skills, reinforced by a weekend retreat. Additional information is available at http://www.strongbonds.org/skins/strongbonds/display.aspx. 

The PICK (Premarital Interpersonal Choices and Knowledge) a Partner Program

This program helps single soldiers make wise decisions when they choose mates.

Additional Phone Numbers and Web Sites

Army Military Family Research Institute: http://www.mfri.purdue.edu/pages/news/soldier_family_well_being.html 

Army OneSource: 1-800-464-8107; http://www.armyonesource.com (User ID: army; Password: onesource)

Department of Veterans Affairs: http://www.va.gov

National Center for PTSD: http://www.ncptsd.org/ 

Deployment Health Clinical Center: 1-800-796-9699; http://www.pdhealth.mil

HOOAH4HEALTH—Deployment: http://www.hooah4health.com/deployment/default.htm

Institute of Medicine—Health of Veterans and Deployed Forces: http://veterans.iom.edu/ 

Operations Noble Eagle, Enduring Freedom, and Iraqi Freedom: http://www.odcsper.army.mil/default.

asp?pageeid+37

Reserve Affairs—Mobilization and Demobilization: http://www.defenselink.mil/ra/html/mobilization.html

Veterans Benefits Administration: 1-800-827-1000

Veterans Health Administration: 1-800-222-8387
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503

The Children and Families of Combat-Injured Service Members

Chapter 31

THE CHILDREN AND FAMILIES OF 

COMBAT-INJURED SERVICE MEMBERS

STEPHEN J. COZZA, MD*; RYO S. CHUN, MD†; and CORINA MILLER, MSW‡

INTRODUCTION 

BACKGROUND LITERATURE

NOTIFICATION OF INJURY

Communicating With Children About the Injury

Travel to Military Medical Facilities and Family Separations

THE HOSPITALIZATION

CHILDREN IN THE HOSPITAL SETTING

SUPPORT TO COMBAT-INJURED FAMILIES WITH CHILDREN

CHILDREN’S RESPONSES TO COMBAT INJURIES

EFFECT OF THE INJURY ON THE PARENT

Principles of Caring for Combat-Injured Families

Long-Term Rehabilitation and Transitions

SUMMARY

ATTACHMENT 1: Parent Guidance Assessment–Combat Injury

attachment 2: Principles of Caring for Combat-Injured Families

and their Children

*Colonel (Retired), US Army; Associate Director, Center for the Study of Traumatic Stress, and Professor, Department of Psychiatry, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; formerly, Chief, Department of Psychiatry, Walter Reed Army 

Medical Center, Washington, DC

†

Colonel (Retired), US Army; Clinical Director, Child and Adolescent Psychiatry Service, Department of Psychiatry, Walter Reed Army Medical Center, 

6900 Georgia Avenue NW, Washington, DC 20307; formerly, Chief, Child and Adolescent Psychiatry Service, Department of Psychiatry, Walter Reed 

Army Medical Center, Washington, DC 

‡

Clinical Social Worker, Department of Psychiatry, Walter Reed Army Medical Center, Building 2, Office #6317, 6900 Georgia Avenue NW, Washington, 

DC 20307-5001; formerly, Clinical Social Worker, National Naval Medical Center, Bethesda, Maryland
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Combat and Operational Behavioral Health

INTRODUCTION

As of July 2008, over 30,000 soldiers, sailors, marines, and airmen have been injured in ongoing operations in Iraq and Afghanistan.1

 A substantial number 

of these injuries have been serious, resulting in limb 

amputations, severe soft-tissue and orthopaedic injuries, traumatic brain injuries (TBIs), eye enucleations, 

and body burns.2 The effect of these severe injuries on 

families, parents, and children is not easily ascertained, 

but will likely be determined by the functional consequences of the injuries. Even when physical recovery 

is complete, families can be profoundly affected by the 

injury of a parent. Because 40% of US service members 

(SMs) have children, averaging about two children 

per parent,3 the authors estimate that approximately 

24,000 military children have been affected by serious combat-related parental injuries within that same 

time period. These numbers do not reflect the many 

other nondependent children whose siblings or other 

military family members have been injured.

Case reports have described the anecdotal experience of combat-injured families and children.4,5 The 

effects appear complex, particularly with children. 

From the initial distress to the longer-term injury adjustment challenges, children and families face difficult 

emotional and practical problems. These phenomena 

have been described and are being addressed in several clinical treatment centers and studied through 

ongoing research. However, no empirical data have 

yet been systematically collected examining the effect 

of combat injury on families. Such investigation is 

required to inform intervention and treatment planning across the injury-to-recovery timeline. In addition, no family- or parent-focused interventions have 

been uniformly implemented and no evidence-based 

treatments developed and evaluated. This chapter 

describes the clinical experience and insights of mental 

health practitioners who have been involved with the 

children and families of the combat injured at Walter 

Reed Army Medical Center (WRAMC) in Washington, 

DC, a major military medical center that has been treating injured SMs since the start of global war on terror 

combat operations.

BACKGROUND LITERATURE

Although no literature exists that systematically 

examines the effect of parental combat injury on military children, other areas of scientific literature help 

the understanding of this population. Several types of 

parental illness have been carefully studied, including 

parental cancer.6–9 In these studies, children’s emotional and functional responsiveness were affected 

by their age and gender. A recent study examined the 

influence of parental multiple sclerosis (MS) on the 

adjustment of children and adolescents as measured 

by parental report.10 The authors found that children 

of MS parents showed greater difficulty in relating 

interpersonally and in managing their lives when 

compared to non-MS children. They also evidenced 

higher levels of distress, but did not show elevated 

levels of emotional or behavioral symptoms indicative 

of psychopathology. 

Family function is central to the child’s response 

to parental illness.11–14 A family’s capacity to maintain structure, to provide emotional support, and to 

diminish distress all appear to help children adjust 

to parental illness. The level of parental disability is 

also a principal factor affecting children’s responses 

to parental illness.15–19 As with many family stresses, 

children’s responses tend to mirror the distress and 

functional capacity of the important adults in their 

lives. Whether the seriousness of the illness or resultant parental disability has a greater influence on 

child functioning and emotional response is less well 

understood. In either case, these findings highlight 

the importance of adopting intervention models that 

improve family and parental functioning when parental health problems exist, to support the health and 

well-being of children.

Sudden health-altering events, such as combat 

injury, may have more profound effects on children 

and families than parental illness. Families have very 

little time to prepare for the consequences of sudden 

injuries. The noninjured parents must often make rapid 

decisions about childcare, or may be so preoccupied 

by the needs of the injured partner that they are too 

overwhelmed to address the needs of children.

Of the few studies that have examined the effect 

of sudden medical events on families, those related 

to TBI are most instructive.20–25 TBI often has a profound effect on children and families,25 with greater 

difficulty in families with young children, those with 

lesser social or financial support, or where psychiatric 

problems are prominent. Elevated levels of emotional 

and behavioral symptoms in children of TBI patients 

correlate with compromised parenting in both the 

injured and noninjured parent, as well as depression 

in the noninjured parent, suggesting the importance 

of healthy family and parental functioning to protect 

children’s mental health.22 Strategies that support 

such outcomes appear warranted; however, no established family-focused interventions have been 

empirically studied in TBI populations. In addition, 
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The Children and Families of Combat-Injured Service Members

there has been no scientific examination of the psychological effect of parental burns, amputation, or 

motor vehicle accidents on children that would help 

in the understanding of the experiences of combatinjured families.

From the initial distress to the longer-term injury 

adjustment challenges, the children and families of 

the combat injured face difficult emotional and practical problems. It is likely that the effects of combat 

parental injury on children are more complicated and 

potentially more challenging than nonviolent and 

accident-related injuries. Often immediate information regarding the nature and severity of the injury 

is limited, and sometimes inaccurate, causing further 

anxiety. Injuries sustained in combat are likely to result 

in sudden family distress and a flurry of urgent activity, leading to disruption of family roles, sources of 

care, and instrumental support. Over time, the consequences of parental injury and required treatment also 

include changes in the child’s residential community, 

loss of military career by the parent, and changes in 

parenting capacity. The cascade of events following 

injury is graphically portrayed in Figure 31-1.

Any serious physical injury may result in the development of comorbid psychiatric symptoms,26 as 

well as physical injuries. Longitudinal data suggest 

that combat-injured SMs may develop complicating 

psychiatric problems, such as posttraumatic stress 

disorder (PTSD) and depression.27 Mental health 

symptoms may present a variable course, resolving 

or commonly worsening during the first year after 

hospitalization.2

In addition to moderate or severe TBI, researchers 

have voiced concern about the influence of milder 

forms of TBI that may not come to medical attention, 

but can result in serious dysfunction or sense of ill 

health.28 When mild TBI is comorbid with other physical injuries, families may contend with the complication of dealing with a parent with psychiatric illness, 

cognitive or personality alterations, as well as physical 

injury. When significant changes in parental ability 

result from injury, parents and children must renegotiate family relationships and integrate the reality of the 

injury, whether physical, psychological, or both, and 

its consequences. Continued scientific investigation is 

required to develop effective preventive interventions 

that address both short- and long-term effects of these 

parental injuries.

Figure 31-1. Child response to events resulting from combat 

injury. 

Drawing courtesy of: Center for the Study of Traumatic 

Stress, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland

NOTIFICATION OF INJURY

SM families are faced with multiple challenges, 

beginning the day the SM receives notification about 

a combat deployment. These challenges continue 

through the deployment cycle and can include many 

changes within the family system resulting from the 

SM’s absence (See Chapter 30, The Impact of Deployment on Military Families and Children). When SMs are 

injured, facing the threat of permanent bodily changes 

or reductions in their physical, cognitive, or psychological functions, greater distress is unavoidable.

Family stress begins with notification of the SM’s 

injury. Although there have been improvements in 

the process of injury notification (eg, when possible, 

injured SMs may contact a spouse or other family 

member directly, relieving their loved ones of the worst 

fear of imminent death), it is not uncommon that initial 

information pertaining to an injury may be incomplete 

or inaccurate, leading to even greater worry. Occasionally, information that a member of a military unit 

has been injured is communicated through informal 

channels, causing broad confusion and anxiety on the 

home front. Only when accurate information about the 

personnel involved and the details of the injury are 

known is some relief achieved. The manner in which 

the information of the injury is related to the spouse 

and family varies significantly from spouse to spouse 

and unit to unit. Typically, the accuracy and detail of 

available information, as well as the mode of its communication, reflect the unique circumstances of the 

injury. Injury notification may be conducted either in 

person or by telephone.

Several clinical examples help to illustrate. One 

spouse of an injured SM recalled that she had been 

visited at home by two rear detachment officers 

TIME (months)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

C

H

I

L

D

S

T

R

E

S

S

L

E

V

E

L

fear of loss of parent change in parenting ability

move from

community

separation from noninjured parent

hospital visits

Trauma Response is a Process

Not an Event
506

Combat and Operational Behavioral Health

dressed in Army combat uniforms. While the sight 

of these visitors at her door raised concern about her 

husband’s health, she also noted with great relief that 

they were not dressed in the formal Class A uniform, 

indicating that they were not part of a death notification team. Another spouse spoke about how she received telephonic notification of her husband’s injury 

while she was driving. Before relating the news of the 

injury, the caller made certain that she had pulled off 

the road, stopped the engine, and was in a safe area, 

to ensure that she was not in danger of having a motor 

vehicle accident as a result of receiving the frightening 

news. Another spouse spoke about having received 

three separate phone calls from three different offices 

that related different versions of her husband’s injury. 

Even the simplest inaccuracies can undermine a family’s confidence in the care that an SM may receive 

after an injury, and are often remembered and related 

by spouses or other family members in the hospital 

setting. Family members typically describe the most 

reassuring and trusted information coming from the 

face-to-face visits of familiar members of their injured 

SM’s unit, rather than from telephone callers who are 

unknown to them.

Communicating With Children About the Injury

Whether injury notification occurs on the phone or 

in person, children may be present when news of the 

injury is shared with adult family members. Children 

may witness the response of their non-SM parents or 

other adults, who may become extremely distressed, 

tearful, or emotionally volatile. When possible, children should be protected from viewing the raw adult 

emotional response to such news because it can be 

both confusing and overwhelming. Also, when possible, information should be shared with adults first, 

so that they can be better emotionally prepared for a 

discussion with their children that is based on accurate 

information.

Most adults understand that some information 

should be shared with children whose parents or close 

relatives have been injured in combat. It is recommended that all children should be given some explanation 

to better understand the emotions and behaviors that 

they see in the adults around them. Depending upon 

their age and psychological and cognitive abilities, 

children have different capacities to understand and 

tolerate sensitive and disturbing news. The amount 

and type of information that adults share should be 

based upon the developmental capacity of any given 

child. Older children and teens are generally capable 

of understanding and accepting more details, including the cause of the injury, the nature and degree of 

the physical wounds, the plan for treatment, and the 

likely effect on the family (eg, expected family separations, visits to the hospital, and changes in childcare 

arrangements). Adults may be more circumspect about 

the details that they share with preschoolers or early 

elementary school children. In some circumstances, 

facts may be briefly withheld from young children 

until a parent’s immediate survivability is determined. 

Although infants and toddlers are not cognitively 

capable of understanding the injury of a SM parent, 

they will quickly respond to perceived changes in the 

emotional climate of a household, changes in behavior or availability of any adult childcare providers, or 

disruptions in their daily schedules or routines. The 

most important communication to children of any 

age is that, despite the news of the injury, they will 

be cared for and that important adults will remain 

available to them.

It is not recommended that children over the age of 

5 or 6 years not be told about an injury for an extended 

period of time because they are likely to overhear adult 

conversations or recognize changes in adult behavior 

that will cause them to worry that something is wrong. 

Adults should never conduct conversations about the 

injury within the earshot of children assuming they do 

not understand. Typically, children will listen and be 

interested in everything that is discussed. When children ask questions, they should be answered matterof-factly and with the level of information that seems 

appropriate and desired by the child. Children should 

be given permission to ask questions and understand 

that those questions will be respected and answered 

truthfully, to the degree that is possible. Sometimes 

the questions that children ask do not have known 

answers, in which case adults should say that they do 

not know. Not uncommonly, children and teenagers 

may worry that their injured SM parent may die. When 

an injured SM has stabilized and is not at risk of death, 

children should be quickly reassured. In situations 

when health status is precarious, adults should be 

careful not to unrealistically reassure children. Adults 

can offer a hopeful message such as, “Dad was hurt 

very badly, but he is being given the best treatment 

possible to help him get better.”

Often non-SM parents or other adults have trouble 

gauging what to tell their children. Adults sometimes 

struggle with their own emotional reactions, which 

may make it particularly difficult for them to determine what is appropriate to pass on to children. These 

adults may need help processing and calibrating the 

amount, content, and timing of the facts that they 

share. Their description of the injury and its consequences may be based more on their own anxiety than 

on the needs of the children. Some noninjured parents 

may choose to share either too much or too little, making it difficult for children to understand the nature or 
507

The Children and Families of Combat-Injured Service Members

seriousness of the injury and its realistic implications 

for the injured parent. Knowledgeable professionals 

should offer parental guidance when needed.

Some adults may choose to withhold important 

information related to serious injuries from children in 

an attempt “not to worry them.” In such circumstances, 

clinicians need to challenge the assumption that such 

“secrets” can realistically be kept from children. The 

clinician should communicate that even younger children can be given some explanation without causing 

them to become overly worried, and may help them 

understand the actions and emotions of the adults they 

see around them. Just as some parents may provide too 

little information about the injury, others share more 

than children are able to tolerate. This may frighten 

them by unnecessarily bringing up unknown future 

consequences. The foundation of the clinician’s helpful 

stance toward the families and children of the injured 

is to increase adult awareness and to help them notice 

and respond appropriately to children’s emotional 

signals.

All children require some patient adult assistance to 

better integrate their understanding of serious injuries. 

Psychologically minded adults implicitly understand 

this need and may demonstrate tremendous creativity 

and sensitivity in meeting the needs of young children. As an example, one mother made a thoughtful 

and developmentally informed decision not to bring 

her nearly 3-year-old son to visit his seriously injured 

father until he was no longer intubated, so that the 

boy could hear his father’s voice when first meeting 

him in the hospital. This sensitive decision enabled 

the young child to relate with his father in the ways 

he was accustomed to despite the seriousness of the 

father’s injuries.

Travel to Military Medical Facilities and Family 

Separations

Once the family has been notified of the injury, a 

period of intense activity typically follows, often leading to disruptions in the family’s schedule or structure. 

Spouses usually join injured SMs being treated at 

military hospitals distant from the family home. When 

necessary, they leave their children under the supervision of other adults either at home or at the homes 

of other family members or friends in local or distant 

communities. Sometimes children are uprooted to join 

parents at the hospital. All these options are likely to 

be unsettling, particularly for young children, with 

resultant disruptions of routines and relationships. 

Recommendations cannot be broadly made about 

where children should be cared for when family 

separations are necessary. When an injury is serious, 

military spouses might fly alone to join their injured 

SMs at military medical centers. Spouses must plan 

for the care of their children and the maintenance of 

their households while they quickly arrange trips to 

distant locations, not infrequently overseas. Planning 

can be complicated as noninjured parents may not 

know how long they will be away from home. Some 

spouses make the choice to bring their children with 

them while others make interim arrangements for 

childcare with friends or neighbors, or send their 

children to stay with relatives in distant places for 

uncertain periods of time. In some cases, families must 

split the children, due to age, logistical requirements, 

or because of custody agreements (stepchildren). Siblings may stay with friends, while others move in with 

relatives. In such circumstances, children are not only 

separated from their parents, homes, and routines, 

they are also separated from their siblings, adding 

distress. Some families are fortunate enough to have 

their extended families move into their homes with 

their children, resulting in less disruption. Decisions 

about childcare and separations are never simple and 

often can result in parental confusion and guilt as they 

try to meet competing responsibilities. The following 

two vignettes provide examples of the complexity 

of military family situations and the solutions that 

families found.

Vignette 31-1: Shirlene, the mother of a seriously injured 

SM, was staying with her son at a military medical center 

across the country from her home in Washington state. She 

had been with her injured son since his admission and was 

torn between staying at the hospital or going home. Her 

younger daughter, Candace, who was living at home with 

her stepfather, had requested that Shirlene return home to 

celebrate the daughter’s birthday. Shirlene was hesitant to 

leave her son’s bedside, but was encouraged by the treatment team to visit with her daughter. During the few days 

that they visited, Candace had the opportunity to talk with 

her mother about some problems that she was having with 

friends. She didn’t want to burden Shirlene during their 

phone calls, and she didn’t feel comfortable talking with 

her stepfather about these problems. Shirlene’s decision to 

leave the hospital had been difficult, but upon her return she 

recognized the importance of this visit and was pleased that 

she had decided to make it.

Although the decision for children to stay with parents at the hospital can be a helpful way of maintaining 

the integrity and support of families, many families 

appropriately choose to have children remain at home. 

The following example describes how decisions are 

often complicated and emotionally difficult.

Vignette 31-2: John was injured in an improvised explosive device (IED) blast that resulted in multiple soft-tissue 

injuries, an upper-extremity amputation, and severe TBI. He 

and his young wife Miriam were parents of a 10-month-old 
508

Combat and Operational Behavioral Health

daughter, Sarah. Miriam had made the decision for Sarah 

to stay with her parents in Oklahoma during the hospitalization. John’s initial prognosis was described as poor and he 

was not expected to walk or talk again. Miriam, his wife of 2 

years, was quite devoted to him and made the decision to 

remain with him and be there for his ongoing therapies. She 

received criticism from hospital staff and from some other 

patients’ wives for her decision to leave their young child 

with her parents. However, she knew that her daughter was 

in a stable environment with people who loved her. Miriam 

wanted to provide ongoing support to her husband, something she felt no one else was able to do. The presence of 

Sarah would have made it hard to give John the care she 

felt he deserved.

THE HOSPITALIZATION

Duration of hospitalization of combat-injured SMs 

can vary in length, based upon the type and seriousness of the injury. Critical specialty care services are 

available at most major military medical centers. 

Because many war-related injuries are extensive, the 

care of patients can be time consuming, often requiring months to years of hospital-based treatment and 

rehabilitative services. Within the hospital setting both 

formal and informal supports and services are available. Specialty care units, such as the US Army Institute 

of Surgical Research Burn Unit at Brooke Army Medical Center, San Antonio, Texas, provide specialized 

care. The course of treatment for the severely injured 

can be unpredictable, involving multiple surgeries, 

as well as other treatment procedures and intensive 

therapies. As a result, treatment plans must be fluid 

and can change, leading to disappointment in both 

patients and their families.

Injured patients cannot be effectively treated within 

the hospital setting without understanding and addressing the needs of families. Loved ones understandably want to spend time with their injured SMs, 

especially when their health status may be uncertain 

or when they are undergoing complicated or painful treatments. Some family members may choose 

to remain in hospital rooms for extended periods of 

time or even continuously. Although healthcare teams 

recognize the importance of family member involvement, and work to incorporate families into the overall 

treatment plan, their presence can also complicate 

the ability to provide effective care. Family members 

who have feelings of anger or frustration related to 

the injury may misdirect those emotions toward the 

treatment team. Families may also bring preexisting 

emotional conflicts and challenges or interpersonal 

difficulties into the hospital setting. It is essential that 

medical teams recognize and address family conflicts 

to find resolutions that support effective treatment.

Many military families are nontraditional in their 

composition. Marital separations and divorces, as well 

as the young age of many injured SMs, can lead to 

conflicts between spouses, former spouses, girlfriends, 

boyfriends, and parents, all of whom may visit the hospital. Due to the stress of the injury, conflict not uncommonly develops along these fracture lines and can lead 

to interpersonal clashes within the healthcare setting, 

making treatment more difficult. In young SMs with 

serious injuries, disagreements can develop between 

the SMs’ mothers, who respond to the regressive needs 

of their incapacitated sons or daughters, and young 

spouses who can feel like intruders to the parent–child 

relationship. Spouses may second guess their commitments to SMs who now are to be permanently altered 

by the injury. Marital dissolution and divorce are not 

rare. Sometimes parents, particularly mothers, can 

unfairly criticize spouses who they believe will abandon their injured children. Legal questions can arise 

as a result of these conflicts; for example, who in the 

family will hold medical decision-making capacity or 

who will be the recipient of insurance or government 

disability payments?

Marriages are not always healthy or functional 

prior to the combat deployment or injury. Military 

family members struggle with many of the same family challenges that all Americans face. Marital conflict, 

separation, divorce, and infidelity occur. When these 

problems are present prior to deployment, an injury 

only compounds them. The case below describes an 

example.

Case Study 31-1: Peter, a marine, was treated at a 

military medical center for a left-side below-the-knee amputation. While in Afghanistan he was called by his wife Diane 

on his birthday, 2 months before his injury. Peter was quite 

pleased until he heard a voice in the background saying, “Tell 

him you’re engaged and wearing my ring. Tell him the marriage is over.” It was in this way he learned that Diane was 

having an affair. She had also emptied their bank account 

and sold their home using the power of attorney Peter had 

provided when he began the deployment. Peter and Diane 

had a 4-year-old son and 18-month-old daughter. Peter was 

unable to get in touch with them and didn’t know whether 

they ever learned of his injury. Having been served divorce 

papers and with no place to return, Peter left the hospital to 

live on his father’s farm in Iowa. He said he would have liked 

his children to receive counseling to make sure they were 

handling their new life well but he didn’t have the physical 

ability to pursue this nor did he have the financial ability to 

fight for custody.

Complicated family situations can affect children as 

well as adults. When the injured SM is divorced and 

a child resides with a former spouse with whom the 

SM sponsor has a conflict-laden relationship, hospital 
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The Children and Families of Combat-Injured Service Members

visits or telephone calls with the injured parent become 

major events to negotiate. When the military parent 

is remarried, the discussions can become even more 

difficult because the current spouse, the divorced parent of the children, or other former in-laws may not 

get along. When families are unable to resolve these 

differences, clinicians should serve as facilitators to 

negotiate communication and visitation.

Military family situations can be complex even 

when relationships are not conflicted. Regulations 

governing marriage within the military are legally 

determined and therefore can lack the flexibility that 

families sometimes wish would be possible. The following case provides an example.

Case Study 31-2: Steven, a transportation driver in the 

Army, suffered a TBI in Iraq from an IED while he was driving 

in a convoy. Steven and his wife, Cathy, had divorced prior 

to his deployment but began working out their differences 

by e-mail and phone while he was in Iraq and planned to 

remarry upon his return. They had two children, ages 9 and 

12 years. After the injury, Cathy and the children joined Steven at the hospital. However, Steven was listed as “divorced” 

on all his paperwork and Cathy, unlike other married military 

spouses, had no rights and was provided no financial compensation for her stay in a hotel close to the hospital. The 

medical staff members were reluctant to speak with Cathy 

because she and Steven were divorced. Steven was given 

written instructions and would lose them. He wanted to pass 

on information to Cathy but he would forget because of his 

TBI. Consequently, there were periods of time when he was 

considered noncompliant, and uninterested and unmotivated 

in his recovery. During the hospitalization the couple remarried, allowing Cathy and the children access to housing 

and her greater involvement in the medical care. Prior to 

the remarriage a well-meaning but misguided administrator 

counseled Steven that perhaps Cathy only wanted to remarry 

him because of the money he would be getting from military 

disability. The family found this to be quite inappropriate and 

unsupportive.

The following vignette provides another example 

of a stressful military family situation.

Vignette 31-3: Beth, a divorced mother of three, was 

injured as a result of crossfire during a small arms firefight. 

She was hospitalized for sustained injuries to her chest 

and upper extremities. Beth was injured 9 months into a 

12-month deployment with a National Guard unit from the 

Midwest. Because of her medical treatment, Beth’s activation 

was extended well beyond the original 12-month period. In 

addition to two biological children, ages 10 and 12, she had 

a 13-year-old foster daughter. All three children remained 

with a caregiver in Beth’s hometown. Because Beth was the 

agency-approved foster mother, her ongoing medical care 

and extended deployment caused the foster daughter to be 

returned to the agency where another foster home had to be 

found. This loss was an additional disruption because the foster child had become an important member of the family.

The needs of a family can change dramatically during the course of hospitalization. Attendance to these 

needs can be extremely supportive to both the SM 

and family as treatment and rehabilitation progress. 

Families sometimes require help finding adequate 

housing, particularly when long-term family stays are 

required. Questions can arise and practical assistance 

may be necessary regarding childcare, family health, 

or educational needs. Familiarity with military regulations and coordination of appropriate paperwork 

to ensure financial support, adequate housing, and 

travel arrangements and support are all necessary for 

military family success during extended combat-injury 

treatments. Some families are able to demonstrate a 

tremendous amount of resourcefulness and identify 

independent ways to meet their own needs. Many 

others require help through the Family Assistance 

Center, social work services, or through active case 

management.

The Psychiatric Consultation Liaison Service (PCLS) 

at WRAMC has developed a system of care—Preventive Medical Psychiatry (PMP)—that includes ongoing 

clinical consultation to injured SMs and their families.29,30 Through PMP, all injured SMs are seen without 

the need for traditional consultation from the primary 

treatment team. Patients are told that members of the 

PCLS routinely see all those who were injured and that 

PCLS is part of the trauma team. As a result, PMP is 

met with little patient or family resistance. The major 

goals of PMP are to place psychological reactions within an appropriate context, to support and encourage 

healthy defenses, and to monitor for development of 

psychiatric disorders. Identified posttraumatic symptoms are explained as expected responses to combat 

and injury, rather than being viewed as necessarily 

pathological. In addition, PMP serves secondary and 

tertiary prevention efforts through posthospitalization 

identification and treatment of at-risk or symptomatic 

SMs. (For more information see Chapter 16, Psychiatric 

Intervention for the Battle-Injured Medical-Surgical 

Patients Following Traumatic Injuries.) 

In addition to PMP, PCLS social workers also provide family assistance. Family support services must 

be individually based, addressing the needs of any 

particular family in crisis at any given time. Many 

solutions are met through referral to resources in the 

surrounding civilian and military communities. Sometimes, effective interventions require more personal 

professional involvement using creative social work 

skills, a willingness to get personally involved, and a 

readiness to “work outside of the box.” As examples, 

WRAMC PCLS social workers have called Operation 

First Response for portable cribs and have found car 

seats for spouses who have precipitously flown into 

town without them. Social workers have arranged for 
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Combat and Operational Behavioral Health

baby items for couples with newborns who were not 

financially prepared and needed to fully equip a new 

nursery. Most families are disorganized when they first 

arrive at the hospital. They may come to the hospital 

without their automated teller machine (ATM) cards, 

other bank cards, or their military or other identification cards. Some go months before they can access 

their pay. Medical treatment centers must expect these 

problems and attend to them as they would the medical care that is afforded the SMs.

The following vignette is an example of how family 

needs can arise during hospitalizations.

Vignette 31-4: Enrico, a US Marine from California, was 

injured by sniper fire to his eye and upper extremity, resulting in eye enucleation and arm amputation. Eventually, 6 

months into the hospitalization, Enrico was able to arrange 

for his fiancée, Maria, to join him from Puerto Rico. They 

were married shortly thereafter and Maria became pregnant. 

She precipitously delivered a premature infant at 25-weeks 

gestation at a local civilian hospital after visiting their emergency room; the infant required a lengthy stay in a neonatal 

intensive care unit. Maria did not speak English fluently and, 

therefore, had difficulty communicating the complex healthcare needs of her family to civilian providers. Active military 

social work assistance was required to coordinate services 

between Enrico’s treatment and the needs of the couple’s 

newborn. Special arrangements were made for vouchers 

that allowed the couple to travel between the military medical 

center and the civilian hospital as they were unable to afford 

these costs. In addition, the social worker coordinated with 

Army Community Service to ensure that nursery equipment 

was delivered to Maria’s temporary housing unit when their 

newborn eventually left the hospital. 

Other innovative solutions have been developed 

by PCLS social workers. To help support the family 

members, a group—Girls Time Out (GTO)—has been 

meeting weekly since January 2005 at WRAMC. GTO’s 

mission is to provide a forum to support the wives, 

mothers, sisters, female friends, and fiancées of injured 

SMs. Group members meet, talk, eat, and learn from 

one another. They occasionally invite guests who present pertinent information to the group. For the past 

several years, GTO members have gotten together 

during the holiday season and made cookies using 

kitchens available in both Occupational Therapy and 

Army Community Service. This activity has allowed 

the women to make and share their favorite seasonal 

treats while getting away from the hospital setting for 

a few hours.

Finally, the importance of understanding and 

attending to family cultural differences cannot be 

overestimated. Recognizing how different races and 

ethnicities respond to trauma is quite important. For 

example, Latinos have been observed to be more 

“hands on” with their injured loved ones. Very often 

Latino family members touch injured patients and 

talk to them regardless of their seeming unresponsiveness. Family members will include the injured 

in prayers (eg, rosaries, novenas), instruct them, 

talk to them as they shave them, and give them the 

latest family news. For non-Latino healthcare providers, these cultural methods may seem foreign. 

Unfortunately, family members can inadvertently 

feel demeaned by their sense of the disapproval of 

the medical staff.

Relationships between family members and the 

healthcare team can become further complicated 

when language barriers exist. Some of the Latino family members may believe that their observations are 

not accepted because they do not speak English. It is 

as though their comments are tainted by ignorance 

simply because they are not bilingual. The following 

vignette provides an example.

Vignette 31-5: Geraldo was wounded by an IED in Iraq 

and was transported for further medical treatment while in 

a coma. His mother, Sonia, remained at his bedside and 

continued to talk to him and to pray out loud. There were 

times when she felt he was listening to her but was unable to 

respond. The medical staff continued to tell her not to expect 

too much and kindly explained that he could not hear her and 

had no awareness. Although Sonia did not speak English, 

she understood the looks the medical staff gave her and 

knew they did not believe her, but this did not deter her and 

she continued stimulating Geraldo throughout the day and 

late into the night. She was quite excited on the day after 

Christmas when she reported that Geraldo had whispered, 

“Feliz Navidad” on Christmas Eve, but no one believed her. 

The clinical social worker supported Sonia in her belief that 

Geraldo had spoken, despite the medical team’s skepticism, 

and encouraged her to continue what she was doing. Ultimately, Geraldo came out of the coma and told his mother 

he knew she had been with him around the clock. He told 

her that he had sensed her in his “sleep” and stated that he 

recognized and was comforted by her perfume, one that 

she had used throughout his life. Geraldo was also able to 

relate conversations that had been held in his room while 

he was in the coma.

CHILDREN IN THE HOSPITAL SETTING

Recognizing and meeting the needs of children 

within general hospital settings is complex. Most 

pediatric hospitals have developed effective ways 

of engaging children and recognizing and meeting 

them at their developmental levels. Hospitals that 

provide care to adult populations have been much 
511

The Children and Families of Combat-Injured Service Members

less effective in planning for the presence of children. 

Because children are important members of military 

families, the identification of, and attention to, their 

unique developmental needs is key if engagement with 

combat-injured families is to be effective.

When the family of a combat-injured patient arrives 

at the hospital, the noninjured parent must navigate 

the medical environment and military system while 

being available to their injured military service member. Noninjured spouses often are inundated by the 

requirements they face, and thus the needs of their 

children can go unmet. When children arrive at the 

hospital, they can quickly become overwhelmed by 

the hospital’s size and complexity. Young parents may 

have little understanding of how to best prepare their 

children for the hospital setting and how to prepare 

them for the visits with their injured parents.

Family members can have a difficult time with 

children’s activity levels, leading to frustration and 

unnecessary harshness. Younger children can be loud 

and boisterous. They may get negative feedback from 

parents or hospital staff members, leaving them to feel 

that they are not wanted. Children may also be viewed 

as obstacles to care. Hospital and nursing personnel 

typically do not know how to engage younger children. They can benefit from simple recommendations 

that can make a child’s visit much more pleasant. For 

example, one 4-year-old boy was repeatedly making 

loud noises and gestures in the hospital that were 

disturbing other patients and hospital staff members. 

His parents and grandmother were embarrassed by the 

behavior and became engaged in a heated and public 

emotional exchange. After a discussion with Child 

and Adolescent Psychiatry Service (CAPS) staff, they 

were helped to recognize that the child had his own 

ways of expressing worries and needed time to play 

and unwind outside of the hospital setting.

Children’s presence within the hospital should 

be time limited and structured. Medical centers that 

provide care to injured service members should ensure 

that there are appropriate areas for family activities 

that are “child and family friendly.” Specific plans need 

to be put in place that allow children to be present and 

involved in their parent’s care, while preparing and 

protecting them from what they are likely to see in 

the hospital setting. Because of the many injured SMs 

being treated at military medical centers, children can 

not only be exposed to their own parent’s frightening 

medical condition, but also the burns, amputations, 

and serious injuries of those other SMs receiving care. 

Recommendations for healthcare treatment facilities’ 

support of families of the combat injured are outlined 

in Exhibit 31-1.

Parents can assist children to prepare for, and 

comfortably participate in, hospital visits. When possible, it is helpful for parents to settle into the hospital 

routine alone, before children arrive. If children must 

accompany parents to the hospital at the first visit, 

it is best that children remain in the hotel or other 

living quarters while the noninjured parent gets to 

know the hospital environment. Parents can help their 

children understand what they may see or be exposed 

to. In order to do this, parents must first integrate the 

experience themselves. The opportunity for parents 

to describe what the hospital looks like, where it is 

located, who are the members of the treatment team, 

the appearance of the hospital room, and the names of 

individuals with whom the injured parent may share a 

room, will all help to orient a child to this new setting. 

When possible, parents can also show children pictures 

of the hospital, the ward, the hospital room, and their 

injured SM parent to best prepare them for what they 

will see when they come.

Preparation for the meeting with the injured parent is 

a continuation of the discussion that began with injury 

notification and continues throughout the hospitalization and recovery period. Children typically want to 

know what is happening and what they can expect 

when they come to the hospital. Noninjured parents 

can best accomplish this by gauging the appropriate 

amount of injury-related information (presence of 

bandages, casts, amputations, or medical equipment) 

and mixing the discussion with descriptions of less 

anxiety-provoking topics, such as the hospital cafeteria, 

the kind of food that they can eat while in the hospital, 

or the hotel or living quarters. With proper planning 

most children will feel comfortable when the time for 

the visit arrives. It is particularly important to carefully 

prepare children when dramatic changes in a parent’s 

appearance occur, such as facial wounds or serious 

burns. The following vignette describes how one couple 

successfully met their young child’s needs.

Vignette 31-6: Teddy was a 31⁄2-year-old boy whose 

father, Bill, had been deployed to Iraq for 6 months when 

he was wounded in an IED explosion. The father sustained 

serious injuries to his face and upper extremities requiring 

unilateral facial bandaging and resulting in an inability to 

effectively use his arms and hands. On the day of Teddy’s 

first visit with his father, his mother spent several minutes 

explaining the nature of the injuries and what he was likely 

to see upon entering his father’s room, to include the presence of facial bandages, as well as his father’s hoarse and 

somewhat unrecognizable voice. Teddy became very excited 

about the prospect of seeing his father. When they entered 

the room Teddy became silent and transfixed by his father’s 

appearance. While his mother tried to reassure him, Teddy 

cautiously approached his father and carefully climbed on 

Bill’s lap when invited. Instinctively, Bill began jostling Teddy 

between his legs, a game they had played often prior to 
512

Combat and Operational Behavioral Health

EXHIBIT 31-1

TREATMENT FACILITIES’ SUPPORT OF FAMILIES OF THE COMBAT INJURED

Recognize the contributions of families as part of treatment and establish appropriate boundaries for involvement

Develop child- and family-friendly treatment environments

	 •	 Welcome children and families

	 •	 Families don’t VISIT, they PARTICIPATE in care

	 •	 Develop appropriate areas for family visiting: in room, on ward, off ward, dining area, family lounge

	 •	 Develop child-appropriate environments within the hospital

	 •	 Ensure adequate available family lodging

	 •	 Consider child life worker involvement within the hospital

Protect children from unnecessary exposures

	 •	 Educate healthcare providers about child developmental issues and exposure risks

	 •	 Develop a systematic methodology to prepare children for hospital visits

	 •	 Support parents in parenting role and encourage them to speak with their children about health status

Develop family intervention strategies

•	 Watch for and address intrafamilial conflicts

	 •	 Consider multifamily or spouse group involvement

	 •	 Recognize the role of bereavement in family transition

	 •	 Actively address expected role changes within the family, especially in TBI and polytrauma victims

Monitor for “at risk” family situations

•	 Traumatic brain injury

	 •	 Polytrauma victims

	 •	 Marital or intrafamilial strife/domestic violence

	 •	 Substance use problems

	 •	 Signs of spousal or parental disengagement

Rally resources to aid

•	 Practical assistance

	 •	 Military Severely Injured Program

	 •	 Veterans Administration resources—Seamless Transition

	 •	 Military OneSource

	 •	 Military treatment facilities/TRICARE

	 •	 Self-help and other support organizations

the deployment. The familiarity of this activity eased Teddy, 

who immediately relaxed and began talking with Bill in a 

more natural and comfortable way. Recognizing the stress 

that Teddy faced, his mother limited the amount of time that 

Teddy stayed in the hospital setting and ensured that he 

spent considerable time at the hotel pool.

SUPPORT TO COMBAT-INJURED FAMILIES WITH CHILDREN

To better meet the needs of the families and children 

of injured SMs, the CAPS at WRAMC has established 

a system of care in which clinicians actively engage 

families of combat-injured SMs. CAPS staff members 

are informed of the pending arrival of the families of 

injured SMs by official notification. Clinicians provide 

an informational briefing to incoming families during 

their orientation at the Family Assistance Center, at 

which time they are given general information about 

CAPS services and how they can access care for identified problems. Families are also notified that they will 

be contacted by CAPS providers within the immediate 

future. This contact is typically made within 1 week of 

arrival at WRAMC.

Available CAPS services include anticipatory parental guidance to the injured SM and spouse, assistance 

in preparing children for their visit to the hospital (to 

include how and what they should be told in anticipation of seeing their wounded parent for the first time), 

supportive reassurance, anxiety relief, and connec-
513

The Children and Families of Combat-Injured Service Members

tion to appropriate resources when required. CAPS 

staff members work collaboratively with WRAMC 

PCLS at the hospital bedside. CAPS staff members 

also provide therapeutic activities to the children 

living at the Fisher and Malone Houses, where families reside during SM treatment, and at the Military 

Advanced Training Center, where wounded SMs and 

their families participate in outpatient occupational 

and physical rehabilitation. Services are offered in an 

outreach or “preclinical” format to support healthy 

family recovery. The goals of the intervention are to 

assist the reunion of the injured SM family, to promote 

children’s mastery of the complex and stressful injury 

experience, and to facilitate and promote the rehabilitation process of the injured parent by acknowledging 

the integral and essential role of parenting in the SM’s 

life. By interacting with families from early in their 

arrival and developing trusting relationships, CAPS 

strives to assist families to avert potential difficulties 

and support their comfort in accepting additional 

services when indicated. When deemed appropriate, 

children and families requiring clinical assessment or 

treatment are referred to the outpatient mental health 

clinic for formal assessment.

At WRAMC and Brooke Army Medical Center, 

mental health clinicians have begun using the Parent 

Guidance Assessment–Combat Injured (PGA–CI) 

instrument as a mechanism to assist in conducting 

discussions with injured SMs and their spouses 

about the needs of their families (especially their 

children) in response to the combat injury. A copy 

of the PGA-CI is included in Attachment 1. This 

semistructured clinical interview is designed to assess family demographics, deployment experience, 

nature of the combat injury, intrafamilial communication about the injury, and the effect of the event 

on family members, and to initiate discussion about 

family expectations and future plans. Often, the 

PGA-CI interview is the spouses’ first opportunity to 

talk about their personal experiences and to describe 

the effect of this powerful event on the family. The 

PGA-CI affords the time to think about their children and to ask questions about how best to meet 

their children’s needs. Ultimately, the PGA-CI was 

designed to assist healthcare professionals in the 

formulation of family assistance strategies and plans, 

with specific interest and emphasis on the positive 

growth of children.

CHILDREN’S RESPONSES TO COMBAT INJURIES

It is expected that all family members are likely to 

show some level of distress because of the sudden 

injury of a military family member. Clinicians have 

anecdotally observed that although most children do 

not initially demonstrate symptoms consistent with 

actual psychiatric disorder, many appear anxious, 

saddened, or troubled by the news. Parents do not 

always accurately recognize the emotional effect of 

the parent’s injury on children. Prior studies have 

shown that parent reports alone are not reliable in 

the determination of child behavioral and emotional 

problems and that cross-informant input from others, 

to include children, is required for accurate assessment.31 Children who have been exposed to trauma 

similarly report different and much higher levels of 

clinical symptoms than their parents, highlighting 

the importance of direct child assessment for accurate evaluation.32 No scientific investigation has yet 

systematically and directly measured the responses of 

children to parental combat injury. This section provides anecdotal descriptions of children with whom 

the authors have engaged.

When children first meet their injured parent, their 

understanding of the injury and the implication of the 

injuries can be limited. They may experience a broad 

range of emotional responses that can be confusing 

both to themselves and to the important adults in their 

lives. Some children become hesitant and afraid of 

what they see. They are often distressed and unable to 

show affection to the injured parent. As a result, some 

injured SMs express feelings of hurt or disappointment 

by these reluctant responses. When this occurs, the 

uninjured parent or another relative may be overly 

forceful in pushing children, especially young children, 

to show affection for the injured.

When parents deploy, children are usually told that 

their parents will safely return home. After the injury, 

children realize that parents cannot always keep promises that they make. A few children have expressed 

confusion and anger toward authority, as if they have 

been wronged. Frequently this anger may be directed 

toward the caregiver or other adults. Alternatively, 

children may verbalize fear and ambivalence. They 

may look to blame others for their parents’ injuries or 

may feel guilty as if somehow they are responsible. 

After the immediate emotional response, children report feelings of relief and gratitude that the SM parent 

is alive and safe. However, emotions can fluctuate in 

character and intensity.

A developmental perspective is helpful when the 

expected responses of children to parental injury are 

considered. For example, although infants and toddlers 

(0–2 years) may be assumed to have little cognitive 

capacity to appreciate their parents’ injuries, they will 

respond based upon changes in the schedules and 

routines of their lives, and the physical and emotional 
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availability of important adults, as well as any changes 

in the emotional tenor (anxiety, interpersonal abruptness, irritability) of these individuals.

Young children (3–6 years) have greater awareness 

of the actual nature of the injury. However, this understanding is likely to be undeveloped and fragile. 

Young children use “magical thinking,” an immature 

cognitive process characterized by egocentric thinking, 

which can lead them to inaccurately take responsibility 

for events that occur. Young children’s cognitive processes become even less reality based at times of high 

anxiety, as occurs after a parent’s injury. For example, 

one 4-year-old son of an injured SM told his grandparent that he was responsible for his father’s injury 

because he did not remind his dad to be careful when 

the SM was deploying. The young child needed to be 

reassured that he did not cause his father’s injury.

The immature cognition capacity of young children 

can lead to an inability to gauge an accurate sense of 

time. For example, a 3-year-old boy, whose father had 

multiple injuries and was prescribed extensive bed rest 

after an amputation, gave his father’s wound a kiss and 

said, “It’s all better now, Dad. Let’s play.” He became 

confused and frustrated when repeatedly told that his 

father could not yet play with him. The staff worked 

with the boy and his parents to establish more circumscribed ways of playing that allowed the father and 

son to enjoy their time together. Because many serious 

injuries can result in months, if not years, of medical 

treatment and rehabilitative services, the patience of 

young children can rapidly dissipate. Professional 

intervention that assists parents in understanding the 

developmental limitations of children and in creating 

new means of interaction can be invaluable for the 

future success of the family.

The clinician must recognize how young children 

perceive and integrate the nature of their parents’ 

injuries. Not uncommonly, young children who see 

their seriously injured parents become disorganized 

and extremely anxious. They may wonder “if this 

powerful and important person in my life can be hurt 

in this way, what could potentially happen to me?” For 

example, the mother of two young sons of a seriously 

injured marine asked to talk with a WRAMC CAPS 

clinician about their behavior. The boys were becoming 

increasingly aggressive, impulsive, and active, especially when their father’s injury was discussed. While 

in the room visiting their father, the boys sat quietly 

and were immobilized, carefully watching him. After 

leaving the room, they became aggressive with each 

other and oppositional to their mother.

During the evaluation, each child was asked to 

“draw a person.” They were given no additional directions and were not specifically requested to draw their 

father. The younger child produced the drawing shown 

in Figure 31-2. He initiated the drawing as one would 

expect, completing the face first, but then proceeded 

to scribble erratically over and around the face. When 

asked what the picture represented, the young boy 

stated, “This is a man in an explosion.” After completing the drawing, the boy shifted to aggressive play 

with toy dinosaurs and jungle animals.

The older 5-year-old brother was also asked to produce a drawing of a person. His drawing is shown in 

Figure 31-3. Unlike his younger brother, he completed 

the drawing in a very careful and methodical fashion. 

However, different from his younger brother and the 

typical approach of other children, the boy started by 

drawing the figure’s feet, which were large and sturdy. 

He then added extended sections of leg bilaterally. 

After adding three sections of leg to the drawing, the 

5-year-old drew a brace between the two legs to hold 

them together. The brace was later erased and is not 

present in the final drawing. This addition betrayed 

the older son’s anxiety about the body’s perceived instability that needed to be supported by an armature. 

He completed the drawing by adding arms, powerful 

shoulder muscles and a small head. There is no apparent torso and the body is joined at the shoulders.

The children’s drawings that appear in these figures 

give some view into their interior psychological worlds 

and their drive to process what they had seen and 

experienced. Their immediate choice to draw injured 

bodies indicated the psychological challenge that each 

faced. The younger son was clearly struggling to make 

Figure 31-2. Drawing of 3-year-old son of severely injured 

service member. Image courtesy of Stephen J Cozza, MD.
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The Children and Families of Combat-Injured Service Members

Figure 31-3. Drawing of 5-year-old son of severely injured 

service member. Image courtesy of Stephen J Cozza, MD.

sense of his father’s injury, but was finding difficulty 

in doing this in any organized way. In comparison, 

his older brother, while equally preoccupied with his 

father’s injury, demonstrated greater capacity to organize his own thoughts and anxieties and develop his 

own solutions (as evidenced by the added brace). This 

greater ability probably indicates the older brother’s 

greater psychological and cognitive capacities. The 

drawings are not presented as examples of psychopathology, but rather to highlight the challenges that face 

the young children of combat-injured SMs.

Older children have more mature developmental 

capacity to meet the stresses of parental injury, both 

cognitively and emotionally. Nonetheless, the schoolaged child may still harbor similar anxieties to those 

of younger children. Fear, in combination with a 

sense of guilt and a desire to take responsible action, 

can complicate the school-aged child’s response, as 

the following two examples illustrate. An 8-year-old 

boy, whose father had multiple severe injuries and 

was unconscious as a result of an IED explosion, expressed his reaction to a 4th of July celebration that 

occurred while he was visiting the hospital. During 

the celebration he was frightened by both the fireworks and low-flying helicopters. He worried that 

his family was being targeted by missile attacks from 

“the bad guys.” He imagined another 9/11 terrorist

attack near the hospital. He was able to talk with the 

staff concerning his frequent worries about his and 

his family’s safety. One 10-year-old girl confided 

that she was sad and missed her two cats that were 

given to a friend and was sure that she would never 

see them again. CAPS staff helped her raise these 

concerns with her parents, who were unaware of the 

impact of this loss.

Not surprisingly, children can be confused about 

expectations related to their responses to the injured 

parent. They may not understand what is or is not appropriate and may feel uneasy bringing up questions. 

One injured SM expressed concern that her children 

were reluctant to have physical contact with her. As 

they had always been affectionate, she could not understand why they no longer wished to be hugged. 

The mother’s apprehension prompted a discussion 

in which the children described the fear that if they 

touched her, they might inadvertently add to her 

ongoing pain. This new understanding allowed the 

mother to reassure the children and to help them find 

ways to express their love and care without fear of 

increasing her pain.

Based upon their developmental stage, teenagers 

are faced with unique challenges related to parental 

injury. At a time when they are normally expected to 

become more independent and less reliant on family, 

they can be confused by a sudden need to once again 

be close to, and intensely involved with, their parents 

and families. Given their near-adult capacity, teenagers may also be asked to shoulder some of the greater 

demands that result from parental injury, including 

increased chores, care for younger children, or assistance in the care of the injured parent. Teenagers may 

be ambivalent and may voice wishes to be with their 

friends, rather than spend time with their families or 

injured parent. When visiting the hospital, adolescents have been observed playing electronic games or 

spending time on computers away from their parents. 

An adolescent’s apparent lack of interest should not 

be construed as apathy. Clinicians should encourage 

parents to discuss their teenagers’ fears about the injury and their ambivalence about the changed family. 

Parents may need to be reminded of the importance of 

remaining involved in their teenagers’ lives, especially 

because this age group is at high risk for engaging in 

dangerous behaviors. Parents should be encouraged to 

be clear about their expectations, set appropriate limits 

on behavior, and consistently administer discipline, 

when appropriate. 

Children and teens can also become activated in 

healthy ways in response to parental injury. One 

injured amputee parent proudly shared that his son 
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started a blood drive for a local hospital in appreciation 

of the care that his father had received. Clearly, this 

boy was able to redirect the unfortunate experience 

of his father’s injury into altruism and leadership that 

supported his father’s healing. Other children have 

channeled their energy and desire to help in positive 

ways within the hospital setting. For example, two 

preteenage children came to visit their single father 

who had serious upper extremity injuries as a result 

of an IED blast. These children cared for their father by 

bringing food and water and assisting him with some 

simple and age-appropriate activities of daily living. 

As a result, the children felt that they were part of their 

father’s treatment and made important contributions 

to his progress. The clinical staff encouraged the father to include his children in these activities as they 

requested, while setting limits where developmentally 

appropriate.

Children whose situations must be closely evaluated are those with preexisting emotional, behavioral, 

developmental, or medical conditions of their own. For 

these potentially more vulnerable children, clinicians 

can expect that the stresses associated with parental 

injury may lead to greater distress or worsening of their 

underlying conditions. Healthcare providers should 

maintain a lower threshold for referral to appropriate 

clinical resources. At times, families that have children 

with preexisting conditions may move from their 

homes to live in the vicinity of the military hospital 

where the parent is being treated. These parents need 

to facilitate continuity of care from earlier treatment 

providers to newly identified clinicians at the military hospital site. Given a family’s preoccupation in 

addressing the medical needs of the injured parent, 

children’s healthcare or educational needs can go 

EXHIBIT 31-2

GOALS FOR CHILDREN OF INJURED SERVICE MEMBER PARENTS 

Develop an age-appropriate understanding of 

what happened to the parent.

Develop an age-appropriate understanding of 

the injury and required medical care that can 

result in

	 •	 family separations,

	 •	 lengthy hospitalizations,

	 •	 multiple procedures, and

	 •	 change in family structure/routine.

Accept that they did not create the problems they 

may now see in their families.

Learn to deal with the sadness, grief, and anxiety 

related to parental injury.

Accept that the parent who went to war may be 

“different” than the person who returned, but is 

still their parent.

Adjust to the “new family” situation by

	 •	 staying hopeful,

	 •	 having fun,

	 •	 being positive about life, and

	 •	 maintaining goals for the future.

unaddressed or inappropriately delayed. Ultimately, 

children must integrate the realities of the parent’s 

illness over time and adjust to the changes that they 

face. Exhibit 31-2 highlights the goals of recovery for 

the children of combat-injured SMs.

EFFECT OF THE INJURY ON THE PARENT

In addition to the direct effect of the injury on children, it is important to consider the psychological effect 

of these injuries on SMs and on their various family 

roles. Depending upon the nature of the injury, SMs 

may have resultant physical, psychological, or cognitive changes that affect their abilities to function in 

virtually all areas of their lives, including parenting. 

Injuries can alter an SM’s capacity to feel comfortable 

in intimate relationships, may create distance with 

those to whom they are married or emotionally close, 

and may undermine their sense of sexual capacity. 

Because the vast majority of injured SMs are young 

men, it is important to recognize the potential for 

narcissistic trauma that negatively affects their sense 

of competence as men, with resulting effect on spouses 

and children.

Injured SMs were likely physically active individuals who incorporated these traits in their parenting 

activities prior to the injury. Physical activities (hiking, 

backpacking, and camping), hands-on activities (playful wrestling), and athletic activities (ball throwing, 

skiing, and golfing) were all likely modes of interaction for young military parents with their children. 

Depending upon the nature of the injury, those modes 

of interaction either may no longer be possible or 

may require significant modification to their previous form. In such cases, injured SMs will need to alter 

their former idealized sense of themselves as parents, 

mourning any related body change or functional loss. 

Clinicians should encourage children and parents to 

explore innovative, mutually developed activities and 

play that allow parents and children to “try on” fresh 

ways of relating. The capacity for the parent–child 

dyad to reestablish enjoyable modes of interaction is 
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critical to future health and happiness. Candid parental 

discussions can allow injured SM parents to reframe 

their situations, develop new skills, and achieve greater 

strength in parenting. Within the hospital setting, occupational therapy and physical therapy services have 

incorporated children into therapeutic activities with 

parents in novel and creative ways.

Principles of Caring for Combat-Injured Families

Recognizing that parental combat injury is a lifechanging event for SMs, their families, and their 

children, the Center for the Study of Traumatic Stress 

at the Uniformed Services University of the Health 

Sciences convened the Workgroup on Intervention 

With Combat-Injured Families. This workgroup 

included expert military and civilian clinicians and 

academicians from around the country, focusing on 

the unique needs of this special population. As a result 

of workgroup meetings, the Center published a fact 

sheet titled “Principles of Caring for Combat-Injured 

Families and Their Children” (Attachment 2). These 

10 principles can be used by hospital- and communitybased professionals in military and civilian settings 

to support the healthy growth and recovery of this 

unique population. The principles of caring are summarized in Exhibit 31-3. 

Long-Term Rehabilitation and Transitions

Although most of this chapter has addressed the 

experiences and needs of the families and children of 

the combat injured during the immediate aftermath of 

injury, their long-term requirements can vary tremendously and must be planned for. Some data suggest 

that injured SMs may develop vulnerabilities as they 

transition back to their homes and communities.1

When families leave the hospital setting they no longer have the intensive resources that were available. 

They can lose connection with the families of other 

injured SMs with whom they may have developed a 

EXHIBIT 31-3

PRINCIPLES OF CARING FOR FAMILIES 

AND CHILDREN OF THE COMBAT 

INJURED 

	 •	 Principles of psychological first aid are

primary to supporting families of combatinjured service members.

	 •	 Medical care for the combat injured must be

family focused.

	 •	 Service providers should anticipate a range

of responses to combat injury.

	 •	 Injury communication is an essential component of care of the families of injured service 

members.

	 •	 Programs to assist the families of combatinjured service members must be developmentally sensitive and age appropriate.

	 •	 Care of the family of injured service members

is longitudinal, extending beyond immediate 

hospitalization.

	 •	 Effective family care requires an interconnected community of care.

	 •	 Care must be culturally competent.

	 •	 Communities of care should address any

barriers to service.

	 •	 Families, communities, and service providers

must be knowledgeable.

EXHIBIT 31-4

Resources 

1. Resources for Recovery—The Combat Injured 

Family: Guidelines for Care. Bethesda, Md: 

Center for the Study of Traumatic Stress, 

Uniformed Services University of the Health 

Sciences. Available at: http://www.centerforthestudyoftraumaticstress.org. Accessed 

October 14, 2009.

2. Sesame Workshop Talk, Listen, Connect: 

Deployments, Homecomings, Changes–

DVD and print materials. Available through 

Military OneSource at: http://www.militaryonesource.com, and by online streamed 

video at: http://www.sesameworkshop.

org/tlc. Accessed October 14, 2009.

3. Lee M, Ingram L. That’s My Hope: Featuring 

a Gallery of Multigenerational Artwork. Early 

Light Press, LLC. 2008. Available at: http://

www.earlylightpress.com. Accessed September 2, 2009. 

4. McCue K, Bonn R. How to Help Children 

Through a Parent’s Serious Illness. New York, 

NY: St. Martin’s Press; 1994.

5. Rauch PK, Muriel AC. Raising an Emotionally 

Healthy Child When a Parent is Sick. New York, 

NY: McGraw-Hill; 2006.

6. Beardslee WR. Out of the Darkened Room: 

When a Parent is Depressed. New York, NY: 

Little, Brown and Company; 2002.

7. Woodruff L, Woodruff B. In an Instant: A Family’s Journey of Love and Healing. New York, 

NY: Random House; 2007.
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sense of fellowship and camaraderie. Families may 

struggle with the realities of being home, having to 

face responsibilities and routines that no longer seem 

manageable. Often injured SMs require continuing 

medical or rehabilitative care. Access to needed services can be problematic or may require the scheduling of appointments at treatment facilities that are 

at great distance from home, adding more stress to 

family routines.

With the return of the injured SM, children may 

expect a return to the lives they remember. They may 

become disappointed with changes that they experience in the family. Older children and teenagers may 

have to pick up additional household responsibilities 

that the injured parent is no longer able to perform. 

When children are placed in a care-provider role to 

the injured SM, emotional challenges can be even 

greater. Teens may be asked to assist with wound 

care, self-care, or other activities of daily living that 

require intimate contact with the parent. This contact 

can be confusing, emotionally upsetting, and lead to 

resentment and frustration. Such activities should be 

minimized.

Finally, longer-term consequences of severe combat injury can result in medical retirement from the 

military service, the loss of a cherished military career, 

and movement from homes in military communities to 

other locations or back to families of origin. Although 

such transitions may increase access to available 

resources, particularly when the extended family is 

supportive, these changes are likely to be stressful for 

both adults and children. Moves from known communities likely mean loss of friends, changes in schools, 

and possible elimination of enjoyable extracurricular 

activities. Moves also can cause relocations to communities that have little understanding or appreciation of military culture and the unique challenges that 

the family has faced. (See Exhibit 31-4 for additional 

resources available to help families of combat-injured 

service members.)

SUMMARY

Combat injury can profoundly affect the lives of 

service members, their families, and their children. 

Upon injury notification, a cascade of events takes 

place that can result in distress and interpersonal turmoil for children and adults in the families of the combat injured. Disruptions in parental functioning and 

family structure are common. The effect on children 

of serious injury to a parent is likely to be profound, 

particularly when it leads to long-term or permanent 

changes in parents, or deterioration in their functioning. Immediately after the injury, noninjured parents 

are focused on the medical well-being of the injured 

SMs and may have difficulty recognizing and meeting 

the needs of their children. Children’s developmental 

and emotional capacities determine their abilities to 

understand and integrate the experience of parental 

injury. Parents and healthcare providers benefit from 

developmentally informed guidance to help children 

accept the injury, manage their distress, prepare for 

hospital visits, reengage the injured parent, and effectively communicate their needs. Family and child 

reactions to combat injury must be understood as a 

longitudinal process beginning with injury notification and continuing through longer-term rehabilitation and potential transitions to new lives and new 

communities.

REFERENCES

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site. Available at: www.icasualties.org. Accessed February 8, 2011.

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Psychiatry. 2006;163:1777–1783.

3. US Department of Defense. 1st Quadrennial Quality of Life Review. Washington, DC; 2004.

4. Cozza SJ, Chun RS, Polo JA. Military families and children during Operation Iraqi Freedom. Psychiatr Q. 2005;76:371–

378.

5. Cohen JA, Mannarino AP, Gibson LE, Cozza SJ, Brymer MJ, Murray L. Interventions for children and adolescents. In: 

Ritchie EC, Friedman MJ, Watson PT, eds. Mental Health Interventions Following Mass Violence and Disasters. New York, 

NY: Guilford; 2006: 227–256.

6. Compas BE, Worsham NL, Epping-Jordan JE, et al. When mom or dad has cancer: markers of psychological distress 

in cancer patients, spouses, and children. Health Psychol. 1994;13:507–515.
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7. Compas BE, Worsham NL, Ey S, Howell DC. When mom or dad has cancer: ii. Coping, cognitive appraisals and 

psychological distress in children of cancer patients. Health Psychol. 1996;15:167–175.

8. Huizinga GA, Visser A, van der Graaf WT, Hoekstra HJ, Hoekstra-Weebers JE. The quality of communication between 

parents and adolescent children in the case of parental cancer. Ann Oncol. 2005;16:1956–1961.

9. Visser A, Huizinga GA, Hoekstra HJ, et al. Emotional and behavioral functioning of children of a parent diagnosed 

with cancer: a cross-informant perspective. Psychooncology. 2005;14:746–758.

10. De Judicibus MA, McCabe MP. The impact of parental multiple sclerosis on the adjustment of children and adolescents. 

Adolescence. 2004;39:551–569.

11. Anthony EJ. The mutative impact of serious mental and physical illness of a parent on family life. In: Anthony EJ, 

Koupernik C, eds. The Child in His Family. New York, NY: Wiley-Interscience; 1970: 131–163.

12. Armistead L, Klein K, Forehand R. Parental physical illness and child functioning. Clin Psychol Rev. 1995;15:409–

422.

13. Finney JW, Miller KM. Children of parents with medical illness. In: Silverman WK, Ollendick TH, eds. Developmental 

Issues in the Clinical Treatment of Children. Needham Heights, Mass: Allyn and Bacon; 1998: 433–442.

14. Korneluk YG, Lee CM. Children’s adjustment to parental physical illness. Clin Child Fam Psychol Rev. 1998;1:179–

193.

15. Power PW. The chronically ill husband and father: his role in the family. Fam Coordinator. 1979;28:616–621.

16. Peters LC, Esses LM. Family environment as perceived by children with a chronically ill parent. J Chronic Diseases. 

1985;38:301–308.

17. LeClere FB, Kowalewski BM. Disability in the family: the effects on children’s well-being. J Marriage Fam. 1994;56:457–

468.

18. Kelley SD, Sikka A. A review of research on parental disability: implications for research and counseling practice. 

Rehabil Couns Bull. 1997;41:105–121.

19. Kotchick BA, Summers P, Forehand R, Steele RG. The role of parental and extrafamilial social support in the psychosocial adjustment of children with a chronically ill father. Behav Modif. 1997;21:409–432.

20. Urbach JR. The impact of parental head trauma on families with children. Psychiatr Med. 1989;7:17–36.

21. Urbach JR, Culbert JP. Head-injured parents and their children: psychosocial consequences of a traumatic syndrome. 

Psychosomatics. 1991;32:24–33.

22. Pessar LF, Coad ML, Linn RT, Willer BS. The effects of parental traumatic brain injury on the behaviour of parents and 

children. Brain Inj. 1993;7:231–240.

23. Uysal S, Hibbard MR, Robillard D, Pappadopulos E, Jaffe M. The effect of parental traumatic brain injury on parenting 

and child behavior. J Head Trauma Rehabil. 1998;13:57–71.

24. Butera-Prinzi F, Perlesz A. Through children’s eyes: children’s experience of living with a parent with an acquired 

brain injury. Brain Inj. 2004;18:83–101.

25. Verhaeghe S, Defloor T, Grypdonck M. Stress and coping among families of patients with traumatic brain injury: a 

review of the literature. J Clin Nursing. 2005;14:1004–1012.

26. Zatzick DF, Rivara FP, Nathens AB, et al. A nationwide US study of post-traumatic stress after hospitalization for 

physical injury. Psychol Med. 2007;37:1469–1480.
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27. Koren D, Norman D, Cohen A, Berman J, Klein EM. Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events. Am J Psychiatry. 2005;162:276–

282.

28. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil. 2006;21:398–401.

29. Wain HJ, Cozza SJ, Grammer GG, et al. Treating the traumatized amputee. In: Schnurr P, Cozza S, eds. Iraq War Clinician Guide. Washington, DC: Department of Veterans Affairs; 2004: 50–57.

30. Wain H, Bradley J, Nam, T, Waldrep D, Cozza S. Psychiatric interventions with returning soldiers at Walter Reed. 

Psychiatr Q. 2005;76:351–360.

	 31. 	 Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: implications of

cross-informant correlations for situational specificity. Psychol Bull. 1987;101:213–232.

32. Meiser-Stedman R, Smith P, Glucksman E, Yule W, Dalgleish T. Parent and child agreement for acute stress disorder, 

post-traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed 

to single-event trauma. J Abnorm Child Psychol. 2007;35:191–201.
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attachment 1: parent guidance assessment—combat injury
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attachment 2: 

principles of caring for combat-injured families and their children
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Family Maltreatment and Military Deployment

Chapter 32

family maltreatment and 

military deployment

RENÉ J. ROBICHAUX, PhD, LCSW,* and JAMES E. McCARROLL, PhD, MPH†

INTRODUCTION

THE ARMY FAMILY ADVOCACY PROGRAM

MILITARY LIFE AND FAMILY MALTREATMENT

Spouse Maltreatment

Child Maltreatment

EFFeCT OF WAR ON FAMILIES

THE ARMY’S RESPONSE TO FAMILY STRESS AND DEPLOYMENT

Summary

*Colonel, US Army (Retired); Social Work Programs Manager, Behavioral Health Division, US Army Medical Command, 2050 Worth Road, Fort Sam 

Houston, Texas 78234; formerly, Chief, Department of Social Work, Brooke Army Medical Center, Fort Sam Houston, Texas 

†

Colonel, US Army (Retired); Psychologist, Center for the Study of Traumatic Stress and Department of Psychiatry, Room B3068, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; formerly, Psychologist, Walter Reed Army Institute of Research, 

Silver Spring, Maryland
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INTRODUCTION

The relationship between family maltreatment (a 

term used to describe child abuse and neglect, and 

domestic violence between married or unmarried 

partners) and military deployment encompasses a 

subset of issues related to the effect of war on families—soldiers, spouses, and children. There have been 

numerous studies describing the effects of deployment on soldiers and families prior to Operation Iraqi 

Freedom and Operation Enduring Freedom.1

 There 

are many factors involved in a military deployment, 

both positive and negative.2 However, the stresses of 

the deployment of a service member are timeless. For 

example, those noted during World War II still occur 

today: uncertainty, separation, privations, bombing in 

noncombat areas, isolation, climate, danger, fatigue, 

differences in status and privilege among ranks and 

services, the length of the deployment, the degree of 

security (which may not allow adequate communication with family members or friends), boredom, and 

interruption of future plans.3

In addition to understanding the psychological 

effect of combat and operational stress on soldiers, 

the military has begun to more fully appreciate war’s 

impact on family members. Families experience many 

stressors that affect soldiers along with their own sets 

of stressors during deployment. Among these are 

managing physical illnesses of the spouse and children, 

pregnancy,4 affective conditions (depression, anger, 

loneliness), marital adjustment, maintaining the home 

and car, assuming sole responsibility for family life, 

playing a dual role as parent, and readjusting following the service member’s return from the deployment.5

Other stressors on families during deployments are the 

threat of soldiers being killed or injured in combat, parenting responsibilities of families in which the mother 

deploys,6 single parents,7,8 the effects of father absence 

on children,9–11 elevated symptoms of depression in 

parents and in children,12 and stress-related problems 

referred to healthcare workers.13 Finally, for both soldiers and spouses there are the issues of infidelity and 

marital trust.2,14

The ability to communicate under most circumstances is an important morale factor for both spouses 

and soldiers.15 During extended conflicts such as World 

War II, Korea, and Vietnam, communication was 

limited to letters. More rapid communication during 

deployment has become possible due to recent technological developments. At the present time, soldiers and 

families have access to a variety of media depending 

on their location and mission. The Internet, cellular 

phones, and e-mail have made virtually instantaneous 

communication possible, but can also produce emotional turmoil and frustration through system failures 

and inability to complete conversations.16

Army wives who had the most difficulty coping 

with the absence of their soldier husbands during the 

1991 Persian Gulf War were younger women with husbands in the lower ranks.17 Attempts to reach younger 

wives in the military community are among the most 

difficult tasks of Army family assistance workers. 

THE ARMY FAMILY ADVOCACY PROGRAM

Since the beginning of military operations in Afghanistan and the subsequent clustering of domestic 

violence fatalities at Fort Bragg, North Carolina in July, 

2002, there has been intense interest in identifying 

deployment stressors that may contribute to increased 

domestic violence. The Family Advocacy Program 

(FAP) is the Army’s mechanism for substantiating 

incidents of maltreatment and caring for victims. The 

Army FAP was formally established in 1976 following 

the enactment of the Federal Child Abuse Prevention 

and Treatment Act of 1974, as amended,18,19 although 

less formal programs existed prior to that time.20 The 

Army FAP is currently regulated by Department of 

Defense Directive 6400.121 and Army Regulation 608-

18.22 The objectives of the FAP are to prevent abuse, encourage the reporting of all instances of abuse, ensure 

the prompt assessment and investigation of all abuse 

cases, protect victims, and treat all family members 

affected by abuse. The Army is required to investigate 

all credible reports of family maltreatment.23

Incidents of abuse may come to the attention of 

the FAP from a variety of military and civil sources 

including law enforcement, medical and dental services, command authorities, and other agencies. When 

incidents of alleged abuse are reported to an Army installation (regardless of whether the incident occurred 

on or off the post), a multidisciplinary case review 

committee at the medical treatment facility on each 

major Army installation reviews them. Substantiated 

incidents of child maltreatment may be categorized as 

one or more of four possible types of maltreatment: (1) 

deprivation of necessities (neglect), (2) physical abuse, 

(3) sexual abuse, and (4) emotional abuse. Substantiated domestic violence can be categorized as physical, 

emotional, or sexual abuse.

If the incident is substantiated, case information is 

forwarded to the Army Central Registry (ACR), a confidential database of demographic and incident data 

on all substantiated child and spouse abuse victims 

and offenders. ACR records are maintained on child 
537

Family Maltreatment and Military Deployment

victims 17 years of age and younger and on married 

soldiers and their spouses. Recently the military services expanded their definition of domestic violence 

to include violence toward a person of the opposite 

sex who is a current or former spouse, a person with 

whom the abuser shares a child, or a current or former 

intimate partner with whom the abuser shares or has 

shared a common domicile.24

MILITARY LIFE AND FAMILY MALTREATMENT

Spouse Maltreatment 

Spouse abuse rates in the ACR have steadily declined from 6.3/1,000 in 2001 to 4.4/1,000 in 2007.25

This decrease is difficult to interpret. Many soldiers 

have deployed for several tours during this period, 

thereby decreasing the number of married persons at 

risk for domestic violence. 

It is broadly believed, at least in the media,26 that 

the stress of military life contributes to family maltreatment. Is there a difference in military and civilian spouse abuse rates of domestic violence? These 

populations have not been directly compared, but 

one study27 compared a reasonably representative 

sample of Army couples to previously collected civilian prevalence data of the US national population.28

The male soldier self-reports of moderate husbandto-wife spousal aggression were not significantly different—11% for the soldiers and 10% for the civilians. 

However, there was a small, but statistically significant 

difference in severe aggression in the Army sample 

(2.5%) compared to the civilian sample (0.7%). The 

authors concluded that the higher Army rates were 

mostly due to differences in age and race and not to 

abuse propensity. 

Military deployment has been suggested as a possible cause of domestic violence,13,25 but little information supports such a claim. Using data from the 

Heyman and Neidig study,27 a secondary analysis 

was performed studying the relationship between the 

length of deployment and spousal aggression. In this 

study, using a large-scale database (n = 26,835), with 

demographic variables controlled, deployment contributed a small, but statistically significant increase 

in the probability of self-reported severe husband-towife violence over a 1-year period.29 The probability 

increased from 4% with no deployment to 5% with 

deployment of 6 to 12 months. The frequency of moderate and severe violence increased with the number 

of weeks deployed.

Two other studies examined the relationship between deployment and domestic violence. Active duty 

deployed (n = 313) and nondeployed (n = 712) male 

soldiers were surveyed after returning from a 6-month 

peacekeeping deployment to Bosnia.30 Postdeployment domestic violence by male soldiers was predicted 

by youthful age and the existence of predeployment 

domestic violence, but not by deployment. Nonwhite 

race and off-post residence also contributed to the 

prediction. The predicted probability of postdeployment domestic violence for a deployed 20-year-old, 

nonwhite soldier living on the military installation 

with a history of predeployment domestic violence 

was 0.20. For the soldier without a history of predeployment domestic violence it was 0.05.30

A second study of the relationship between domestic violence and deployment was conducted on wives 

of male soldiers who deployed to Bosnia.31 Soldiers 

in the previous survey30 and spouses in this survey 

were not matched because surveys were anonymous; 

however, both reported their experiences relative to 

the same deployment. There were 368 wives of soldiers 

who had been deployed and 528 wives of nondeployed 

soldiers who retrospectively provided domestic 

violence data for both the pre- and postdeployment 

periods. There were no significant differences in the 

frequency of domestic violence between the deployed 

and nondeployed groups for pre- or postdeployment 

time periods. Deployment was not a significant predictor of domestic violence during the first 10 months of 

the postdeployment period, but younger wives and 

those who were victims of predeployment domestic 

violence were more likely to report postdeployment 

domestic violence than older wives and those who had 

not been identified as victims during predeployment. 

Anecdotal reports suggest that abuse is most likely to 

occur several months after the soldier’s return from 

deployment, but there are no studies to support this 

observation.

As a result of these latter two studies, it was concluded that prevention and intervention programs 

for postdeployment domestic violence should target 

younger families, persons with a domestic violence 

history, and those who live off post. Increased opportunities for counseling these groups on the risk of 

postdeployment domestic violence may be helpful. 

Such programs might emphasize increased awareness 

of personal risk for domestic violence, self-monitoring, 

and early help-seeking.

Child Maltreatment 

In 1990, prior to the Persian Gulf War (1990–1991), 

the child victim maltreatment rate was 6.9/1,000 

children. After a steady decrease of child maltreatment rates through the 1990s, the rates increased 
538

Combat and Operational Behavioral Health

from 5.2/1,000 in 2000 to 6.2/1,000 in 2004, and then 

decreased to 5.0/1,000 in 2007. Child neglect is the type 

of maltreatment most affected by the deployments. 

Neglect rates decreased from a high in 1991 (3.6/1,000) 

to a low in 2000 (2.7/1,000), an overall decline of 25%. 

By 2004, however, the rates had increased to 4.5/1,000, 

which is above the 1991 level. The neglect rates were 

3.5/1,000 in 2005, 3.3/1,000 in 2006, and 3.7/1,000 

in 2007. Neglect rates were highest for the youngest 

children and decreased as age increased. The rates of 

child physical abuse decreased from 3.1/1,000 in 1990 

to 1.0/1,000 in 2007.25

A study of child maltreatment cases in military 

families living in Texas between 2000 and 2003 found 

that both departure to and return from an operational 

deployment impose stresses on military families and 

are likely to increase the rate of child maltreatment.32

For each 1% increase in the percentage of active duty 

personnel departing to or returning from deployment, 

there was approximately a 30% increase in the rate of 

child maltreatment.32

A second study found approximately a 40% increased rate of child maltreatment when the soldier 

parent was deployed.33 The rates of child neglect 

were nearly twice as high during deployment. 

However, the rate of physical abuse was less during 

deployment. The rate of neglect by female civilian 

spouses was almost 4 times greater during deployment and the rate of physical abuse was almost twice 

as great. The authors speculate that the increased 

risk of child maltreatment may be a function of 

deployments creating a situation similar to that of 

single parents in the general population, for whom 

the research has demonstrated an increased risk for 

child maltreatment due to limited financial resources 

and greater levels of physical exhaustion. Finally, a 

study of trends in child maltreatment cases recorded 

in the ACR from 1990 to 2004 indicated that child 

neglect rates increased during the Middle East wars 

(in the Persian Gulf War [1990–1991] and Operation Iraqi Freedom/Operation Enduring Freedom 

[2002–2004]).34 

Earlier research demonstrated little or no relationship between deployment and domestic violence.29–31

This research, however, was performed during deployments (Bosnia in 1998–1999 and earlier) that were of 

relatively short duration and did not involve extensive 

combat operations. These deployments, thus, represent 

an entirely different scenario for soldiers and families 

compared to the current conflicts in Iraq and Afghanistan. Recent research has shown a probable effect of 

lengthy deployment on child maltreatment.32–34

EFFECT OF WAR ON FAMILIES

Clinical depression of the nondeployed spouse may 

contribute substantially to the observed increase in 

the child neglect rates during combat deployments. 

The majority of the neglect complaints received by the 

Army FAP involved both a lack of child supervision 

and dirty homes, which present a health risk to children. Caretakers who are depressed have little energy 

to both maintain a house and provide suitable activities for young children. The Army Medical Command 

(MEDCOM) has published written guidance for its 

healthcare providers to increase screening for depression in family member spouses. New policy changes 

encouraging social workers to leave their clinic offices 

and aggressively reach out to isolated and depressed 

mothers has underscored the MEDCOM’s desire to 

intervene early and avoid serious negative family 

outcomes due to depression.

Military spouses have reported their belief that 

military stress increases the number of divorces.35,36

If military stress contributes to marital conflict and 

marital dissolution, deployment should increase both 

these outcomes. Soldiers have reported that deterioration of a marital or romantic relationship is one of the 

negative consequences of deployment.2

 Several studies have addressed this point. Spouses of nearly 400 

enlisted soldiers who deployed to Somalia in 1992 to 

1993 reported that difficulties encountered during the 

soldier’s deployment, such as pregnancy, loneliness, 

death of a friend or relative, or having problems communicating with the soldier spouse have less impact 

on marital satisfaction, and are less stressful than is 

often assumed.5

 A study of over 800 enlisted soldiers 

who participated in Operations Desert Shield/Storm 

(1990–1991) found no significant overall change in 

marital satisfaction.37

The “stress hypothesis” is commonly cited to 

explain the observed increases in divorce rates 

among military couples and predicts that soldiers 

who are deployed will experience higher rates of 

divorce compared to soldiers who do not deploy.38

Additionally, the hypothesis suggests that longer 

deployments will be more damaging to marriages 

than shorter deployments. After correlating deployment histories with personnel records for marital 

status and controlling for variables such as gender, 

race, and age at marriage, the opposite outcome was 

found. For enlisted soldiers, the longer that a service 

member was deployed while married, the lower the 

subsequent risk of marital dissolution. The same effect 

was also observed for soldiers in the Army Reserve 

and Army National Guard. One of the overall conclusions was that deployment appears to enhance the 
539

Family Maltreatment and Military Deployment

stability of the marriage. It follows from an analysis 

of the number of days deployed and its relationship 

to marital dissolution that the longer the deployment, 

the greater the benefit to the marriage. However, the 

effects of military service and deployment in particular on marital stability are complex and are affected by 

service member factors such as gender, race/ethnicity, 

age at marriage, and children.38

In addition to the stress hypothesis is the selection 

factor present in service recruitment.38 Military marriages may be at increased risk for dissolution because 

the various military services recruit from relatively 

high-risk populations and provide incentives such 

as healthcare, housing allowances, separate rations, 

moving expenses, and survivors’ benefits that encourage marriage. Recent challenges to meeting recruiting goals may lead to waivers of some standards for 

recruitment; these modified standards may lead to a 

vulnerable group of recruits. In fiscal year 2007, more 

than 11% of Army recruits were given waivers. Waivers were given to some enlistees for medical problems, 

drug and alcohol issues, and criminal backgrounds.39

Although the group with waivers is considered the 

most vulnerable based on factors associated with 

impulsivity, anger control, and substance abuse, the 

remaining 88% are also considered to be vulnerable 

to marital problems based on age, ethnicity, and potential for career advancement in the civilian labor 

market.40 Thus, soldiers marry younger and have 

children sooner than their civilian counterparts, both 

of which are associated with increased risk of divorce 

and marital conflict.38

THE ARMY’S RESPONSE TO FAMILY STRESS AND DEPLOYMENT

The Army has responded to its many deploymentrelated challenges by increasing the number of human 

service workers to help soldiers and families in the 

high-tempo environment of repeated deployments 

to the Middle East. By 2004, the Army had placed 70 

clinical social workers at various installations that 

regularly deployed large numbers of soldiers (power 

projection platforms) to support soldiers and family 

members adjusting to the psychological challenges 

associated with deployment. Additionally, the Department of Defense has provided on contract over 84 

military and family life consultants, who arrive at an 

installation for temporary duty during peak periods 

of deployment activity, to assist with education and 

consultation related to deployment stress issues. These 

contracted master’s- and doctoral-level social workers and psychologists have been particularly active in 

support of Army National Guard and Army Reserve 

units during their redeployment activities.

Army chaplains have increased their outreach 

to couples struggling in their marriages against a 

backdrop of multiple deployments. A program entitled “Strong Bonds” combines elements of marriage 

preparation and marriage enrichment and is generally 

delivered in a group setting to both the active and reserve components. Family life chaplains also provide 

traditional couples’ counseling to individual families 

seeking to improve communication, goal setting, and 

problem resolution skills.

Funds have recently been set aside to hire approximately 1,000 family readiness support assistants to 

organize the family support activities centered at the 

battalion level. Pilot projects have attested to the enormous advantage that can accrue from the networking 

and outreach efforts provided by the addition of these 

funded positions. They have succeeded in improving 

the flow of information between the military unit and 

the individual family as well as encouraging support 

between families. Their activities have served to mitigate the feelings of isolation and alienation reported 

by the wives of young soldiers during the Persian Gulf 

War (1990–1991). 

The FAP is directed by the US Army Family and 

Morale, Welfare, and Recreation Command. Among 

the many FAP services provided to families is the New 

Parent Support Program (NPSP). The NPSP can conduct home visits for high-risk families as well as many 

educational programs for parents of young children. 

The FAP currently provides 52 NPSP home visitors and 

plans to add an additional 100 in support of families 

who are coping with parenting young children amidst 

the added stress of multiple deployments.

In July 2006 MEDCOM directed that all parents 

(both military and civilian spouses) of children born 

in Army medical treatment facilities and civilian hospitals receive briefings designed to reduce and avoid 

injuries inflicted in response to children’s uncontrolled 

crying. The Center for Health Promotion and Preventive Medicine has developed materials to educate new 

parents in understanding the causes of inconsolable 

crying and offer solutions for them. The Department 

of Defense, in partnership with the National Center 

on Shaken Baby Syndrome, has launched a campaign 

directed at service families to raise awareness while 

offering sources of help to address this problem.

Drawing from lessons learned from the 2003 and 

2004 Fatality Review Board findings, the Army MEDCOM has also directed that when healthcare providers 

identify high-risk families, their cases be assessed by 

a team and managed by an identified social worker 

case manager until the risk is determined to be sufficiently reduced.
540

Combat and Operational Behavioral Health

Child development centers at various power projection platforms have, since the war’s inception, offered 

hours of free respite care for parents of children while 

the other parent is deployed. Those installations where 

this service has been most highly used have seen fewer 

referrals to the FAP for child neglect.

The programs outlined here represent a broad first 

effort to manage the psychological stressors associated 

with high personnel and operational tempo, but more 

needs to be learned about the effectiveness of these 

programs. As the Army increases its capacity to address 

the psychological consequences of deployment for the 

active force and its relation to family conflict and family 

maltreatment, a significant benefit would accrue from 

having trained marriage and family therapists as part 

of any increased behavioral health workforce. There are 

about 60 such therapists currently on staff in various 

hospitals across the Army. They have demonstrated 

their value in a number of substantive ways. Pre- and 

postintervention outcome self-report questionnaires 

indicate clinically significant improvements in distress 

symptoms. At those installations where marriage and 

family therapists provided couples’ counseling to 

identified domestic violence cases, the couples were 

significantly more likely to successfully complete the 

required treatment. For many soldiers struggling with 

the need to seek help for depression and posttraumatic 

stress, family therapy has proven to be extremely efficacious in breaking through denial and rationalizations that may have precluded individual therapy. It is 

believed that participating as a family in therapy can 

be helpful to all. War disrupts everyone’s lives; therapy 

with a family can be less threatening than identifying 

an individual as “damaged” or “broken.”

SUMMARY

Deployments place additional stresses on military 

families. Research conducted prior to the wars in 

Iraq and Afghanistan showed little or no significant 

relationship between deployment and domestic violence. More recent research has shown increases in 

child maltreatment, especially child neglect, during 

the deployment periods. The Army has responded 

with many new and expanded efforts to address the 

many challenges of soldiers and families associated 

with repeated deployments. The results of some research, such as the effect of deployment on military 

marriages, have been counterintuitive, showing 

increased strength of such marriages. However, this 

finding is not without significant caveats. Much more 

needs to be learned to address problems encountered 

in the various phases of deployment: how to prepare 

soldiers and families for deployment, which services 

are most helpful to family members while the soldier 

is deployed, and how to facilitate resumption of postdeployment family life.

REFERENCES

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Military Medicine. Washington, DC: Department of the Army, Office of The Surgeon General, Borden Institute; 2005: 

1395–1424.

2. Newby JH, McCarroll JE, Ursano RJ, Fan Z, Shigemura J, Tucker-Harris Y. Positive and negative consequences of a 

military deployment. Mil Med. 2005;170:815–819.

3. Menninger WC. Psychiatry in a Troubled World. New York, NY: MacMillan; 1948.

4. Haas DM, Pazdernik LA, Olsen CH. A cross-sectional survey of the relationship between partner deployment and 

stress in pregnancy during wartime. Women’s Health Issues. 2005;15:48–54.

5. Schumm WR, Bell DB, Knott B, Rice RE. The perceived effect of stressors on marital satisfaction among civilian wives 

of enlisted soldiers deployed to Somalia for Operation Restore Hope. Mil Med. 1996;161:601–606.

6. Kelley ML, Herzog-Simmer PA, Harris MA. Effects of military-induced separation on the parenting stress and family 

functioning of deploying mothers. Mil Psychol. 1994;6:125–138.

7. Bowen GL. Single fathers for the defense. Soc Casework: J Contemp Soc Work. 1987;6:339–344.

8. Schumm WR, Rice RE, Bell DB, Perez MMV. Trends in single parenting in the Army. Psychol Reports. 1996;78:1311–

1328.
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9. Jensen PS, Grogan D, Xenakis SN, Bain MW. Father absence: effects on child and maternal psychopathology. J Am 

Acad Child Adolesc Psychiatry. 1989;28:171–175.

10. Jensen PS, Lewis RL, Xenakis SN. The military family in review: context, risk, and prevention. J Am Acad Child Psychiatry. 1986;25:225–234.

11. Amen DG, Jellen L, Merves E, Lee RE. Minimizing the impact of deployment separation on military children: stages, 

current preventive efforts, and system recommendations. Mil Med. 1988;153:441–446.

12. Jensen PS, Martin D, Watanabe H. Children’s response to parental separation during Operation Desert Storm. J Am 

Acad Child Adolesc Psychiatry. 1996;35;433–441.

13. Blount BW, Curry A Jr, Lubin GI. Family separations in the military. Mil Med. 1992;157:76–80.

14. van Vranken EW, Jellen LK, Knudson KH, Marlowe DH, Segal M. 82nd Airborne Division Sinai MFO Deployment Family 

Health Study I-IV. The Impact of Deployment Separation on Army Families. Washington, DC: Walter Reed Army Institute 

of Research; 1983.

15. Schumm WR, Bell DB, Ender MG, Rice RE. Expectations, use, and evaluation of communication media among deployed 

peacekeepers. Armed Forces Soc. 2004;30:649–662.

16. Ross BJ. The emotional impact of e-mail on deployment. US Naval Institute Proceedings. 2001;127:85–86.

17. Rosen LR, Westhuis DJ, Teitelbaum JM. Patterns of adaptation among Army wives during Operations Desert Shield 

and Desert Storm. Mil Med. 1994;159:43–47.

18. Child Abuse Prevention and Treatment Act, 42 USC §5101 et seq (1989).

19. Child Abuse Prevention and Treatment Act Amendments of 1996, 42 USC §5116 et seq.

20. Wichlacz CR, Randall DH, Nelson JH, Kempe CH. The characteristics and management of child abuse in the US 

Army-Europe. Clin Pediatr (Phila). 1975;14:545–548.

21. US Department of Defense. Family Advocacy Program (FAP). Washington, DC: DoD; 2004. DoD Directive 6400.1.

22. US Department of the Army. The Army Family Advocacy Program. Washington, DC: HQDA; 2007. Army Regulation 

608-18.

23. McCarroll JE, Newby JH, Dooley-Bernard M. Responding to domestic violence in the US Army: the Family Advocacy 

Program. In: Kendall-Tackett KA, Giacomoni SM, eds. Intimate Partner Violence. Kingston, NJ: Civic Research Institute; 

2007: Chap 12.

24. US Department of Defense. Domestic Abuse Involving DoD Military and Certain Affiliated Personnel. Washington, DC: 

DoD; 2007. DoD Instruction 6400.06

25. Spouse and child maltreatement rates in the ACR computed from data compiled by James E. McCarroll, Center for the 

Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, 

Md. 

26. Thompson M. The living room war. Time. 1994;143:48–51.

27. Heyman RE, Neidig PH. A comparison of spousal aggression prevalence rates in US Army and civilian representative 

samples. J Consult Clin Psychol. 1999;67:239–242.

28. Straus MA, Gelles RJ. Physical Violence in American Families: Risk Factors and Adaptations to Violence in 8,145 Families.

New Brunswick, NJ: Transaction; 1990.

29. 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.
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30. McCarroll JE, Ursano RJ, Newby JH, et al. Domestic violence and deployment in US Army soldiers. J Nerv Ment Dis. 

2003;191:3–9.

31. Newby JH, Ursano RJ, McCarroll JE, Liu X, Fullerton CS, Norwood AE. Postdeployment domestic violence by US 

Army soldiers. Mil Med. 2005;170:643–647.

32. Rentz ED, Marshall SW, Loomis D, Casteel C, Martin SL, Gibbs DA. Effect of deployment on the occurrence of child 

maltreatment in military and nonmilitary families. Am J Epidemiol. 2007;165:1199–1206.

33. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Child maltreatment in enlisted soldiers’ families during combat-related 

deployments. JAMA. 2007;298:528–535.

34. McCarroll JE, Fan Z, Newby JH, Ursano RJ. Trends in US Army child maltreatment reports: 1990–2004. Child Abuse 

Rev. 2008;17:108–118.

35. Rosen LN, Durand DB. Coping with the unique demands of military family life. In: Martin JA, Rosen LN, Sparacino 

LR, eds. The Military Family: A Practice Guide for Human Service Providers. Westport, Conn: Praeger; 2000: 55–72.

36. Rosen LN, Durand DB. Marital adjustment following deployment. In: Martin JA, Rosen LN, Sparacino LR, eds. The 

Military Family: A Practice Guide for Human Service Providers. Westport, Conn: Praeger; 2000: 153–165.

37. Schumm WR, Hemesath K, Bell DB, Palmer-Johnson CE, Elig TW. Did Desert Storm reduce marital satisfaction among 

Army enlisted personnel? Psychol Reports. 1996;78:1241–1242.

38. Karney BR, Crown JS. Families Under Stress: An Assessment of Data, Theory, and Research on Marriage and Divorce in the 

Military. Santa Monica, Calif: RAND National Defense Research Institute; 2007. Report No. DRR-4071-OSD.

39. Madhani A. US Army lowers its recruiting standards: more recruits have criminal records, no high school diploma. Chicago Tribune. October 11, 2007. Available at: http:/archives.chicagotribune.com/2007/oct/11/news/chi-recruit11oct11. 

Accessed December 17, 2008.

40. Bachman JG, Segal DR, Freedman-Doan P, O’Malley PM. Who chooses military service? Correlates of propensity and 

enlistment in the US armed forces. Mil Psychol. 2000;12:1–30.
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The Families and Children of Fallen Military Service Members

Chapter 33

THE FAMILIES AND CHILDREN OF 

FALLEN MILITARY SERVICE MEMBERS

DOUGLAS H. LEHMAN, MSW, LCSW,* and STEPHEN J. COZZA, MD†

INTRODUCTION

MILITARY RESPONSE TO THE DEATH OF A SERVICE MEMBER

THE MILITARY CARE TEAM

GRIEF RESPONSES

Adult Grief Responses

Children’s Grief Responses

Children and Military Funerals

Traumatic Grief

Support Services and Organizations

SPECIAL CIRCUMSTANCES

Death, Illness, or Injury of a Leader

Suicide

Missing in Action and Prisoners of War

Mass Casualties

Death of a Spouse or Child

Media

SUMMARY

ATTACHMENT: RESOURCES FOR FAMILIES OF DECEASED SERVICE MEMBERS

*Treatment Provider, Department of Behavioral Health and Family Advocacy, Evans Army Community Hospital, 7500 Cochrane Circle, Fort Carson, 

Colorado 80913 

†

Colonel, US Army (Retired); Associate Director, Center for the Study of Traumatic Stress, and Professor, Department of Psychiatry, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; formerly, Chief, Department of Psychiatry, Walter Reed Army 

Medical Center, Washington, DC
544

Combat and Operational Behavioral Health

INTRODUCTION

As of October 2007, over 4,000 US service members 

had died in the line of duty in Iraq and Afghanistan. 

Forty-four percent of military service members are 

parents1

 and constitute a relatively young adult population. Families of service members killed in combat are 

likely to include children of varying ages, one third of 

whom are under the age of 5. Not infrequently, these 

young families may include wives who are pregnant 

at the time of death or newborns who have never met 

their deceased parents. Deceased service members 

may have younger siblings, cousins, nieces, or nephews who, while not part of the nuclear military family, 

are other child mourners. Caring for the family after 

the loss of a service member requires sensitivity and 

consistency. This chapter will focus on the needs of 

the families of the fallen, with special emphasis on the 

needs of children and the programs in place to meet 

those needs.

MILITARY RESPONSE TO THE DEATH OF A SERVICE MEMBER

Beginning in 1950, the Army has published an instruction guide to assist survivors of fallen soldiers.2

A Guide for the Survivors of Deceased Army Members describes the notification process and services available 

to meet the needs of mourning families. Subjects range 

from discussing the role of the casualty assistance officer (CAO) to funeral and postfuneral procedures. 

Army Regulation 600-8-1, the Army Casualty Program,

3

describes in detail the responsibilities and services 

provided by the military to families of the deceased, 

explaining the casualty assistance program and the 

role and duties of the CAO. 

Family notification of combat death has changed in 

the past century. During World War II, Army families 

were informed of a service member’s death by a telegram from the Army Adjutant General. The telegram, 

which typically arrived weeks after the death, stated 

the known factual information about the death and 

offered a brief statement of regret. A letter offering 

the military’s condolences and outlining survivors’ 

benefits followed the telegram. By the end of the Korean War, the Army sought to improve this process by 

personalizing notification. Initial notification was still 

sent by telegram but was followed by the arrival of 

an Army officer who visited the family’s home, verified the death, and provided additional details. The 

personal visit was meant to convey greater organizational appreciation and respect for the sacrifice of the 

deceased soldier and the loss to the family.4

A substantial change in the notification process 

occurred during the Vietnam War, when the next of 

kin was first contacted with the news of death by a 

“casualty notifier,” an officer of equal or higher rank 

than the deceased. Personal notification was followed 

by a telegram of confirmation. Only equal ranking 

officers, senior officers, or noncommissioned officers 

made the death notification. To minimize the family’s 

shock, death notifications occurred only between 6:00 

am and 10:00 pm. The Vietnam era’s expanded casualty 

assistance program was similar to the current format 

for notifications and standards.4

 Another significant 

change occurred in 1970, adding notification of secondary next of kin, identified by the next of kin, such 

as former spouses, grandparents, or friends. The CAO 

offered assistance to the family during this difficult 

time.

Since Vietnam, other changes in notification and 

family assistance have taken place. After the 1985 

airplane crash in Gander, Newfoundland, that killed 

248 soldiers and 8 crew members, the CAO’s role was 

expanded to help the immediate family and to support the secondary next of kin in greater depth. These 

changes included regularly scheduled CAO family 

briefings, as well as government-funded travel to and 

from funerals and memorial services for certain family 

members.4

 Recently, a distinction has been made between the individual (or team) who notifies the family 

of the soldier’s death and the CAO who provides ongoing support to the family. This distinction is recognized 

as important because of negative associations with the 

death notification. After the notification, the family is 

informed of the CAO’s role, and the CAO calls on the 

family to offer assistance and support.4

Since 2003, death notification has changed as a result 

of surveys of Navy families and casualty assistance 

call officers (CACOs).5

 According to the CACO survey, 

95% of the families of deceased Navy military members had a high level of satisfaction with the services 

they received. Respondents identified the need for 

more training to increase knowledge of the CACO’s 

duties and responsibilities. The CACOs felt that they 

should remain engaged with the families for a longer 

period of time, as well as needing more knowledge 

about specific benefits. As a result, Navy training has 

been increased from 1 to 2 days, Web access has been 

expanded, and personnel services have increased to 

include operations for survivors available 24 hours a 

day, 7 days a week. The Navy responds to casualties 

through its casualty assistance calls program and the 

assigned program coordinator.
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The Families and Children of Fallen Military Service Members

Recent changes to survivor benefits include allowing a surviving spouse and dependents to remain in 

Army base housing for a full year after the death of a 

soldier, compared to 6 months, which was the policy 

before the global war on terror, and an increase in 

the monetary survivor benefit to $400,000 across the 

services. Another change requires all death reports 

to be reviewed by a field-grade or higher-ranking officer. This change was made to ensure the accuracy of 

the report’s details and reduce the likelihood of later 

changes to the report that could lead to erroneous 

interpretations of the death.

Since 2006, the National Defense Authorization Act 

has mandated that all services collect data “regarding 

the incidence and quality of casualty assistance provided to survivors of military decedents, including surveys 

of such survivors and military and civilian members 

assigned casualty duties.”6 In response to the act, the 

Army’s Families First Casualty Call Center created an 

outreach survey instrument that collects information 

from outbound calls and mailed questionnaires. The 

survey was designed to capture feedback and the next 

of kin’s level of satisfaction during the casualty assistance process. 

The Army’s Casualty and Mortuary Affairs operation center (CMAOC) has been tasked with the collection and analysis of data received from completed 

surveys. The CMAOC began surveying next of kin in 

2005 with 33 questions related to four primary areas: 

(1) notification, (2) CAO performance, (3) Casualty 

and Mortuary Affairs activities, and (4) postinterment 

activities. The survey results below were collected from 

the families of service members who died between 

March 2005 and March 2006 (approximately 1,000 

identified contacts). The results indicate that families 

have largely been satisfied with the CMAOC process. 

A quality-assurance working group has identified key 

areas where CMAOC scored at least 90% satisfactory 

from the respondents:

	 •	 97% stated that their CAO displayed/expressed sufficient compassion for their loss;

	 •	 93% stated that their CAO made their family

a priority and was responsive to their needs;

	 •	 93% stated that their CAO explained all

funeral options and assisted with funeral arrangements;

	 •	 92% stated that the CAO explained all authorized expenses for the funeral; and

	 •	 91% responded that their CAO explained all

qualified benefits and entitlements.

The working group also proposed the following 

procedural changes to address areas of need identified 

by the survey: 

	 •	 Command should prioritize predeployment

education of benefits, living wills, entitlements, and forms. 

	 •	 An inventory process should be standardized

before deployment, and summary courtsmartial officers should determine whether 

the service member completed an inventory 

prior to deployment. 

	 •	 Throughout the CAO assistance process,

families should receive continuous updates 

about survivor benefits. 

	 •	 CAOs should perform a final review of applicable benefits with the families before ending their assignments (formalized by a check 

list). 

	 •	 CAOs should inform survivor families of

services available through casualty assistance 

centers. 

	 •	 Atraining module on personal-effect processing should be developed, and CAOs need to 

be trained in this area. 

In addition to these existing tools, the Office of the Secretary of Defense developed a universal survey to assess 

satisfaction with the casualty assistance process that was 

disseminated to surviving primary next of kin across all 

services beginning in the first quarter of 2007.

THE MILITARY CARE TEAM

The care team concept developed from the Spouses’ 

Project at the Army War College, Carlisle Barracks, 

Pennsylvania.7

 The team typically consists of spouse 

volunteers from a previously formed family readiness group in the same battalion or company as the 

deceased service member. Care team training mirrors 

CAO training, although it has been formalized in 

different ways at some sites. For example, spouses 

at Fort Carson, Colorado, have developed and use a 

“smart book” training manual.8

 In many other places, 

care team practices have been implemented with less 

formal procedural development. 

The care team offers short-term respite and supportive care to families of the deceased and also helps 

the families of seriously wounded soldiers. The team 

is designed as temporary transitional assistance until 

the survivor’s support structure is in place. Each care 

team consists of an on-site leader as well as other 

participants. The care team works with the casualty 

notification team if a surviving family member has 
546

Combat and Operational Behavioral Health

agreed to this arrangement. Care team members help 

activate preestablished plans to assist family members, 

coordinate more effective use of military and community resources, and develop additional personalized resources to assist surviving family members. 

Care teams have been successful in personalizing the 

notification and early assistance support to casualty 

families. The teams have also reduced stress on spouses 

of volunteers, relying on team strength rather than 

overburdening individuals.

GRIEF RESPONSES

Adult Grief Responses

Grief is a reaction people have to loss in their lives. 

Grief includes a range of responses that vary according 

to type of loss, its meaning to the individual, and each 

individual’s particular circumstances and experiences. 

When people grieve, they are coming to terms 

with life-changing loss. Healthy grieving allows the 

individual to begin finding new ways of living while 

coping with the gaps created by the loss. The grief 

process has no time limit. The phases described in 

Table 33-1 provide a general timeline that a grieving 

adult may experience; however, it is not uncommon 

for individuals to move back and forth between 

phases or manifest responses from multiple phases 

simultaneously. 

Everyone experiences the grief process physically, 

emotionally, psychologically, socially, and often spiritually. Physical reactions can include pain, dizziness, 

shortness of breath, and sleep disturbances (hypersomnia or insomnia). Grieving adults may experience 

a variety of emotional reactions, including shock, tearfulness, fear, anger, and envy. Adults may sometimes 

have confusing or contradictory thoughts. They may 

feel guilty, expect the return of the deceased, or become 

troubled by disturbed memories or dreams. Socially, 

a grieving adult is likely to feel lonely or isolated and 

may find a need to redefine or reestablish relationships. 

Grieving adults may find spiritual or religious practice 

to be profoundly helpful and reassuring. Sometimes 

the death of a loved one can cause adults to question 

the basis of their religious faith.

Grief symptoms may include an overwhelming 

sense of loss with strong feelings of yearning or longing 

for the loved one. Survivors may feel a profound sense 

of emptiness and a sense that a part of them has died. 

Grieving survivors often speak of generalized pain 

or heaviness in their chest. They may feel depressed 

and hopeless about the future. Things that once were 

important may no longer seem to matter. Those who 

suffer traumatic loss may cry easily and lose interest in 

eating; they may experience stomach upset, headaches, 

and feelings of restlessness. A commonality among 

survivors is the desire to preserve the memory of their 

loved ones and the belief that their loved ones believed 

in and drew meaning in their military mission. PolitiTABLE 33-1

ADULT GREIVING PROCESS TIMELINE

Phase I II III IV

Description Responses can result from 

the initial impact of 

notification and occur 

immediately after the 

notification

Responses comprise 

withdrawal and 

confusion

Responses consist of 

an adjustment to the 

death

Responses are characterized by reconstruction and reconciliation

Response “Fight or flight” Anger, fear, guilt, rage Positive thoughts 

begin

Hope

Thought Numb or disoriented Ambiguity and uncertaintyProblem solving Consolidation of problem solving

Direction Searching for a lost object Bargaining, detachment, depressionSearching for new 

objective

Reattachment

Search behavior Reminiscing Perplexed and scanningFocus on exploration Reality testing

Guidance needed Accepting feelings Task orientation and 

direction

Support and spiritual 

insights

Breakthrough and 

reinforced hope
547

The Families and Children of Fallen Military Service Members

cal, cultural, and economic states are crossed by these 

dual focuses.9

Children’s Grief Responses

Children experience a sudden and profound life 

change when they lose a parent in combat. In all cases, 

the death of a parent is premature to the age and health 

of that individual, as well as to the relationship with 

the child. Since 2001, thousands of children have lost 

military parents from combat operations in Iraq and 

Afghanistan. Military deaths have affected countless 

other children whose service member siblings, cousins, 

aunts, uncles, and other extended family members 

have died in the line of duty. These losses can be 

equally profound.

Similarly to adults, children mourn the deaths of 

loved ones. Family death affects children of all ages, 

from infants and toddlers to teenagers (see Exhibit 

33-1). Children, like adults, feel a deep sense of loss or 

sadness when a loved one dies. Many people assume 

that because children do not understand death in the 

same way as adults, they have less of an emotional 

response, but this is not true. Children are likely to be 

powerfully affected by the deaths of loved ones but 

may be less able to express confusing thoughts and 

feelings in words. While many children may express 

feeling sad, cry, or become more withdrawn, others 

express their emotions by reverting to earlier childhood behaviors. Infants and toddlers are likely to 

experience the death through the emotional responses 

or change in availability of the important adults in 

their lives, and react to these changes. Very young 

children can demonstrate changes in sleeping or eating 

patterns, increasing tantrums, or overactive behavior. 

School-aged children may express emotional concerns 

through physical complaints such as stomachaches or 

headaches. Teenagers often wish to present themselves 

as independent and not in need of adult help. Their 

sullenness or seeming disconnectedness should not be 

mistaken for a lack of emotional response to a death. 

Behavioral changes in any grieving child are more 

likely to be an emotional response than a disciplinary 

problem.

Children who lose military family members during 

wartime are similar to other grieving children in many 

ways. However, certain unique aspects characterize 

military family loss. Service members may be deployed 

for long periods before a death, and children may 

have become adjusted to the physical absence of the 

deceased parent or family member, making it more 

difficult to accept the permanence of the loss. Because 

military deaths during wartime are viewed as public 

events, family privacy during grieving may be diminished. Family members and communities should assist 

in protecting children from disturbing media exposure 

or other unwanted intrusions on the grieving process. 

Bereaved families living on military installations will 

likely be surrounded by community support and attention. Typically this interest is wanted and appreciated 

by families, but limits may need to be set by families to 

ensure that the attention does not become burdensome. 

Reserve and National Guard families or those living 

outside of military communities may find their grief 

is less well understood by well-intentioned civilian 

families in their neighborhoods. Children who attend 

schools with few other military children may find 

themselves isolated in their experiences of loss. Finally, 

not all military deaths are the same—some children 

may lose loved ones to combat, but others lose parents 

as a result of accidents or other causes.

A child’s response to parental death is related to the 

surviving parent’s response to the death: “Children 

appear to be at risk for concurrent and later difficulties primarily in the extent they suffer a higher probability of inadequate parental functioning or other 

environmental support before as well as after the loss 

of a parent.”10(p431) Bivariate and multivariate analyses 

show that the health of the surviving parent relates 

directly to how well a child will adjust11; however, 

even a “healthy” parental response does not guarantee 

a “healthy” child response. Even if a child appears to 

be transitioning well through the grieving process, it 

is helpful to notify other adults in the child’s life of the 

death. Teachers, coaches, healthcare providers, and 

spiritual and religious leaders can often offer support 

to grieving children within the context of their daily 

interactions. 

Children are extremely aware of the attitudes, behaviors, and emotions of the adults they see around 

them. Parents and caring adults should help children 

understand what they are likely to see as people 

mourn. Children can be reassured when they understand that expressions of emotions, including sorrow, 

are natural ways of showing how much people cared 

for the deceased and how much their loved one will 

be missed. Children will feel more confident when 

they see adults handling emotionally painful situations without losing control. Tears and sorrow are to 

be expected. However, adults should protect children 

from witnessing frightening or uncontrollable displays 

of emotion. If such a situation occurs, adults should 

talk to youngsters about what they witness so that the 

event is more understandable and less frightening.

Very little has been written about children experiencing the loss of a parent in a wartime environment; 

however, an overwhelming amount of literature 

explores the issues of grief in children experiencing 
548

Combat and Operational Behavioral Health

EXHIBIT 33-1

CHILDREN’S EMOTIONAL AND BEHAVIORAL RESPONSES TO DEATH 

Infants and toddlers: 

	 •	 crying

	 •	 searching for parents/caregivers

	 •	 clinging

	 •	 changing sleeping and eating habits

	 •	 regressing to earlier behavior (eg, bedwetting,

thumb sucking)

	 •	 repeating play or talk

Preschoolers (age 3–5):

•	 fearing separation (eg, from parents/loved

ones)

	 •	 clinging

	 •	 throwing tantrums, having irritable outbursts

	 •	 fighting

	 •	 crying

	 •	 withdrawing

	 •	 regressing to earlier behavior (eg, bedwetting,

thumb sucking)

	 •	 sleeping difficulty (eg, nightmares, difficulty

sleeping alone)

	 •	 increasing occurrence of usual fears (eg, the

dark, monsters)

	 •	 magical thinking, believing the person willreappear

	 •	 acting and talking as if the person is not sick or

is still alive

Younger school-age children (ages 6–9):

	 •	 reacting in anger, lying, bullying

	 •	 denying

	 •	 acting irritably

	 •	 blaming self

	 •	 fluctuating moods

	 •	 fearing separation, being alone, or experiencing

recurring events

	 •	 withdrawing

	 •	 regressing to earlier behavior

	 •	 having physical complaints (eg, stomachaches,

headaches)

	 •	 experiencing school problems (eg, avoidance,

academic difficulty, difficulty concentrating)

Middle-school children (ages 9–12)

	 •	 crying

	 •	 longing for someone who has died

	 •	 acting aggressively, irritably, bullying

	 •	 experiencing resentment

	 •	 experiencing sadness, isolation, withdrawal

	 •	 having fears, anxiety, pain

	 •	 suppressing emotions, denial, avoidance

	 •	 blaming self, guilt

	 •	 sleeping disturbance

	 •	 worrying about physical health and having

physical complaints

	 •	 declining academic success, discipline, attendance, memory

	 •	 thinking and talking repetitively

	 •	 expressing ‘‘hysterical” concerns and need to

help

Early teens and adolescents (ages 13–18):

	 •	 experiencing resentment, loss of trust

	 •	 feeling guilt, shame

	 •	 experiencing depression, having suicidal

thoughts

	 •	 distancing, withdrawal, panic

	 •	 swinging moods, irritability

	 •	 experiencing anxiety, panic, dissociation

	 •	 experiencing anger

	 •	 involving self

	 •	 exaggerating euphoria

	 •	 acting out (engaging in risky, antisocial, or illegal behavior)

	 •	 using substances

	 •	 fearing similar events, illness, death, the future

	 •	 changing appetite and sleep patterns

	 •	 experiencing physical complaints or changes

	 •	 declining academics, refusing to go to school

traumatic loss or death of a parent under other circumstances. The distinction is important to understanding 

how the death and loss of a loved one is further exacerbated by the subsequent social, educational, and 

financial changes that the military family experiences 

as isolation from a known life style and disruption of 

daily routines.11

Typically, the family is young; a social change occurs from military family to civilian family; the family 

moves; and the financial benefits are limited. Family 

moves likely lead to changes in communities, schools, 

peer groups, and activities. Thus, the family’s changes 
549

The Families and Children of Fallen Military Service Members

can limit the children’s support systems. Such transitions can be extremely challenging to both children 

and surviving parents. These transitions can, in some 

ways, become the most complicating elements of the 

death for children.

In a briefing for care team training, Chaplain James 

Ellison of Fort Carson asks the trainees to think about 

how many times they have experienced the death of 

an immediate family member and to reflect on the 

types of life-changing experiences that resulted. He 

then discusses how children who have experienced 

the death of a parent have a “life-changing experience” 

on three levels:

1. the loss of the parent,

2. the loss of the same relationship with the 

surviving parent, and

3. the loss of a sense of the family system.

Children and Military Funerals

Military traditions and rituals follow the death of 

a service member from the arrival of the uniformed 

death notification team through graveside military 

honors. Family members can decide to what degree 

they will incorporate military tradition into their 

mourning process. Many children and families find 

military ceremonies comforting; others do not. The 

military funeral tradition is long, rich, and includes 

activities and rituals that may evoke a variety of reactions. Children may have varying levels of information 

about the nature of death, and the family funeral may 

be the child’s first exposure to funeral ceremonies. 

Caskets, military uniforms, the firing of weapons, and 

the folding of flags can all spark curiosity, interest, 

and sometimes confusion and fear as well. Helping 

children prepare for and understand these events also 

helps them integrate the complex and emotionally 

charged experience of a military family funeral. 

Although funerals are a time of family pain, they 

are also a time of family gathering. Contact with other 

family members and close friends before, during, and 

after the ceremony can be reassuring to children and 

demonstrate that sadness does not need to be borne 

alone. Children and family members may choose to 

express pride for the life of the deceased, reminisce 

about shared experiences, or say nothing at all. Children particularly value the power of storytelling. 

Stories evoking positive memories of the deceased can 

be especially helpful.

It is best to allow children to establish their own 

levels of comfort and involvement in funeral services. 

Gentle adult reassurance can be very helpful. However, 

it is inadvisable to force children to attend viewings 

or funeral services when they demonstrate significant 

discomfort in these situations. If the family chooses an 

open casket viewing, children may or may not want to 

view the deceased. They should never feel compelled 

to approach or touch the body, nor should they be 

forbidden to come near the casket if they wish. When 

children choose to move closer, adults should monitor 

younger children, calmly comfort them if necessary, 

and answer any questions they might have. When 

properly prepared, most children will feel at ease 

participating in the funeral service. 

Children should be allowed to behave like children.

Their participation and activities during the funeral 

service may vary depending on age. Older children 

may appear uninterested or bored during the ceremony, but they may actually be trying to observe 

and integrate what they are experiencing. Some young 

children may appear to be uninvolved or run around 

and cause disruptions. Their activity may be the 

healthy expression of normal childhood behavior or a 

manifestation of their own anxiety. Disruptive, unruly, 

and disrespectful behaviors are likely to be signs that 

children are overwhelmed and would benefit by taking 

a quiet break away from activities. A funeral is typically 

not the appropriate time to discipline children. 

Traumatic Grief

Death within a family is always a painful experience. Like families of police officers and firefighters, 

military families are aware of the inherent risks of 

serving in harm’s way. Nevertheless, military deaths 

are painful and typically sudden and unexpected. 

Combat, combat-related, and training deaths, which 

are all forms of sudden traumatic death, are especially hard on military (families) widows. These deaths 

often cause significant damage to the body, often

making it non-viewable or non-recoverable.12(p50)

Traumatic deaths are distinct from anticipated 

deaths, and their effect on spouses, families, children, 

and communities may be profound. The following are 

general characteristics of traumatic deaths:

	 •	 can occur without warning, providing no

opportunity to anticipate, prepare, or say 

goodbye;

	 •	 can be untimely, including the death of one’s

child at any age;

	 •	 can occur as the consequence of violence and

can result in violent harm to the body;

	 •	 can include more than one person; and

	 •	 can be the result of the willful misconduct of

others, such as carelessness or negligence.
550

Combat and Operational Behavioral Health

Many individuals experience the sudden traumatic 

loss of a loved one at some point in their lives. Such 

losses can be complicated for adults and children to 

integrate. Communities often share these traumatic 

losses and experiences.

Traumatic grief symptoms may occur following 

a sudden traumatic loss. In contrast to normal grief, 

traumatic grief symptoms may include feelings of 

horror and anxiety; other feelings may be emotional 

numbness and a sense of disconnection. Some people 

cannot remember significant parts of what happened; 

others are plagued by memories or a sensation that 

they are reexperiencing or reliving the event through 

painful flashbacks. Traumatic deaths often cause extreme distress that can interfere significantly with daily 

functions over an extended period of time.

Those suffering traumatic loss may develop symptoms of posttraumatic stress disorder (PTSD). PTSD is 

diagnosed when the following three symptom clusters 

are present: (1) reexperiencing of the traumatic event 

as indicated by painful, intrusive thoughts or avoidance indicated by marked efforts to stay away from 

activities, places, or things related to the loved one’s 

death; (2) emotional numbing, as indicated by feeling detached from others; and (3) difficulty sleeping, 

irritability, difficulty concentrating, and a tendency 

to become startled easily and detached from others. 

Even if full criteria for a diagnosis of PTSD are not met, 

individuals can suffer from symptoms caused by the 

loss, such as self-blame and guilt. People may imagine 

ways they could have or should have prevented this 

loss from occurring or ways they could have rescued 

the person, and they may experience guilt about events 

that occurred prior to the death.

Traumatic losses often threaten the survivor’s sense 

of personal safety, security, and ability to trust others. 

Accepting the reality of the sudden traumatic loss can 

take a significant amount of time. Survivors may know 

intellectually that their loved one is dead but may find 

themselves expecting the loved one to walk through 

the door or call on the telephone. Parting with a loved 

one’s possessions can be difficult. It may be especially 

disturbing when a loved one’s body is not recovered. 

Sudden traumatic losses often raise existential and 

spiritual issues, such an inability to make sense of the 

loss or a feeling of betrayal by God.13

For some children, the extent of emotional response 

may be similarly extreme, or they may have difficulty 

grieving in a healthy fashion. Some bereaved military 

children may reexperience the death through nightmares, troubling memories, or repetitive play. They 

may avoid being reminded of the person who died 

or may continue to demonstrate profound sadness 

or inconsolable anxiety long after the death. In such 

circumstances a child may demonstrate symptoms of 

traumatic grief, which requires professional evaluation and treatment. When adults are concerned that a 

child is struggling to adjust to the death, they should 

speak with the child’s pediatrician and seek referral 

to a child and adolescent psychiatrist, psychologist, or 

other mental healthcare provider. Such conditions are 

treatable but could worsen if left untreated.

Support Services and Organizations

Multiple community and healthcare services are 

available in military and civilian communities around 

the country to meet the needs of families that have 

lost a member during service. Several organizations 

now exist to provide support to military widows and 

widowers as well as military children who have lost 

parents. Gold Star Wives of America is an organization 

of military widows and widowers whose spouses have 

died while on active duty or from service-connected 

disabilities. This organization has been serving war 

widows and widowers from all conflicts and serviceconnected disabilities since its founding in 1945. 

The Tragedy Assistance Program for Survivors 

(TAPS) also provides a support network for the surviving families of those who have died in service. TAPS 

sponsors an annual children’s camp in Washington, 

DC, which provides 

multiple group and individual activities to assist 

the children in expressing feelings that may not be 

appreciated by others who cannot relate to their experience. The camp has normal social and outdoors 

activities to promote peer support and in addition 

to group sessions that allow the children to do important processing and grieving . . . there is (also) a 

program enabling the surviving spouses to do similar therapeutic work with other spouses, while the 

children are engaged in their camp.13(p273)

Several other organizations have developed programs to assist military children with the trauma, grief, 

and loss from their parent’s combat death, injury, or 

illness. More information about the National Military 

Family Association, Zero to Three’s Coming Together 

Around Military Families program, and the Military 

Child Education Coalition’s Living in the New Normal 

initiative, as well as other resources are provided in the 

attachment to this chapter.

Uncomplicated grief is often managed within 

families, communities, or groups of friends. Widowed 

spouses and children may find benefit in joining therapeutic or self-help groups that focus on grief. Typically, 

such groups include other grieving individuals and 

allow an opportunity for adults and children to interact 
551

The Families and Children of Fallen Military Service Members

with others who have had similar experiences. Grief 

counselors, chaplains, mental health providers, or peer 

facilitators may lead these groups. For some adults 

and children, individual grief counseling sessions may 

be more comfortable. Again, counselors, chaplains, 

mental health providers, or other professionals may 

provide these services. Military OneSource is also an 

important resource for identifying community services 

for families.

When symptoms of traumatic grief, PTSD, or 

depression are present, or when health risk behaviors such as increased alcohol use develop, referral 

to competent mental health treatment is necessary. 

Psychiatrists, psychologists, social workers, and counselors provide mental healthcare in military medical 

treatment facilities, through local community mental 

health services, and by participating TRICARE civilian healthcare professionals. However, the recent 

Department of Defense Task Force on Mental Health 

has identified multiple barriers that can block access 

of bereaved military family members to appropriate 

care.14 Widowed spouses and children should be encouraged to advocate for their own needs in finding 

resources. Primary care providers, chaplains, and 

community service professionals can all assist in this 

goal. Health and community professionals can also 

assist families who avoid mental healthcare because 

of the associated stigma.

Changes in cultural status of bereaved families can 

cause them to feel simultaneously disconnected from 

the military community and not yet comfortable in the 

civilian community into which they are transitioning. 

As stated in Military Widow: A Survival Guide, bereaved 

spouses may feel that 

even though you remain a military dependent, your 

status within the military has changed. You are a 

dependent without a living spouse. You are no longer affiliated with a particular command or unit. . . .

The unspoken lack of acceptance of, or comfort with, 

widows in the military infrastructure is a key aspect 

of what contributes to military grief complex.12(p108)

Such experiences can complicate the families’ ability 

to connect with needed mental health services.

SPECIAL CIRCUMSTANCES

Death, Illness, or Injury of a Leader

Emotions run high in a unit when a leader is killed. 

Somehow no one expects the leader to be vulnerable. Because the leader’s spouse is usually the one 

helping others, knowing how to help the spouse is 

often hard for the unit. Also, the leader’s spouse may 

find accepting help from the unit difficult. When a 

leader dies, the unit has suddenly lost its direction 

for the active duty members as well as their family 

members, creating a significant change in everyone’s 

life. Being aware of this effect can help the unit cope 

with the loss.

Suicide

For surviving family members dealing with the 

aftermath of a suicide, the grieving process can be 

compounded by feelings of failure, shame, and guilt. 

Public scrutiny and military inquiry into the nature of 

the death can complicate a family’s normal grieving. 

In such circumstances, families may be uncomfortable 

about using military or family traditions in honoring 

the dead. Because adults may be hesitant to share 

information with children (even information that is 

appropriate and could be helpful), children may be 

particularly vulnerable to problems integrating the 

death. Often children have an awareness of the nature 

of the death but are met with silence when they ask 

questions. Being sensitive to the unique nature of the 

child’s loss will better enable a caregiver to provide 

comfort and support. 

Missing in Action and Prisoners of War

Families of service members who are missing in 

action or prisoners of war are forced to deal with the 

uncertainty of the status of their loved one. The suffering that might have to be endured for an indefinite 

period of time exacerbates this highly emotional and 

painful ordeal. Providing ongoing emotional, spiritual, 

and logistical support to the families of these service 

members presents a unique challenge. It should be 

kept in mind that each family’s needs and wants will 

reflect its particular situation; families should be encouraged to ask for the type and amount of assistance 

they prefer.

Mass Casualties 

Multiple injuries or deaths are certainly one of the 

most difficult situations a military unit might face. 

When multiple tragedies occur at the same time, the 

affected surviving families share a unique bond. After 

a few days or even weeks, they may be interested in 

getting connected with each other. Even when tragedies occur at the same time, no two families manage 

the events exactly the same. 
552

Combat and Operational Behavioral Health

Death of a Spouse or Child

In many instances military units adopt the cohesive 

characteristics and nurturing tendencies of a family. 

When trauma occurs within a unit, the potential for impact on many or all members of the “unit family” can 

be far reaching, especially in the case of the death of an 

active duty service member’s spouse or child. The loss 

of a spouse or child in any circumstance is traumatic, 

but when it occurs within the close-knit atmosphere 

of a military unit, the effects can be compounded. But 

the same circumstances that make this loss so painful 

for a unit are the very sources for rallying support, 

providing comfort, and creating a healing environment 

for those left behind.

Media

Americans are particularly proud and interested in 

the lives of their servicemen and women. Today news 

coverage is instantaneous to audiences throughout the 

world. Whenever a service member is killed or injured, 

Americans want to know the “who, what, when, where, 

and why” of the incident, and the media is eager to 

report it. Embedded reporters may provide immediate 

coverage of the spouse’s deployed unit, and fatalities 

may become special reports on the evening news. With 

the presence of cellular and satellite phones, it is possible for the news of the death of a service member to 

bypass the normal channels of notification.

In the most stressful hours of coping with trauma 

in the unit, the media may approach family members 

for a formal interview, an informal comment, or a gut 

reaction. Mentoring the affected family members by 

encouraging them to use the public affairs office for 

any media interaction is beneficial. Contacting the 

command whenever the media approaches a unit’s 

family member is also advisable. 

SUMMARY

The families and children of service members who 

die in the line of duty face profound challenges. Most 

military families are by nature healthy and resilient, 

and most can be expected to transition through a 

period of grieving to a new state of health within the 

civilian communities to which they move. However, 

all grieving families can benefit from community 

resources. Professionals need to be mindful of the 

expected reactions of adults and children as they 

traverse healthy grieving. As this chapter highlights, 

impediments to healthy resolution can occur when 

symptoms of traumatic grief, PTSD, depression, or 

health-risk behaviors develop. Professionals must 

also remember that children who lose a parent are at 

added risk for developing behavioral problems, in 

comparison to their nongrieving peers. Awareness 

of developmental differences in children of all ages 

can be instructive in understanding when children 

are adjusting well and when they could benefit from 

additional help.

REFERENCES

1. US Department of Defense. 1st Quadrennial Quality of Life Review. Washington, DC: DoD; 2004.

2. US Department of the Army. A Guide for the Survivors of Deceased Army Members. Washington, DC: DA; 1989. DA Pamphlet 608-4.

3. US Department of the Army. Army Casualty Program. Washington, DC: DA; 2007. Army Regulation 600-8-1.

4. Ender MG, Bartone PT, Kolditz TA. Fallen soldiers: death and the US military. In: Bryant CD, ed. Handbook of Death 

and Dying. Thousand Oaks, Calif: Sage; 2003: 544–555. 

5. Michael Wardlaw, Casualty Assistance Director, US Navy. Measuring Customer Satisfaction for Navy Casualty Assistance 

Calls Program (CACP). Unpublished research proposal; data are from casualty assistance call officers’ surveys, 2003. 

	 6.	 National Defense Authorization Act. 10 USC §1475. Available at: http://uscode.house.gov/download/pls/10C75.

txt. Accessed March 25, 2011. 

7. Army War College Spouses’ Project. A Leaders Guide to Trauma in the Unit. Carlisle Barracks, Penn: Army War College; 2004: 6. Available at: http://www.carlisle.army.mil/usawc/dclm/docs/traumapdf.pdf.Accessed December 12,

2009.

8. Roy C. Care Team Smart Book [unpublished manual]. Fort Carson, Colo: Family Readiness Center; 2005.
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9. Deb Busch, founder of Helping Unite Gold Star Survivors at Fort Hood, Texas. Personal communication, December 

13, 2007.

10. Tremblay GC, Israel AC. Children’s adjustment to parental death. Clin Psychol: Sci Pract. 1998;5:424–438.

11. Katler N, Lohnes K, Chasin J, et al. The adjustment of parentally bereaved children: factors associated with short-term 

adjustment. Omega: J Death Dying. 2002–2003;46(1):15–34.

12. Steen JM, Asaro MR. Military Widow: A Survival Guide. Annapolis, Md: Naval Institute Press; 2006.

13. Hardaway T. Treatment of psychological trauma in children of military families. In: Webb NB, ed. Mass Trauma and 

Violence: Helping Families and Children Cope. New York, NY: Guildford Press; 2004: 259–282.

14. Department of Defense Task Force on Mental Health. An Achievable Vision: Report of the Department of Defense Task Force 

on Mental Health. Falls Church, Va: Defense Health Board; 2007. Available at: http://www.health.mil/dhb/mhtf/

MHTF-Report-Final.pdf. Accessed November 5, 2009.
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ATTACHMENT: RESOURCES FOR FAMILIES OF DECEASED SERVICE MEMBERS

Organizations and Programs

The Arlington National Cemetery Commemorative Project 

In 2009, the Arlington National Cemetery Commemorative Project, in partnership with Rich Clarkson and 

Associates and the National Geographic Society, produced For Children of Valor: Arlington National Cemetery.

This volume is a special commemorative gift book for children who since September 11, 2001, have lost close 

loved ones who were on active duty and are now buried at Arlington National Cemetery. For Children of Valor

was written to help these children understand and process their grief. The book also includes a resource guide 

for parents.

Military OneSource 

Military OneSource is a service provided by the Department of Defense at no cost to active duty, National 

Guard, and reserve service members and their families. Military OneSource is available by phone, online, and 

face-to-face through private counseling sessions in the local community. Its highly qualified consultants provide 

assistance with childcare, personal finances, emotional support during deployments, relocation information, and 

resources needed for special circumstances. Assistance includes personalized consultations on specific issues 

such as education, special needs, and finances, as well as customized research detailing community resources and 

appropriate military referrals. Available at: http://www.militaryonesource.com. Accessed August 19, 2009.

TRICARE 

TRICARE is the healthcare program serving active duty service members, National Guard and reserve 

members, retirees, their families, and survivors worldwide. As a major component of the military healthcare 

system, TRICARE brings together the healthcare resources of the uniformed services and supplements them 

with networks of civilian healthcare professionals, institutions, pharmacies, and suppliers to provide access to 

high-quality healthcare services while maintaining the capability to support military operations. Available at:

http://www.tricare.mil. Accessed August 19, 2009.

Military Homefront

Military life comes with unique challenges, from shopping at the commissary to moving to foreign lands. 

Having trusted information on how to deal with these challenges can make the difference between stress and 

success. Military Homefront provides accurate and up-to-date information about Department of Defense programs serving troops and theirfamilies.Available at: http://www.militaryhomefront.dod.mil.AccessedAugust

19, 2009. 

The Military Child Education Coalition’s Living in the New Normal Initiative

Sparked by concerns about military children dealing with illness, injury, or death of a parent, the Living in 

the New Normal (LINN): Helping Children Thrive in Good and Challenging Times initiative was developed by 

the Military Child Education Coalition (MCEC) through collaboration with experts in the fields of trauma and 

grief, resiliency, healthcare, and child development. LINN encourages families to ensure that their children have 

the tools to weather life’s storms, fosters home-front efforts to support military children, and provides educators 

and other concerned adults with information to help them support children during times of uncertainty, trauma, 

and grief. LINN’s efforts are predicated on the belief that children are courageous and resilient and that these 

skills can be strengthened through deliberate encouragement by the adults in their lives. Available at: http://

www.militarychild.org/linn.asp. Accessed August 19, 2009.
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National Military Family Association

The National Military Family Association is dedicated to providing information to and representing the 

interests of family members of the uniformed services. Its Web site provides extensive information for military 

families and support service staff. The association publishes a monthly newsletter as well as a weekly legislative e-mail newsletter, the Government and You E-News. Available at: http://www.nmfa.org. Accessed August

19, 2009.

Zero to Three’s Coming Together Around Military Families Initiative 

The nonprofit Zero to Three organization’s Coming Together Around Military Families initiative increases 

awareness of the impact of trauma, grief, and loss on very young children through specialized training and 

support for the professionals who are supporting military families in and around military installations with 

high deployment rates. Of primary focus are the special circumstances of families that experience trauma and 

loss as a result of a service member’s deployment.Available at: http://www.zerotothree.org/military.Accessed

August 19, 2009.

Tragedy Assistance Program for Survivors

The Tragedy Assistance Program for Survivors (TAPS) was founded in the wake of a military tragedy in which 

surviving family members realized that the tragedy they shared, losing a loved one in the line of military duty, 

was far different from other types of losses. These families shared pride in their spouses’ service to America as 

well as tremendous sadness at the ultimate sacrifice their loved ones made. TAPS has experienced, empathetic 

caseworkers who act as liaisons with federal, state, and private agencies in helping family members find solutions to problems. Available at: http://www.taps.org. Accessed August 19, 2009.

Gold Star Wives of America

Founded in 1945, Gold Star Wives of America Inc is an organization of military widows and widowers whose 

spouses died while on active duty or from service-connected disabilities. Gold Star Wives received a federal 

charter from Congress on December 4, 1980. Available at: http://www.goldstarwives.org. Accessed August 19,

2009.

Uniformed Services University of the Health Sciences Center for the Study of Traumatic Stress 

The Center for the Study of Traumatic Stress conducts research, education, consultation, and training on preparing for and responding to the psychological effects and health consequences of traumatic events, including 

natural (hurricanes, floods, and tsunamis) and human-made disasters (motor vehicle and plane crashes, war, 

terrorism, and bioterrorism). The center’s work spans studies of genetic vulnerability to stress, individual and 

community responses to terrorism, and policy recommendations to help the nation and its military and civilian 

populations. Available at: http://www.centerforthestudyoftraumaticstress.org. Accessed August 19, 2009.

The National Child Traumatic Stress Network

Established by Congress in 2000, the National Child Traumatic Stress Network is a unique collaboration of 

academic and community-based service centers whose mission is to raise the standard of care and increase access to services for traumatized children and their families across the United States. Combining knowledge of 

child development, expertise in the full range of child traumatic experiences, and attention to cultural perspectives, the network serves as a national resource for developing and disseminating evidence-based interventions, 

trauma-informed services, and public and professional education.Available at: http://www.nctsn.org.Accessed

August 19, 2009. 
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American Academy of Child and Adolescent Psychiatry 

Established in 1953, the American Academy of Child and Adolescent Psychiatry is the leading national professional medical association dedicated to treating and improving the quality of life for children, adolescents, 

and families affected by mental disorders. The academy is a membership-based organization composed of over 

7,500 child and adolescent psychiatrists and other interested physicians. Its members actively research, evaluate, diagnose, and treat psychiatric disorders, giving direction and responding quickly to new developments 

in addressing the healthcare needs of children and their families. The academy widely distributes information 

in a effort to promote understanding of mental illnesses and remove the stigma associated with them, advance 

efforts in prevention of mental illnesses, and assure proper treatment and access to services for children and 

adolescents. Available at: http://www.aacap.org. Accessed August 19, 2009.

American Academy of Pediatrics 

The American Academy of Pediatrics is an organization of 60,000 pediatricians committed to the attainment 

of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young 

adults. Its uniformed services section was founded in 1959 with a mission to improve the health of infants, children, adolescents, and young adults served by medical providers in the US Army, Navy, Air Force, and public 

health agencies. The section provides unique educational forums to address the global issues of military pediatric 

providers. Available at: http://www.aap.org. Accessed August 19, 2009.

Suggested Literature and Resources Guide from the Military Child Education Coalition 

The MCEC recommends the use of these books by children experiencing and coping with trauma, grief, and 

loss only with direct parental supervision or guidance and support from other caring adults. This list was compiled by a committee of MCEC advisors representing various perspectives: psychologists, educators, military 

families, grief specialists, and professional developers, and is reproduced here with permission from the MCEC. 

The statements included in this list are opinions based on the MCEC perspective and guiding principles and are 

not intended to be a comprehensive review of the literature, but rather a guide.

Early Elementary Level

	 •	 A Bunch of Balloons, by Dorothy Ferguson.

 Synopsis: Author discusses loss and grief by introducing a story about a little child who loses a balloon. 

The author then introduces the topic of death and grief and leads the reader through activities using 

balloons to capture what is lost and what remains in the grieving child’s life. The goal is to help grieving 

children acknowledge what they have lost and celebrate what they still have left when someone they 

love has died. 

	 •	 I Had a Friend Named Peter: Talking to Children About the Death of a Friend, by Janice Cohn.

 Synopsis: A young child learns of the sudden death of her school friend, Peter, who was accidentally hit 

by a car while chasing a ball. Excellent introduction helps adults understand the many questions children 

pose following the death of a loved one. Addresses dying, funerals, and burial in direct language. Also 

has a school setting with teacher and classroom. Picture book. 

 Teachable moments: Have child talk about memories of the deceased—the likes and dislikes of the 

person. For sudden death situations, ask children how they would say goodbye to the person.

	 •	 A Good Day, by Kevin Henkes.

 Synopsis: Four little creatures encounter dilemmas in their day. Using their circumstances, relatable to 

the young child, this story presents a simple message of reassurance in times of sadness, disappointment 

and challenge. This book encourages hope and resilience and invites discussion with children regarding 

their own situations.

	 •	 Ragtail Remembers—A Story That Helps Children Understand Feelings of Guilt, by Liz Duckworth.

 Synopsis: The death of an old cat who was a playful companion and good friend of the storyteller, a 
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mouse named Ragtail. The language is clear and direct, which lends to the open discussion of feelings 

and emotions that are experienced when there is a death and loss. It demonstrates the importance of 

friends, the help rendered by a wise bluejay that acts as a faithful guide and teacher and becomes a new 

friend and playmate of the mouse. It is also about honoring and remembering in death.

	 •	 The Fall of Freddie the Leaf, by Leo Bascaglia.

 Synopsis: Freddie learns about the cycle of life from his fellow leaf friend, Daniel. Freddie comments 

on his experience regarding his mentor’s death and then his own death. 

 Caution: ensure child understands that death is not sleeping, but is permanent. 

	 •	 The Wall, by Eve Bunting.

 Synopsis: In this moving picture book, a little boy and his father visit the Vietnam Veterans Memorial 

(“The Wall”) to find the name of the boy’s grandfather. They notice details: items left in remembrance, 

the uniformity of the engraved lettering, a veteran who is an amputee, and more. Together they make 

a rubbing of the name, which is a popular tradition. 

	 •	 When Dinosaurs Die: A Guide to Understanding Death, by Marc Brown and Laurie Krasney.

 Synopsis: Uses dinosaurs to explain in simple language the feelings people may have regarding death 

of a loved one and ways to honor the memory of someone who has died. Does not tell a story; addresses 

fears, curiosity, customs, and acknowledges military death and war.

 Caution: Some may take offense that the death of a pet is represented as equal to the death of a person. 

 Teachable moments: Dinosaurs are extinct (this can cause a whole separate discussion). Look closely at 

the drawings for details related to the children’s questions in the book.

Mid-Elementary Level

	 •	 Everett Anderson’s Goodbye, by Lucille Clifton.

 Synopsis: Written in verse and beautifully illustrated with charcoal line drawings, this book features a 

young African-American boy whose father has died. The theory of stages of grief is presented through 

the eyes of the young boy and his profound loss. Theories differ in describing grief as stages, phases, 

or processes. Stages imply a linear progression. Current research emphasizes grief as a process with 

phases that individuals may experience at different times. 

	 •	 Geranium Morning, by Sandy Powell.

 Synopsis: Two elementary-aged kids, a boy and a girl, each lose a parent, a father and a mother, respectively. The father dies suddenly in an accident and the mother dies from illness. The children help each 

other deal with their grief; story expresses the value of shared experience as the root of recovery. 

 Teachable moments: Talk about the benefit of sharing a new friendship with someone who has had a 

similar experience. 

 Note: This book is out of print, but used copies may be available online. 

	 •	 I Don’t Have an Uncle Phil Anymore, by Marjorie Pellegrino.

 Synopsis: When a young boy’s uncle dies, he must board a plane and fly to the funeral. He recalls the 

fun times he had with his Uncle Phil and how he used to play and do special things with his Uncle Phil 

and his cousin. He worries about his cousin and aunt and who will play with his uncle now. The boy 

witnesses the support of his uncle’s fellow firefighters when the funeral procession passes the firehouse. 

The boy calls this a sad parade. The boy hugs his cousin Jenny and comforts her when she exclaims 

while playing blocks, “I don’t have a daddy anymore.”

	 •	 I Miss You—A First Look at Death, by Pat Thomas.

 Synopsis: The story uses language that is gentle, simple, clear, and straightforward, directed to a little 

girl. It explains death as a natural part of life, that after death, the body stops working. It discusses the 

funeral and provides an excellent discussion of the variation in cultural practices and beliefs regarding 

death. The question, “What about you?” that appears at the bottom of several pages stimulates discussion of questions a child may have about death, feelings and emotions a child may experience, and the 
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difficulty of understanding. There are suggestions for how to use the book at the end that are useful 

and instructive. A list of suggested books and resources is provided; the glossary is rather brief. 

 Caution: On page 23, one line, “the souls of other people who have passed away,” is unusual because 

otherwise very factual and realistic text is used throughout the story. 

	 •	 Memory String, by Eve Bunting.

 Synopsis: A young girl’s mother dies and her stepmother helps her remember the love they shared using buttons as mementos. Highlights stepmother relationship as helpful. 

 Teachable moments: Gather buttons—including military buttons or insignia—to make a memory string. 

Discuss the meaning of each button and why it holds that meaning.

	 •	 The Hero in My Pocket, by Marlene Lee.

 Synopsis: A brother and sister, ages 10 and 7, experience the loss of their father who died serving in the 

US military. The children progress through the grief process and positive recovery is encouraged. 

 Teachable moments: Children can write or draw their part of the story on “Hero Pages” in the book to 

give voice to their thoughts and feelings. Discuss keepsake memento child may have (or want) of the 

deceased (95% of children have a keepsake object [transitional linking object] from a deceased parent 

that they keep in their rooms). Gather “remember letters” or have class write “remember letters.”

	 •	 What Does That Mean? A Dictionary of Death, Dying and Grief Terms for Grieving Children and Those Who

Love Them, by Harold Smith and Joy Johnson.

 Synopsis: More of an encyclopedia than a dictionary, the clever format of word, pronunciation, definition and example or quotes, sometimes from known literature, could be a good, objective classroom 

resource. 

	 •	 Owen & Mzee, by Isabella Hatkoff, Craig Hatkoff, and Paula Kahumbu.

 Synopsis: This is the tale of a baby hippo named Owen and his friend Mzee, a 130-year-old giant tortoise. 

Owen is a survivor and an orphan as a result of the December 2004 tsunami in Southeast Asia. This 

profound true story offers a potent reminder that even in the face of tragedy, the power of friendship 

endures—and that our most important friends are sometimes those we least expect. A true demonstration of resilience and living in a “new normal.” 

	 •	 Annie Loses Her Leg but Finds Her Way, by Sandra J Philipson and Robert Takatch.

 Synopsis: Based on an actual incident, this is both a poignant and funny story of a 9-year-old English 

springer spaniel who loses her front leg to cancer. Two children, Annie and her high-spirited brother, 

Max, experience her illness and recovery in very different ways. Max is in denial, and Annie is in a state 

of sad acceptance. This is a book about love, loss, friendship, and optimism. 

Elementary and Early Teen Level

	 •	 A Taste of Blackberries, by Doris Buchanan Smith.

 Synopsis: Two ’tween boys, best friends, “planned to have fun all summer,” but one boy dies suddenly. 

Novel follows range of thoughts, emotions, and actions of surviving best friend. 

	 •	 Coping With Death and Grief, by Marge Eaton Heegaard.

 Synopsis: Eight vignettes about the death of a person and the children affected. Several different kinds 

of death and relationships are illustrated in easy-to-read format, followed by factual discussion points 

about grief, changes in relationship, realities of day-to-dayness, and many other aspects. References 

military funerals, playing “Taps,” and much discussion about school settings, including death discussed 

in the classroom. 

 Teachable moments: Discuss the concept of grief as a fact, a normal aspect of the human condition. 

Discuss how the relationship to someone is a primary factor in one’s experience with grief. 

	 •	 How It Feels When a Parent Dies, by Jill Krementz.

 Synopsis: Eighteen kids, boys and girls ages 7 to 16, wrote personal essays about their experiences and 

feelings about the death of their parent. Different types of loss are represented, as are a range of normal 

feelings: anguish, guilt, confusion, anger, as well as the children’s lives since the death. 
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 Teachable moments: Discuss how book shows that grief reactions and responses are as individual as 

people. With teenagers, discuss aspects that make it individual (age at time of death, family composition, type of death). 

	 •	 Part of Me Died, Too: Stories of Creative Survival Among Bereaved Children and Teenagers, by Virginia Lynn 

Fry.

 Synopsis: First-person stories by kids of different ages who experienced loved ones’ deaths (father, 

mother, friend, other relative) from different means (sudden death, lingering illness, and suicide). They 

describe their reactions and effects. Table of contents lists type of death and ages of kids so reader can 

go right to the section. In the epilogue the kids reflect on their original writings and talk about how they 

are now. Also lists follow-on reading suggestions. 

 Teachable moments: Discuss how the book shows that grief reactions and responses are as unique as 

individuals. With teenagers, discuss aspects that make it individual (age at time of death, family composition, type of death). 

	 •	 What We Do When Someone Dies, by Caroline Arnold.

 Synopsis: Fact-based book that explains vocabulary related to someone dying and afterwards (obituaries, 

funeral service, etc). Ranges from concept that all living things must die to what happens to the body, 

funeral ceremonies, and afterwards. Acknowledgment of multicultural beliefs and customs. Acknowledges that people die in war. Discusses Memorial Day and Arlington National Cemetery. 

 Teachable moments: Discuss military-related traditions (“Taps,” veterans’ cemeteries, flags, etc). Discuss how having facts helps alleviate some of the fear associated with the difficult topic of death (fear 

of the unknown, fear of taboo topic, etc). Further discussion on respecting culture and traditions of 

different religions and nationalities, and allow child to choose topics to discuss further since book is 

fact-based.

Teen Level

	 •	 Fire in My Heart, Ice in My Veins—A Journal for Teenagers Experiencing Loss, by Enid Samuel Traisman.

 Synopsis: A workbook that allows teens to describe their feelings and thoughts related to the death 

of someone they cared about. A brief statement appears at the top of the page, followed by several 

responses to encourage and focus their expressions in writing or drawings to remember and honor the 

one who died. The statements are very probing. This process allows teens to be open and candid about 

their feelings. 

 Teachable moment: Provides valuable discussion opportunities between caring adults and teens experiencing loss. 

	 •	 The Grieving Teen: A Guide for Teenagers and Their Friends, by Helen Fitzgerald.

 Synopsis: Written about and for teens, this guidebook covers a wide range of situations and topics—and 

suggestions—for grieving teens and those who care about them. Teen voices are heard throughout the 

book. Does not discuss death of service members but it does discuss secondary losses and complicating 

factors such as dealing with the press and sudden death. 

 Teachable moments: Discuss what kind of secondary losses or compounding factors someone may have 

experienced.

	 •	 The Healing Your Grieving Heart Journal for Teens, by Alan Wolfelt and Megan Wolfelt.

 Synopsis: Guided journal encourages teens to self-explore through self-expression. Designed as a companion book to Healing Your Grieving Heart for Teens: 100 Practical Ideas. Useful weeks, months, or even 

years following the death of a loved one. 

	 •	 When a Friend Dies: A Book for Teens about Grieving and Healing, by Marilyn Gootman.

	 	 Synopsis: The book is about acceptance and compassion. Focuses on answering teen/preteen questions

about death.

	 •	 You Are Not Alone: Teens Talk About Life After the Loss of a Parent, by Lynne Hughes.

 Synopsis: The author, Lynne Hughes, the founder of the Comfort Zone Camp for grieving children who 

have lost parents or siblings, personally experienced the death of her parents at an early age. The voices 
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of teens who have attended the camp provide illustrative insights into ways young people have dealt 

with loss. As the title suggests, teens are encouraged to seek help and to know that there are others who 

share feelings of immeasurable loss. 

	 •	 Finding My Way: A Teen’s Guide to Living With a Parent Who Has Experienced Trauma, by Michelle D Sherman and DeAnne Sherman.

 Synopsis: An interactive workbook format that offers teens practical tools and information about posttraumatic stress disorder and other responses to trauma. Clearly and concisely written, it encourages 

teens to address their own emotions and key issues in dealing with a parent who has experienced trauma. 

The gentle guide, using honest and concise language, offers valuable tools for coping, identifying social 

support networks, and dealing with friends. An extensive resource list, glossary, and frequently-askedquestions section completes this useful manual.

	 •	 Facing Change: Falling Apart and Coming Together Again in the Teen Years, by Donna O’Toole.

 Synopsis: Founded on the belief that young adults can make effective choices that can transform pain 

into resilience, the author provides an abundance of information and coping choices to assist the process. 

A book about loss, change, and possibilities. 

Adults—General

	 •	 Ambiguous Loss: Learning to Live With Unresolved Grief, by Pauline Boss.

 Synopsis: Offers insight into the meaning and impact of ambiguous loss and suggestions for coping. 

Author draws from her own research, including interviews with military spouses of service members 

who are missing in action or prisoners of war. Ambiguous Loss is applicable to families of those with 

traumatic injury or Alzheimer’s disease, or who are missing. 

	 •	 Helping Children Cope With the Loss of a Loved One: A Guide for Grownups, by William Kroen.

 Synopsis: Answers questions relative to developmental ages, uses vignettes along with practical and 

theoretical advice. 

	 •	 Life and Loss: A Guide to Help Grieving Children, by Linda Goldman.

 Synopsis: Tools, ideas, and inventories for educators and other community members to use in helping 

kids commemorate loss. Discusses different types of childhood losses and avoids clichés. Provides an 

example of a “community care team” concept to help the grieving child. 

	 •	 Raising Our Children to Be Resilient, by Linda Goldman.

 Synopsis: Resource for adults to understand how children experience traumatic events and empowering 

them to be resilient.

	 •	 Raising an Emotionally Healthy Child When a Parent Is Sick, by Paula K Rauch and Anna C Muriel. 

 Synopsis: A friendly and accessible guide to communicating with children about illness, death, and dying. Assists parents in understanding unique temperaments of individual children and practical advice 

and examples of how to establish and organize a family support system. 

	 •	 Military Widow, by Joanne M Steen and Regina Asaro.

 Synopsis: An insider’s perspective to understanding and surviving the death of a military service member, 

as well as implications for surviving dependents. Helpful blend of personal experiences and professional 

references and research. Addresses the unique aspects and challenges of military widowhood.

	 •	 Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment, by

Martin EP Seligman.

 Synopsis: “Positive psychology” is a new approach to psychology focusing on mental health rather than 

mental illness. Readers learn that happiness can be cultivated by identifying and using many of the 

strengths and traits that they already possess; their signature strengths. By calling upon these strengths 

in all the critical aspects of life, one develops buffers against misfortune and negative emotion. Break 

free from learned helplessness to learned optimism resulting in greater resilience.
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	 •	 A Parent’s Guideto Building Resiliencein Children and Teens: Giving Your Child Roots and Wings, by Kenneth 

R Ginsburg.

 Synopsis: This practical guide assists parents in showing their children how to be more resilient when 

facing compounding stressors by developing healthy coping strategies. Dr Ginsburg introduces parents 

to the seven “crucial Cs”: (1) competence, (2) confidence, (3) connection, (4) character, (5) contribution, 

(6) coping, and (7) control, and how they work together to help kids 18 months to 18 years bounce back 

from challenges and manage stress.

Adults—Educational Focus

	 •	 Grief Comes to Class: An Educator’s Guide, by Majel Gliko-Brado.

 Synopsis: Short, to-the-point guide, based on results of a study conducted through the College of Education at Montana State University to obtain perceptions and feelings about bereaved children. The views 

of teachers, parents, and the children are represented in the discussion of the environment, culture, individual personality, and circumstances. Examples of children’s experiences are interspersed throughout 

the text, especially helpful in the section on developmental changes among children of different ages, 

with special attention on teen grief. The “What You Can Do to Help” section offers sample letters and 

activities for the classroom, with a teacher/parent/student conference plan that can be modified and

personalized. 

	 •	 Helping Children Grieve & Grow—A Guide for Those Who Care, by Donna O’Toole.

 Synopsis: This booklet provides a useful, easily understood synopsis to help children to grieve and to 

grow. The format is functional in its arrangement of concise information with practical suggestions on 

understanding reactions and what to do to encourage the children. It speaks of resilience in children and 

offers resources available both nationally and locally. The language is compassionate and demonstrates 

that the writer has broad experience in the field.

Adults—Reference

	 •	 25 Things to Do: Activities to Help Children Suffering Loss or Change, by Laurie A Kanyer.

 Synopsis: Practical and simple activities to engage a child suffering a painful loss or change. A creative, 

sensitive, “Mr. Rogers”-like reference for parents and caregivers. Encompasses a broad range of loss 

topics children may encounter in their developmental years; from the loss of a pet, to the divorce of 

their parents, to the death of a loved one. 

	 •	 35 Ways to Help a Grieving Child, by the Dougy Center: The National Center for Grieving Children and 

Families.

 Synopsis: Drawn from stories, suggestions, and insight shared by children and their family members at 

the Dougy Center, this book explores behaviors and reactions of children at different ages and maturity 

levels; outlets for children to safely express their thoughts and feelings; and ways to be supportive during difficult times, such as a memorial service, anniversary, or holidays. 

	 •	 How to Go on Living When Someone You Love Dies, by Terese A Rando.

 Synopsis: Step-by-step guide for adults to talk about death with children of all ages to help understand 

what they think, how they feel, and what they comprehend. Directly addresses how adults can help, 

providing checklists, scripts, and quick reference information.

	 •	 How Do We Tell Children: Helping Children Understand and Cope When Someone Dies, by Dan Schaefer and 

Christine Lyons.

 Synopsis: Written by a former funeral home director who dealt with thousands of families, this book 

helps adults understand how to talk with children openly about death. Covers age range from 2 to 

teenager. Helpful for adults to understand what children can and cannot grasp at certain developmental 

stages. 

	 •	 Losing Parents to Death in the Early Years, by Alicia Lieberman.

 Synopsis: Written by one of the mostrespected professionals in the field of early trauma/loss, the author
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explains how vulnerable children can be given their immaturity. Addresses difficult issues that arise as 

a result of death due to military service or socially-stigmatized causes.

	 •	 Treating Trauma and Traumatic Grief in Children and Adolescents, by Judith Cohen.

 Synopsis: This book describes the state-of-the-art cognitive-behavioral therapies used in treating children 

who are exposed to trauma and traumatic death. While it is mainly targeted for therapists and clinicians 

who work with this population of children, it is also an excellent reference for others who would like 

to understand the most effective, evidence-based approaches to helping children and adolescents who 

suffer with trauma-related disorders. 
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Chapter 34

ESTABLISHING AN INTEGRATED 

BEHAVIORAL HEALTH SYSTEM OF 

CARE AT SCHOFIELD BARRACKS

MICHAEL E. FARAN, MD, PhD*; ALBERT Y. SAITO, MD†; EILEEN U. GODINEZ, PhD‡; WENDI M. WAITS, 

MD§; VICTORIA W. OLSON, MBA¥; CHRISTINE M. PIPER, APRN, BC¶; MARGARET A. McNULTY, DrPH**; 

and CHRISTOPHER G. IVANY, MD††

INTRODUCTION

EARLY EFFORTS 

SOLDIER AND FAMILY ASSISTANCE CENTER

Concept Development, Structural Framework, and Financing 

Recruitment, Advertising, and Implementation

Outcomes and Current Activities

SCHOOL-BASED MENTAL HEALTHCARE

Early History

Program Evaluation and Student Demographics

Future Directions

BEHAVIORAL HEALTH LIAISON PROJECT

Army Community Service Support for 2004–2005 Deployments

Predeployment Support 

Deployment Sustainment 

Redeployment and Reintegration

Lessons Learned

SUMMARY

*Colonel, US Army (Retired); Director, Child, Adolescent, and Family Behavior Health Proponency, Madigan Army Medical Center, Madigan Annex 

Building 9913A, Ramp 2, McKinnley Road, Tacoma, Washington 98431; formerly, Director, School Based Mental Health, Child and Adolescent Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii

†

Clinical Director, Child and Adolescent Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, 

Hawaii 96859-5000; formerly, Staff Psychiatrist, Department of Child Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii 

‡

Inspector General Chief, Inspections and Outreach Branch, US European Command, CMR 480, Box 1865, APO AE 09128; formerly, Chief, Plans 

Analysis and Integration Office, US Army Garrison, Hawaii

§

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry Service, Department of Psychiatry, 1 Jarrett White Road, Room 4B106, Tripler 

Army Medical Center, Hawaii 96859-5000; formerly, Child and Adolescent Psychiatry Fellow, Tripler Army Medical Center, Honolulu, Hawaii

¥

Executive Director, Hawai’i Army Museum Society, Post Office Box 8064, Honolulu, Hawaii 96830-0064

¶

Colonel, US Army (Retired); Coaching Trainer/Instructor, LivingWorks, Inc.; formerly, Chief, Soldier and Family Assistance Center, Schofield Barracks, Hawaii 

**Captain, US Navy (Retired); Assistant Professor, Department of Nursing, Kapiolani Community College, 4303 Diamond Head Road, Honolulu, 

Hawaii 96816

††Major, Medical Corps, US Army; Psychiatrist, Department of Behavioral Health, Evans Army Community Hospital, Building 7500, 1650 Cochrane 

Circle, Fort Carson, Colorado 80913; formerly, Division Psychiatrist, 4th Infantry Division, Fort Hood, Texas 
564

Combat and Operational Behavioral Health

INTRODUCTION

In 2003, members of four US combat infantry 

units (three Army units and one Marine Corps unit) 

participated in an anonymous mental health survey 

taken either before deployment or 3 to 4 months after 

their return.1 The percentage of soldiers and marines 

whose responses met the screening criteria for major 

depression, generalized anxiety, posttraumatic stress 

disorder (PTSD), or alcohol misuse was significantly 

higher after duty in Iraq (15.6%–17.1%) than after 

duty in Afghanistan (11.2%), particularly with regard to PTSD. The rates of PTSD are similar to those 

experienced in Vietnam, which led to large numbers 

of soldiers becoming disabled. Soldiers and marines 

whose responses were positive for a mental disorder 

were twice as likely to distrust mental health professionals, viewed seeing mental health practitioners 

as harmful to their career, and believed that mental 

healthcare does not work. The stigma of seeking help 

increased with the presence of mental disorders. Notwithstanding the reported stigma, veterans of Operation Iraqi Freedom (OIF) utilized mental healthcare at a 

higher rate during the first year postdeployment than 

veterans of Operation Enduring Freedom (OEF) in 

Afghanistan or those from other deployments. About 

one third of the OIF veterans sought mental healthcare 

during their first year as compared to 22% for OEF and 

24% for other regions.2

Recent ongoing studies suggest that deployment 

also significantly increases the risk of mental health 

problems in military children, family violence, and 

divorce. Anecdotal reports from the field suggest that 

soldiers who are worried about their families are not 

as able to focus on the mission. Family satisfaction and 

resilience are important factors contributing to soldier 

readiness and retention, and attrition of soldiers with 

mental health issues is particularly high. Hoge and colleagues2 found that attrition for any reason during the 

first year postdeployment from OIF was 17%, and those 

who reported a mental health concern were significantly 

more likely to leave the service. Other studies reported 

that 47% of all soldiers hospitalized for the first time 

for any mental disorder were separated from the Army 

within 6 months.3 Innovative mental health initiatives 

are required to meet these and other challenges facing 

the volunteer Army to conserve the fighting strength 

and meet the needs of soldiers and their families. 

The lineage of community mental healthcare in the 

military is rich, beginning in earnest during World 

War II, when clinicians and commanders alike recognized that psychiatric casualties decreased as morale 

increased.4

 Psychiatrists grasped the importance of 

treating soldiers within their social structures and 

strengthening their identification with their units, 

which led to cohesion with their peers and unit leadership. As clinicians came to recognize the soldier as 

a part of an interdependent network of social forces, 

they realized that much of their treatment amounted 

to intervention in some part of the social structure, 

and that the psychiatrist was often poorly equipped 

for these tasks.5

 Individuals in the community—social 

workers, chaplains, and spouses of active duty members in volunteer positions—encountered less stigma 

and had greater knowledge of individual units and 

access to a wider pool of community programs than 

did hospital-based psychiatrists. As psychiatrists 

embraced multidisciplinary approaches, treatment 

moved out of medical centers and became integrated 

into the military social network, shifting emphasis 

toward prevention and leading to the community 

mental healthcare system. 

The impetus for extending community mental 

healthcare to military family members, especially 

during deployments, rests on the emerging belief 

that strong social supports enhance the mental wellbeing of the parent remaining at home, which in turn 

prevents psychopathology in children. Research has 

shown that children’s behavioral problems increase 

(especially in young boys) when the nondeployed 

parent suffers from psychopathology.6 Practical 

remedies, such as strong spouse and family support 

groups; male companionship for young boys (eg, a 

big brother program or family members); education 

programs for spouses about separation and reunion; 

and regular communication with the deployed parent 

require community-level intervention.6 Rear detachment units, wives’ clubs, schools, childcare groups, 

and other community organizations can greatly 

contribute to building resilience in family members. 

Mental health providers have unique skills for identifying individual problem areas, but their interventions 

are most effective when integrated with the work of 

community groups that support families. Likewise, 

mental health providers working in interdisciplinary 

clinics located close to military housing areas are better 

able to implement treatment plans that involve these 

vital social support systems than those who work in 

hospital-based programs.

The responsibility for taking care of the physical 

and emotional needs of soldiers and their families is 

shared by numerous military, federal, and state agencies. These agencies each have specific portions of the 

overall caring “pie,” but historically have functioned 

independently. Often agencies staunchly protect their 

own areas of concern, which unfortunately may result 

in inefficient and costly duplication of services and 

staff. It is a significant challenge to integrate agencies 
565

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

in a common goal. Wenger and Synder7 describe the 

emerging concept of “communities of practice” and 

discuss how disparate groups with a shared agenda 

can come together, learn from each other, and develop 

strategies that work toward a common goal. Large 

numbers of corporations and governmental agencies 

are employing these principles with success; however, 

many organizations need leadership “buy-in” to facilitate cooperation and collaboration. 

The objective of this chapter is to describe the development of a multidisciplinary, integrated system of 

mental health support and care at Schofield Barracks 

in Oahu, Hawaii, during the deployment of the 25th 

Infantry Division Light (25th ID), aimed at promoting resilience and wellness in the Army community. 

Primary focus will be on the Soldier and Family Assistance Center (SAFAC), followed by a brief discussion 

of a school mental health initiative,8 mental health 

support to family readiness groups (FRGs [composed 

of Army spouses who support families]), and the Army 

Community Service (ACS). The discussion of the latter 

programs will focus on how these efforts came together 

to provide care for the soldiers and family members 

in the Schofield catchment area during OIF and OEF. 

(This chapter will not include detailed discussion of 

the Family Advocacy Program or the Army Substance 

Abuse Program [ASAP]. The Family Advocacy Program provides services when domestic violence is 

identified, and the ASAP delivers a wide range of 

prevention and treatment services for alcohol and 

drug abuse.) The overall development of the Schofield 

community behavioral health system is presented in 

chronological order to emphasize the importance of the 

process as it evolved within the entire community. 

EARLY EFFORTS

Schofield Barracks, including Wheeler Army Airfield, is located in central Oahu on 167,919 acres of 

land. It is home to the 25th ID and supports approximately 14,500 active duty soldiers. Additionally, about 

9,500 civilian employees and 3,000 contract employees 

work at Schofield. On post there are three elementary 

schools and an intermediate school that are part of the 

Hawaii Department of Education (DoE). Besides the 

usual stressors for military families, such as frequent 

moves and transitions, additional stressors of living in 

Hawaii are the high cost of living, parents’ concerns 

about their children’s education, and cultural differences. As with other overseas assignments, most families living in Hawaii are isolated from their extended 

families and visit their relatives on an infrequent basis 

because of travel costs. The Army community receives 

its primary healthcare at Schofield Barracks Health 

Clinic, except for specialty care, which occurs at Tripler 

Army Medical Center (TAMC), located 20 miles from 

Schofield and over an hour’s commute during rush 

hour. Before the establishment of the SAFAC, almost 

all child, adolescent, and adult mental health services 

(other than services for active duty personnel) were 

delivered at TAMC. 

In June 2003, the leadership of the 25th ID began 

preparation for deployment of a brigade combat team 

(BCT) to Afghanistan. By early fall of that year, the unit 

rotation schedule had expanded to include deployment of the entire 25th ID at Schofield. The 2nd BCT 

was slated for deployment to Iraq in January/February 2004, and the 3rd BCT and Division Headquarters 

were slated for Afghanistan between February and 

May. At the time, the 25th ID was the only division 

deploying to two separate theaters of combat operations. The division was also called upon to mobilize 

the US Army Reserves and Hawaii National Guard as 

part of the deployment. 

Through a combined effort of the 25th ID, Schofield 

Garrison Command, and TAMC, plans immediately 

began for soldier and family readiness and assistance 

during the deployment cycle, which presented significant challenges to these organizations. The 25th ID 

was deploying over 11,000 soldiers and leaving behind 

25,000 family members, including nearly 800 pregnant 

women. Because of the availability of medical care at 

TAMC, the division had a higher proportion of families than usual with “exceptional family members,” 

individuals with medical and mental health needs that 

require specialized care. During the first deployment, 

80% of the families of deployed soldiers elected to 

remain in Hawaii rather than return to their homes on 

the mainland during the deployment, which increased 

the need for mental healthcare. 

The predeployment preparation for soldiers and families began in earnest in November 2003 with coordination of services among the various on- and off-post agencies. Mental healthcare was already becoming integrated 

with the involvement of FRGs, schools, and the ACS; for 

example, since 2001, Child and Adolescent Psychiatry 

Service (CAPS) at TAMC had already been involved in 

a school mental health program at Schofield.

During the summer of 2004, it became clear that the 

OIF and OEF deployments were resulting in significant 

mental health casualties.1

 The FRGs, CAPS, and ACS 

began discussing ways to meet the projected increased 

need for support and mental health services for the 

entire community, and informed the commander of the 

25th ID, Major General Eric Olson, of their concerns. In 

December 2004, the 25th ID division surgeon returned 

from Afghanistan to meet with the commander of 
566

Combat and Operational Behavioral Health

Schofield Barracks Health Clinic and leaders in mental 

health at TAMC. This meeting resulted in a commitment to develop a mental health initiative, which later became the SAFAC. 

SOLDIER AND FAMILY ASSISTANCE CENTER

Concept Development, Structural Framework, and 

Financing 

The purpose of the SAFAC was to execute a plan 

that provides mental health support for returning soldiers and their families. Early in the process, six guiding principles for SAFAC’s development emerged: 

1. a variety of mental health resources would 

be developed and integrated under a single 

umbrella organization to facilitate coordination of services and increase capacity and 

flexibility in delivery of these services; 

2. a single point of entry would be established 

to make access to care easy and simple; 

3. the mental health resources of the 25th ID 

would be combined with those of the Schofield Barracks Community Mental Health 

Clinic; 

4. the funding of the SAFAC would be shared 

between Schofield Barracks Health Clinic and 

the 25th ID; 

5. leadership for the newly established clinics 

could come from either the 25th ID or from 

Schofield Barracks Health Clinic; and 

6. every effort would be made to decrease the 

stigma in seeking mental health assistance. 

Several of these principles were unique to the Army 

experience, specifically principles 3, 4, and 5. Responsibility and leadership for the SAFAC would be shared 

so that the 25th ID had a vested interest in the direction 

and success of the initiative. A process action team, 

which was established and chaired by the rear division 

commander of the 25th ID, met monthly to evaluate 

progress and institute new initiatives or major changes 

in directions. A work group headed by the commander 

of Schofield Barracks Health Clinic met weekly to plan 

the next steps and evaluate progress.

The first task of the work group was to estimate the 

numbers of various specialty providers that would be 

required for the SAFAC to adequately meet the needs 

of the community. This process required estimates 

of baseline morbidity rates in soldiers and family 

members during peacetime, as well as rates resulting 

from deployment. Early estimates for the soldiers deployed to OIF and OEF were based on the research of 

Hoge et al,1

 and the work group assumed that not all 

soldiers with difficulties would seek help. Hoge et al1

reported that rates for PTSD were lower in OEF than 

OIF. Soldiers of the 25th ID deployed to either OIF or 

OEF. Rates of PTSD for soldiers were projected to be 

approximately 8% to 11%. Rates of other anxiety/depression were estimated at 5% to 7%, serious domestic 

violence at 8%, moderate domestic violence at 22%, 

divorce at 10%, and children with mental health issues 

at 25%. Projections of the rates of the mental health 

problems in the adult family members were based on 

the rates in soldiers. Because the SAFAC needed to care 

for not only the current active duty population but also 

the deployed reserve and National Guard soldiers and 

their family members, actual numbers for the entire 

population were not available. 

No algorithm was available to estimate the numbers 

of providers in each specialty needed to serve this 

population; the Army’s system of resource allocation 

is not based on empirical evidence. To develop an algorithm that later could be tested, several assumptions 

were necessary. These assumptions were (a) the average number of visits per year each individual would 

make, (b) the proportion of individuals who would 

require medications, (c) the numbers of patient visits 

each specialty provider could reasonably provide in 

a year, and (d) the ratio of patients who could be seen 

by a nurse practitioner versus a psychiatrist versus 

another provider. Based on these assumptions and 

those listed below, algorithms were developed and 

later refined. 

Exhibit 34-1 lists the assumed number of visits 

per year per specialty provider and the formula for 

its calculation. For example, it was assumed that 

an adult psychiatrist would be able to handle 3,290 

visits per year based on 7 hours of patient contact 

a day, two patients per hour, 5 days a week, for 47 

weeks each year; each patient visiting the three clinics 

would require an average of six visits a year; 0.8 of the 

adults being seen in the Soldier Assistance Center or 

the Adult Family Member Assistance Center would 

require medications; and approximately 50% of the 

patients under 18 years of age seen in the Child and 

Adolescent Assistance Center would require medications. There would be three psychiatrists to every one 

nurse practitioner for adults and one child psychiatrist 

to one nurse practitioner for children and adolescents. 

The ratio of social workers to psychologists would be 6 

to 1. Child psychiatrists, child nurse practitioners, and 

child psychologists would be in equal proportion. This 

algorithm could be further refined as actual data were 

collected, and it could be easily modified to adjust to 

differences in other clinics or at other installations. 
567

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

EXHIBIT 34-1

ALGORITHMS FOR CALCULATING PROVIDER NUMBERS

Visits per Practitioner per Year

	 •	 Psychiatrist: 3,290*

	 •	 Social worker: 1,645†

	 •	 Psychologist: 1,645†

	 •	 Nurse practitioner: 3,290*

	 •	 Child psychiatrist or child nurse practitioner: 2,467‡

	 •	 Psychologist: 1,645†

*7 h × 2/h × 5 days/wk × 47 wks = 3,290

†

7 h × 1/h × 5 days/wk × 47 wks = 1,645

‡

7 h × 1.5/h × 5 days/wk × 47 wks = 2,467

Formulas for Number of Practitioners Required

	 •	 Psychiatrists and nurse practitioners: population × 6 visits/patient/year × .8 needing medications ÷ 3,290

visits/psychiatrist/year

	 •	 Social workers and psychologists: population × 6 visits/patient ÷ 2,209 visits/provider/year

	 •	 Nurse practitioners: population × 6 visits/patient × .8 needing medications ÷ 3290 visits/year

	 •	 Child psychiatrists: population × 6 visits/patient × 0.5 needing medications ÷ 2,467 visits per year

	 •	 Child nurse practitioners: population × 6 visits/patient × 0.5 needing medications ÷ 1,645 visits/year

	 •	 Child psychologists: population × 6 visits/patient ÷ 1,645 visits/year

Proposed Ratios

	 •	 Adult psychiatrists to nurse practitioner = 3:1

	 •	 Adult social workers to psychologists = 6:1

	 •	 Child psychiatrists to child nurse practitioners = 1:1

By January 2005, five areas of care (Exhibit 34-2) 

were identified and a timeline for implementation of 

the clinics determined. Table 34-1 lists the projected 

deployed population and the estimated number of 

providers required in each of the five areas using the 

various algorithms. There would be a single point of 

entry into the mental health system (to be available 

24 hours a day), which became known as the Triage 

Assistance Center. Other areas of care were the establishment of three new clinics and augmentation of the 

Marriage and Family Assistance Center and the ASAP. 

The new clinics were called the Soldier Assistance Center (SAC), the Adult Family Member Assistance Center 

(AFMAC), and the Child and Adolescent Assistance 

Center (CAAC). The designation “assistance center” 

was utilized in an attempt to decrease the stigma surrounding mental healthcare. 

Funding was approved the same month. Preliminary estimate of the cost of the SAFAC for one year was 

$5.4 million. The 25th ID agreed to fund approximately 

20% of the total, including renovation of a floor in a 

EXHIBIT 34-2

SOLDIER AND FAMILY ASSISTANCE 

CENTER FIVE AREAS OF CARE

1. Triage Assistance Center telephone line (24 

hours a day/7 days a week) 

2. Soldier Assistance Center

3. Adult Family Member Assistance Center

4. Child and Adolescent Assistance Center

5. Marriage and Family Assistance Center

clinic to house the AFMAC, and hiring three providers to augment drug and alcohol treatment for family 

members and six social workers to bolster the AFMAC 

and the Marriage and Family Assistance Center. The 

remainder of funds came from TAMC. The 25th ID 

also assumed an active role in the SAFAC’s develop-
568

Combat and Operational Behavioral Health

ment, providing additional leadership and assistance 

to the assistant division surgeon and technical support 

through the loan of a division logistics officer. 

Recruitment, Advertising, and Implementation

The reorganization of the Community Mental 

Health Clinic and division mental health services into 

the SAC occurred immediately, and the SAC opened 

the second week in January 2005. Demand at the start 

far outweighed availability, and additional providers 

were immediately needed. In February, TAMC’s chief 

of psychiatry (Colonel CJ Diebold) and residency program director (Colonel David Orman) provided staff 

psychiatrists’ and residents’ time to the SAC as part 

of the graduate medical education program. This interim solution was essential to maintaining the SAC’s 

function while providers were recruited and hired. 

Specialty experts at Schofield Barracks Health Clinic or 

TAMC interviewed prospective candidates and made 

hiring recommendations. By April 2005, essentially all 

the positions had been filled. 

Although some family members were already being 

seen in limited numbers in the SAC, the AFMAC and 

Triage Assistance Center opened on March 15. In April, 

the division mental health staff returned from OEF and 

OIF, including the chief, Major Brian Bacon, who was 

appointed chief of the SAC, and division psychologist 

Captain Richard Schobitz, who became chief of the 

AFMAC and CAAC. The opening of the CAAC was 

delayed a month due to difficulty in recruiting child 

psychiatrists, but by May 2005 all clinics were operating at or above optimal staffing levels. 

Early in the program’s development organizers initiated an aggressive campaign to decrease the stigma 

associated with seeking mental health assistance at 

the SAFAC, and increase awareness among providers of war-related psychological trauma. Hoge and 

colleagues1

 found that the greater the likelihood of 

trauma, the greater the stigma in seeking help. The 

advertising campaign was initiated in February 2005, 

promoting the SAFAC and its available resources 

throughout the community. Ten thousand refrigerator 

magnets were produced that listed SAFAC’s mission 

and services, as well as the 24-hour triage telephone 

number. The television channel on post also promoted 

the new resources and encouraged people in need to 

seek help. Unit leaders were informed by their chains 

of command that any soldier having emotional difficulties should be identified and offered the opportunity to visit the SAFAC. Division leaders met regularly 

before and after redeployment to ensure that soldiers 

at risk were identified. 

The National Center for PTSD was invited to Schofield Barracks to instruct primary care providers in 

recognizing war-related mental health disorders and to 

teach behavioral health providers cognitive-behavioral 

therapy for PTSD. National Center for PTSD staff Matthew Friedman, MD, PhD (the center’s director); Frederick Gusman, MSW; Julia Whealin, PhD; and Gregory

Leskin, PhD, conducted 3 days of classes for the staff 

at Schofield Health Clinic and TAMC. Dr Whealin continued to come once a week to colead a soldier PTSD 

group at the SAC. Efforts by the center increased the 

knowledge of PTSD and depression among primary 

care providers and have been very beneficial to the 

entire Schofield Barracks community. The effectiveness 

of this campaign in decreasing stigma cannot be known; 

however, the demand for SAFAC services, particularly 

during the initial stages, has taxed its resources.

One of the SAFAC’s initial efforts was the Soldier 

Readiness Program (SRP), in which a mental health 

provider interviewed every soldier prior to and immediately upon redeployment, and those having serious 

concerns or requesting assistance were immediately 

referred to a doctoral-level provider. The psychology 

and psychiatry departments at TAMC supplied additional staff for the SRPs until the SAFAC was fully 

operational (currently the majority of the staffing of 

SRPs is done by the SAFAC).

TABLE 34-1

PROJECTED DEMAND OF PROVIDERS BASED ON POPULATION

Psychiatrists Psychologists Nurse Practitioners Social Workers

Soldier Assistance Center 4.10 1.95 1.37 11.72

Adult Family Member Assistance Center 2.41 1.15 0.80 6.88

Child and Adolescent Assistance Center 1.06 2.13 1.06 0

Marriage and Family Assistance Center 0 0 0 8.07
569

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

Outcomes and Current Activities

Key to success of the SAFAC team is flexibility. With 

regular moves of the active duty staff, contracts that 

require year-to-year negotiation, and deployments, 

staff flexibility to meet the demand of the current 

situation is critical. The clinics are organized under an 

“umbrella” of services, which allows for movement of 

staff between clinics to meet the changing needs of the 

population. For example, when some of the soldiers of 

the 25th ID deployed in summer 2006, staff were shifted from the SAC to the AFMAC, increasing services 

for family members while the soldiers were deployed. 

Additionally, two social workers transitioned from the 

AFMAC to the Marriage and Family Assistance Center 

in response to increased need. Recently the ASAP had 

a 2-month backload, which was relieved when the SAC 

developed a behavioral change group specifically for 

ASAP clients. In September 2005, the CAAC opened 

evening hours to see children, facilitating access for 

parents who work. A new position has been added 

to conduct outcome studies on the SAFAC’s efficacy. 

Despite minor fluctuations over time in each clinic’s 

staffing, the initial estimates for overall numbers of 

the various providers have proven to be fairly accurate. Figure 34-1 illustrates the number of client 

appointments at the three clinics from January 2005 

to November 2006.

Within the Schofield Barracks community, the 

SAFAC is involved in a variety of activities. Staff 

members teach classes and present seminars at ACS. 

A team composed of an AFMAC child psychologist 

and an ACS social worker present briefings at district 

schools on topics relevant to military children, such 

as “Effects of Deployment on Children,” “Children 

and Redeployment,” and “Building Resilience.” 

Every unit that returns from OIF or OEF receives a 

reintegration briefing from the SAFAC. In addition, 

a monthly caregiver team meeting is dedicated to 

improving community outreach, family support, and 

crisis intervention. 

Since the deployments of the Hawaii Army Reserve 

units and the National Guard, numerous requests have 

been made for outreach services on other islands in Hawaii, as well as in Alaska, Samoa, Guam, and Saipan. 

A SAFAC team was appointed to provide services at 

these geographically remote areas through ongoing 

visits to each of these locations. 

SCHOOL-based MENTAL HEALTHcare

SAC CAAC

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

3,000

2,600

2,200

1,800

1,400

1,000

600

200

1,745

1,858

2,160

1,745 1,759

1,749

1,490

1,732

1,938

2,499

2,163

AFMAC TOTAL

Figure 34-1. Monthly patient or client visits in the three 

Soldier and Family Assistance Center clinics, January 2005 

to November 2006.

AFMAC: Adult Family Member Assistance Center

CAAC: Child and Adolescent Assistance Center

SAC: Soldier Assistance Center

In partnership with Solomon Elementary School 

in Schofield Barracks, CAPS developed a model for 

school mental health preventive care, early intervention, evaluation, and treatment of military children. 

Dr Mark Weist, director of the Center of School Mental 

Health at the University of Maryland, was consulted 

during the establishment of the Solomon Wellness Educational Program (SWEP), which began in 2001 with 

the goal of facilitating easy access to mental healthcare 

for students.8

 The project initially expanded to four 

schools. The following discussion only pertains to 

Solomon Elementary School, because it has the longest 

history and has received the most evaluation. Although 

not discussed here, programs at the three other schools 

are ongoing and highly valued by each school. 

Solomon Elementary is a public school administered 

and funded by the Hawaii DoE. Administrators, teachers, counselors, and support staff are state employees. 

The school currently has an enrollment of about 830 

students, 99% of whom are military dependents. The 

students come mainly from families of junior enlisted 

active duty soldiers who are usually assigned to a 

3-year tour in Hawaii. Of the students, at least one 

third transition (move from the area) each year. A large 

proportion of these families have young children, as 

reflected by the school’s eight kindergarten classes, 

eight first-grade classes, six second-grade classes, five 

third-grade classes, four fourth-grade classes, and four 

fifth-grade classes. Of the children at Solomon, 49% 

qualify for a reduced-price or free lunch. In addition, 

seven self-contained special education preschool classes serve 51 young children with severe communication 

disorders, autistic disorder, global developmental delays, or severe behavioral disorders. An additional 69 
570

Combat and Operational Behavioral Health

special education students are in kindergarten through 

fifth grade. Three self-contained classrooms are for 

children with severe behavioral disorders, serving 12 

children from 5 years to 11 years of age. 

Early History

A formal agreement has existed between Solomon 

Elementary and the Child Psychiatry Service at TAMC 

since 1985. Second-year child psychiatry fellows spent 

one half day per week for 6 months providing consultation services at the school for children referred 

by school counselors. Fellows mainly provided triage 

after observing the children and discussing the counselors’ concerns. Children in need of services were 

referred to TAMC or to a civilian provider through 

TRICARE—the military’s health insurance program. 

In 2000, CAPS decided to offer more services by sending the child psychiatry fellow into the school for a full 

day each week for the entire school year. The referral 

process remained the same, but full evaluations were 

now conducted at the school. These early experiences 

helped form the vision and goals of a comprehensive, 

integrated, school mental health program: 

Vision: Develop and implement a comprehensive 

array of school programs and services to support students, family, and community.

Goals: 

	 •	 Provide a full continuum of mental health

promotion and intervention programs and 

services, including early identification and 

intervention, prevention, evaluation, and 

treatment.

	 •	 Remove barriers to learning and improve the

academic success of students. 

	 •	 Enhance strengths andprotective factors in students, families, and the school community.

	 •	 Promote quality oflife and wellness in military

families. 

	 •	 Provide training, staff development, and

research opportunities to improve children’s 

mental health and education.8

Several tenets were developed concurrently to 

guide program decisions. The first tenet stated that 

SWEP is a collaborative program responsive to the 

needs of its stakeholders. An advisory board composed 

of various stakeholders in the school and community 

meets on a monthly basis. The board’s responsibility 

is to attend to the mental health of the students, teachers, parents, and the community. For example, to deal 

with the increased interpersonal difficulties between 

students at recess, the board developed a program 

of structured games and contests that resulted in declining referrals to the office during recess. Another 

example was the regular publication of a newsletter 

for teachers on mental health topics. During the first 

OIF deployment of the 25th ID, the advisory board 

held parent support meetings at the school to help the 

nondeployed parent and children successfully cope 

with the situation. The board also established a crisis 

plan to ensure a coordinated, empathic response to 

the children and families of soldier parents who were 

killed or severely injured. The plan called for verification of all information before intervention, followed by 

a clearly defined, graded approach to meeting families’ 

needs with sensitivity. 

The second tenet required that all programs and 

services for children and families be coordinated. DoE 

and TAMC policies needed to be integrated, followed 

by frequent and clear communication. This led to 

weekly triage meetings following an algorithm for how 

a child is referred for evaluation and provided care, attended by the treating physicians, counselors, a school 

behavioral specialist, a student services coordinator, 

the school principal, and the medical director. After 

appropriate parental consents are given, information 

about the child and family is shared, and a coordinated, 

multidisciplinary treatment plan is devised. 

Program Evaluation and Student Demographics 

SWEP incorporates ongoing performance improvement to ensure timeliness and quality of services, including a recent review of 133 closed charts of students 

evaluated from August 2001 to February 2007. Of the 

133 children referred to SWEP, nine failed to appear 

for their initial appointments, for a noncompliance rate 

of 7%, and 113 of the 124 evaluated were seen within 4 

weeks of the date of referral, including over one third of 

the children who were seen within 10 days of referral. 

Although 11 children were seen after 4 weeks, three 

were delayed due to cancellations by the parents and 

four because of school vacations, particularly during 

the winter holiday vacation when school was closed 

for 2 weeks. The majority of the children evaluated 

were 7 years of age and under (Figure 34-2). 

The majority of children had externalizing disorders, with a boy-to-girl ratio of about 4 to 1. Modalities 

of treatment at the school included individual and 

group therapy, family therapy, parent guidance, and 

pharmacotherapy. Of the children treated, only four 

required a higher level of behavioral intervention, including special education certification. Three of these 

children were diagnosed with bipolar disorder and the 

other child (whose parents were both deployed) was 
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Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

diagnosed with severe attention deficit hyperactivity 

disorder and oppositional defiant disorder.

Other services provided by SWEP included quarterly teachers’ workshops and parent workshops on 

behavioral interventions, as well as a recently initiated bullying awareness and prevention program. 

For the past 3 years, SWEP physicians have provided 

weekly consultations to the Primary School Adjustment Program, which screens all younger children 

and identifies those having trouble adjusting to the 

school environment. Two paraprofessionals then offer 

individual and small group services to these children. 

The child psychiatry fellows have given guidance and 

instruction on topics such as child development, as 

well as offering workshops to the parents. Addition120

100

80

60

40

20

0

Age 9 43 5 8 6 7 10 11 Total

# Male # Female

Figure 34-2. Ages and gender of children evaluated at Solomon Elementary School in the Solomon Wellness Educational 

Program, from August 2001 to February 2007 (total: 133).

ally, support groups for children whose parents are 

separating and divorcing have been initiated.

Along with training opportunities for TAMC child 

psychiatry fellows, SWEP has expanded to include 

training of social work students from the University 

of Hawaii. A formal memorandum of agreement was 

established whereby master’s-level students obtained 

practicum experience at SWEP under the supervision 

of the medical director, child fellows, and a DoE school 

social worker. Practicum students performed intakes 

and offered individual and family therapy, parent 

guidance, and group therapy. A similar collaborative agreement was established with the university’s 

Counseling Education Department, whose practicum 

student performed intakes, provided therapy, and 

received training in psychological testing.

Future Directions 

Efforts are underway to use measurements before 

and after program participation to document student 

progress. The Strengths and Difficulties Questionnaire9

 has been administered to teachers and parents 

before and at selected intervals after to determine the 

treatment’s effect. In addition, patterns of behavioral 

referrals to counselors or the vice principal are being 

analyzed before and after treatment to determine if 

treatment has an impact on disciplinary referrals. Further efforts are planned to identify deployment-related 

stresses on parents and children, including effects of 

reunions and postdeployment family readjustment. 

BEHAVIORAL HEALTH LIAISON PROJECT

In February 2004, the TAMC psychiatry residency 

program launched a behavioral health liaison (BHL) 

project, modeled on a similar program conducted at 

Letterman Army Medical Center in San Francisco, California (1988–1989), aimed at familiarizing psychiatry 

residents with operational Army units.10 Unbeknownst 

to organizers, it also resembled a program being 

piloted simultaneously by ACS in the 1st Armored 

Division using social workers as consultants, which 

later gained widespread acceptance as the Soldier 

and Family Life Consultants (or Military Family Life 

Consultants) program.

The BHL program was different, however, in that 

residents supported the rear elements of a deployed 

military force. It included both service and training 

missions, providing preventive and consultative mental healthcare to rear-detachment units and FRGs, as 

well as familiarizing residents with these units and 

their day-to-day activities. The BHL team consisted 

of 17 TAMC psychiatry residents at various levels of 

training, along with a supervising attending psychiatrist. Each resident was assigned a 25th ID unit to support; junior residents were given battalions and senior 

residents were given brigades. Over the course of a 

12-month deployment cycle, BHLs provided education 

on relevant psychosocial issues to rear-detachment 

commanders and FRG leaders, and facilitated access 

to mental health resources for soldiers and their family members.

Initial challenges included generating interest 

among residents while minimizing additional demands on their already burdensome academic schedules. At a minimum, residents were required to contact 

their assigned unit’s FRG leader and offer the group 

an initial educational briefing. Beyond that, they were 

encouraged, but not required, to attend their unit’s 

monthly FRG meetings and provide additional education and consultation as requested.

Outcome data later revealed that almost exactly one 

third of the residents perceived their welcome by the 
572

Combat and Operational Behavioral Health

unit as “easy/welcoming,” one third perceived their 

welcome as “average,” and one third perceived their 

welcome as “difficult/unwelcoming” (Figure 34-3). 

Although these relationships were not objectively 

measured, a direct correlation was perceived between 

the openness with which units welcomed their BHL 

and the amount of contact the BHLs subsequently had 

with their assigned units; disinterested units did not 

receive as many visits or educational briefings as units 

that proactively reached out for assistance. 

Every interested unit received an initial briefing 

from their BHL on the emotional cycle of deployment, a concept originally described by Pincus and 

colleagues.11 Topics covered in subsequent briefings 

are listed in Exhibit 34-3. Beyond the initial contact, 

residents had a substantial amount of flexibility in 

choosing how to work with their FRGs and remained 

involved with the groups on a variable basis. Some 

attended FRG meetings every month, kept in close 

contact with FRG leaders, and attended various unit 

functions. Others took a more passive role, remaining 

available to field questions from FRG leaders only 

when issues arose.

When the program ended, feelings about the proEXHIBIT 34-3

FAMILY READINESS GROUP BRIEFING 

TOPICS 

	 •	 Behavioral health liaison introduction

	 •	 Emotional cycle of deployment

	 •	 Common mental illnesses

	 •	 Combat stress/posttraumatic stress disorder

	 •	 Children and deployment

	 •	 Midtour rest and recuperation

	 •	 Loss and grieving

	 •	 Reunion and reintegration

Easy/Welcoming Average Welcome Difficult/Unwelcoming

6

4

2

0

Number of Respondents

Figure 34-3. Quality of welcome by unit in the behavioral 

health liaison project.

gram were overwhelmingly positive among FRG leaders, who unanimously felt that the program should be 

continued following redeployment. The psychiatry 

residents, however, had a mixed response. Ultimately, 

the program was discontinued and replaced with a 

mandatory 2-month senior resident rotation through 

the SAC, with supervision by either the 25th ID 

division psychiatrist or an active duty community 

psychiatrist. 

Army Community Service Support for 2004–2005 

Deployments

The deployment of the 2nd BCT to Iraq in January 

2004, followed by the deployment of the 3rd BCT to 

Afghanistan in March 2004, prompted further community efforts to prepare and support soldiers and 

families of the 25th ID. ACS took a leadership role 

in ensuring that 25th ID soldiers and families were 

trained and ready to handle what became a long and 

challenging 18 months. ACS concentrated on preparing the families of the 2nd BCT first, followed by the 

3rd BCT, and then launched an aggressive sustainment program of continued support to families during the deployment. Finally, ACS developed a robust 

redeployment program that strategically addressed 

reintegration issues. 

Predeployment Support 

ACS developed a four-pronged approach to predeployment support including (1) dissemination of 

information, (2) training and education, (3) community outreach, and (4) mental health integration. The 

extensive community outreach element included three 

deployment information fairs with more than 20 community service organizations participating, such as 

finance, legal, and housing assistance organizations; 

TRICARE; child development centers; and SAFAC. 

Military and civilian organizations were available to 

answer questions and provide information about making personal deployment decisions for soldiers and 

families. The fairs were open to the entire community; 

local sponsors provided door prizes and refreshments. 

More than 2,500 soldiers, families, and community 

members attended the three fairs.

A separate job fair was conducted with the community employment assistance program to educate 

spouses about employment opportunities. Many 

spouses were undecided about whether to remain in 

Hawaii or move back to the mainland during deployment. Because employment factored into this decision, 

ACS partnered with over 30 local businesses and organizations to extend employment opportunities to 
573

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

spouses. More than 250 spouses attended the fair. 

Community town hall meetings, beginning several 

months before deployment, offered the latest information from the division commander about deployment 

status and myriad community service providers. The 

division commander and his staff were on hand to 

answer questions and quell any rumors or misinformation. The town hall meetings continued on a monthly 

basis throughout the duration of both deployments. 

Free childcare during the meetings ensured high 

attendance. Additionally, over 30 school briefings 

were presented to teachers, school administrators, 

counselors, and parents, in partnership with CAPS, on 

deployment-related topics affecting children.

ACS training and education opportunities included: 

	 •	 preparation and guidance for FRG leaders,

either as individuals or in classes, on how to 

best support families and themselves during 

deployment;

	 •	 education of rear-division commanders

(nondeployed) in collaboration with division 

training resources;

	 •	 financial readiness classes for soldiers and

families to prepare them for the financial issues of deployment; and 

	 •	 family wellness classes teamed with various

TAMC child and adolescent psychiatrists, 

SAFAC staff, and chaplains. 

The ACS provided over 58 sessions of financial 

readiness training. Numerous other classes for families covered such topics as “Impact of Deployment on 

Children,” “Helping Children Cope With Stress,” and 

“Dealing With Rumors.” Several classes addressed 

relationship issues for parents and the importance 

of meaningful communication during separation 

between spouses. ACS contracted Drs John and Jane 

Covey to train 27 ACS employees and chaplains for 

certification in “Seven Habits of Highly Effective 

Families”; the trainees in turn conducted almost two 

dozen 1-day sessions for Army couples. 

ACS joined with the SRP to offer soldiers a plethora 

of information, as well as collecting data on soldiers 

and their families. ACS designed a predeployment 

information sheet, distributed to all soldiers, asking 

for information on the soldiers and their families, their 

needs, potential concerns, and requested assistance. 

Data were collected for ACS to determine where 

spouses would be residing during the deployment 

and any special needs they may have. Single soldiers 

were asked to provide an address of a parent or friend 

they wanted to be kept informed during their time 

deployed. Upon completion of the forms, over 8,500 

records were collected and input into a database. 

Demographics such as spouse or parent addresses, 

pregnancies, family members with special needs, non–

English-speaking spouses, and planned relocations 

were used to develop specific deployment programs 

for target audiences. Approximately 22% of spouses 

moved to the mainland, 9% of married women were 

pregnant, 13% of spouses did not speak English as their 

first language, 15% had a special-needs family member, 56% of soldiers were married, and 69% of those 

married had children. A deployment newsletter was 

published bimonthly and mailed to over 8,000 spouses, 

parents, and friends of soldiers, containing information 

on Army community services available to families and 

important resource telephone numbers. 

Deployment Sustainment 

To ensure that quality services were available for 

spouses, ACS extended its operations to 7 days a 

week. Classes and training for FRG leaders and family 

members continued, with frequent seminars on such 

topics as “Coping With Deployment,” “Care for the 

Care-Giver,” and “Taking Care of Me.” ACS offered a 

weekly “spouses night out” every Thursday with pizza 

and other refreshments provided by sponsors, fun activities, and free childcare (also available for the FRG 

Wednesday meetings). Guest speakers, craft nights, 

game nights, support groups, and more were offered 

during the 52 weekly sessions. In addition, ACS made 

20 hours a month of free childcare easily accessible to 

spouses to provide child-free opportunities for errands 

or respites. However, 88% of childcare employees 

were spouses of deployed soldiers, and burnout and 

stress were common among staff. In hindsight, the 

free childcare was excessive and created challenges for 

subsequent deployments when expectations could not 

be sustained because of decreased funding.

ACS worked directly with the 125th Signal Battalion to connect soldiers and families via video 

teleconference (VTC) equipment available 7 days a 

week. Spouses found seeing their deployed spouses 

and speaking to them face to face to be comforting, but 

children had mixed experiences with the VTC sessions. 

Younger children sometimes became visibly upset by 

seeing mom or dad on the screen, while others used 

the opportunity to update their parents on school and 

home activities. In general, the VTC sessions proved 

to be very valuable to families.

Redeployment and Reintegration

In December 2004, ACS developed a workshop to 
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Combat and Operational Behavioral Health

prepare spouses and families for reunion after deployment. ACS again invited Drs John and Jane Covey 

to participate. The workshop included a list of local 

professionals who offered such classes as “Effects of 

Combat Stress on Families,” “Helping Children Prepare for Reunion,” and “Putting the Welcome in Welcome Home.” The workshop was in a “round-robin” 

format, affording spouses the opportunity to attend 

three of the five sessions provided. Over 150 spouses 

attended. The workshop was followed by a series of 

programs with guest speakers offered every 2 weeks in 

the evenings. Mental healthcare providers, chaplains, 

and social workers were brought in to present topics 

on reunion and reintegration. 

ACS developed a “Ready 4 Reunion” DVD with 

three segments that addressed reunion and reintegration, one of which focused on children and deployment and was produced by ACS with the help 

of local volunteers and a TAMC child psychiatrist. 

The other two segments were taken from “Operation 

Ready” material (www.mwrarmyhawaii.com/acs/

managing_deployment.asp). Mailed to over 6,000 

family members, the DVD had a 3-fold purpose: (1) 

to reach as many spouses as possible, both those who 

remained in Hawaii and those who had moved back 

to the mainland; (2) to provide spouses with reunion 

information in their own homes; and (3) to generate 

awareness of the postdeployment reintegration process and encourage spouses to take advantage of the 

training and services available to them. The DVD was 

successful in generating interest in reunion training 

and was later made accessible on the ACS Web site 

(http://www.mwrarmyhawaii.com/). 

To facilitate reintegration, the 25th ID planned to 

provide comprehensive training to redeploying soldiers and families beginning 90 days before homecoming and ending 30 days after redeployment. The resulting Tropic Lighting University, based on Iron Horse 

University at Fort Hood, Texas, was a three-phase 

reunion program designed specifically for intensive 

reunion training to soldiers and their spouses. 

Phase I included intensive reunion training to 

spouses beginning 90 days prior to homecoming. 

Phase II, the 3-day deployment cycle support program 

mandated by the Army, included a series of briefings, mental health screenings, and medical checks. 

Spouses were invited to attend the briefing portion of 

this phase. Phase III occurred immediately following 

the soldier’s 30-day leave period and consisted of a 

series of classes over 2.5 days. Four target audiences 

were identified for training: (1) single soldiers, (2) 

single soldiers with children, (3) married soldiers, and 

(4) married soldiers with children. Unit integrity was 

maintained throughout the program. Tropic Lighting 

University trained over 10,000 soldiers. The curriculum 

included 

	 •	 stress management (2 hours) for all soldiers,

	 •	 anger management (1 hour) for all soldiers,

	 •	 money management (1.5 hours) for all soldiers, 

	 •	 single parent workshop (1.5 hours),

	 •	 single soldier workshop (1.5 hours),

	 •	 marriage workshop (3 hours),

	 •	 communication with children (1 hour), and

	 •	 divorce recovery (2 hours) for soldiers going

through a divorce.

Lessons Learned

	 • 	 Partnership with the mental health community was invaluable and should be mirrored 

on all Army installations. 

	 • 	 Global war on terror funds provided ACS

with the needed financial resources to provide 

extensive deployment services.

	 • 	 Twenty hours a month of free childcare was

excessive and created an unsustainable expectation.

	 • 	 ACS and childcare staff experienced burnout.

Extended hours and additional childcare 

requirements put a great deal of stress on 

the staff, many of whom were spouses of 

deployed soldiers. 

	 • 	 Keeping the community informed and building relationships with schools helped identify 

potential family issues and at-risk families, 

and connected families with available resources before issues became elevated. The 

community served as ACS’s eyes and ears. 

The responsibility for taking care of the physical 

and emotional needs of soldiers and their families is 

shared by numerous military, federal, and state agencies. These agencies each have specific portions of 

the overall caring “pie,” but historically have largely 

functioned independently. Often agencies staunchly 

protect their own areas of concern (“defend their 

turf”), which unfortunately may result in duplication 

of services and staff, and that is not only inefficient 

and costly, but also results in barriers to care due to 

lack of coordination of services and multiple portals 

of access. It is a significant challenge to integrate 

agencies in a common goal. Wegner and Synder10

describe the concept of “Communities of Practice” as 

being the “organizational frontier” and define how 

disparate groups that have a “shared agenda” may 

come together, learn from each other, and develop 
575

Establishing an Integrated Behavioral Health System of Care at Schofield Barracks

strategies that work toward a common goal. Large 

numbers of corporations and governmental agencies 

are employing the principals embodied in the concept 

of a “community of practice” with success. However, 

within many organizations there needs to be a “buy 

in” from the leadership. 

SUMMARY

The rapid development and success of SAFAC is 

attributable to strong leadership in the 25th ID and 

TAMC. Likewise, strong leadership from the Schofield 

Barracks Garrison Command, the National Center for 

PTSD, and the Hawaii DoE district superintendent 

facilitated the coming together of the various agencies, schools, and the SAFAC in maximizing resource 

utilization and cooperation. For example, the SAC, 

composed of the combined mental health resources of 

the 25th ID and the Community Mental Health Clinic, 

greatly increased capacity and access to care for soldiers returning from OIF and OEF. Such collaboration 

greatly expands the Army’s ability to provide mental 

healthcare for soldiers. Taking mental healthcare to 

the community is another important principle. School 

mental healthcare brings services to youth where they 

spend a large portion of their day. It is often more 

convenient for parents and has less stigma for children and parents alike than going to a mental health 

clinic. Outreach in collaboration with ACS educates the 

community and further decreases stigma. Embedding 

mental health resources within the FRGs provides 

direct support to spouses during deployments and 

makes seeking help easily accessible. 

Occasional conflict in Schofield’s program had a 

negative impact on services. Areas that presented difficulties were the direction and control of social work 

resources and, to a lesser extent, integration of substance abuse resources, particularly for family members. These problems were never fully overcome.

Based on the experience with integrating mental 

health resources in an Army community like Schofield 

Barracks, the following is recommended:

	 •	 Command and control of mental health resources must be established and made clear 

under a single umbrella organization. The 

combination of all mental health resources 

under a single organization greatly facilitates 

integration and coordination of services. 

Failure to integrate such services generates 

numerous and costly problems even in a 

peacetime environment. If psychology, psychiatry, and social work need to respond to a 

crisis as a team, then these agencies should be 

organized as a team with a leader.

	 •	 The current system of accounting for providers’ clinical time must be changed to reflect the 

value of prevention and early identification 

programs. Under the present accounting system, programs that emphasize prevention and 

early identification are not counted as patient 

care and actually count against “productive 

work.” Similarly, community outreach is not 

quantified as productive workload. 

	 •	 Army combat units such as the 25th ID should

play an integral role in any mental healthcare 

initiative. Shared responsibility between 

mental health components and combat units 

greatly enhances the care of soldiers and their 

families.

Another important concern is allocation of mental 

health resources within the Army system. Traditionally, Army staffing guidelines have called for approximately one adult psychiatrist for every 7,000 adults and 

one child psychiatrist for every 18,000 youths under 

age 18. The experiences described in this chapter, as 

well as empirical evidence, suggest that one medication-prescribing practitioner is needed for every 3,000 

adults, and one child medication provider for every 

3,300 children. This is a greater than 2-fold increase in 

adult providers and almost a 5-fold increase in child 

providers. Even so, this staffing level does not take into 

account the numbers of youth seen in schools or those 

treated at TAMC. Additionally, these data represent a 

system that permits ready access to care. Within the 

SAFAC, nurse practitioners were used as much as possible for prescribing medication in both the adult and 

child clinics to reduce expenses. The assumptions in 

the algorithms described in this chapter need further 

testing; however, the estimated numbers of providers 

the equations predicted appear to be fairly accurate, 

and in general do not overestimate the need. 

REFERENCES

1. 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.
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2. 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.

3. Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among US military personnel in the 1990s: association with 

high levels of health care utilization and early military attrition. Am J Psychiatry. 2002;159:1576–1583.

4. Jones FD. From combat to community psychiatry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, eds. Military 

Psychiatry: Preparing in Peace for War. In: Zajtchuk R, Bellamy RF, eds. Textbooks of Military Medicine. Washington, DC: 

Department of the Army, Office of The Surgeon General, Borden Institute; 1994: 230–235.

5. Satin DG. Allocation of mental health resources in a military setting: a community mental health approach. Mil Med. 

1967;132:698–703.

6. Jensen PS, Grogan D, Xenakis SN, Bain MW. Father absence: effects on child and maternal psychopathology. J Am 

Acad Child Adolesc Psychiatry. 1989;28:171–175.

7. Wenger E, Snyder WM. Communities of practice: the organizational frontier. Harvard Bus Rev. Jan–Feb 2000;139–

145.

8. Faran ME, Weist MD, Saito AY, Yoshikami L, Weiser JW, Kaer B. School-based mental health on a United States Army 

installation. In: Weist M, Evans SW, Lever NA, eds. Handbook of School Mental Health: Advancing Practice and Research. 

New York, NY: Kluwer Academic/Plenum Publishers; 2003: 191–214.

9. Violence Institute of New Jersey at UMDNJ. Strengths and Difficulties Questionnaire. Available at: http://www. 

sdqinfo.com/. Accessed January 4, 2010.

10. Leamon MH, Sutton LK. Graduate medical educators and infantry commanders: working together to train Army 

psychiatry residents. Mil Med. 1990;155:430–432.

11. Pincus SH, House R, Christenson J, Adler LE. The emotional cycle of deployment: a military family perspective. US 

Army Med Depart J. 2001;PB 8-01-4/5/6:15–23.
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Disaster Psychiatry

Chapter 35

DISASTER PSYCHIATRY

ARTIN TERHAKOPIAN, MD, MPH*; DAVID M. BENEDEK, MD†; and ELSPETH CAMERON RITCHIE, MD, 

MPH‡

INTRODUCTION

HISTORICAL BACKGROUND

RECENT MISSIONS

The September 11, 2001, Attack on the Pentagon

The December 26, 2004, Southeast Asia Tsunami

Hurricanes Katrina and Rita in 2005

SUMMARY

*Major, Medical Corps, US Army; Chief, Inpatient Psychiatry, Department of Behavioral Health, William Beaumont Army Medical Center, 5005 North 

Piedras Street, El Paso, Texas 79920; formerly, Chief, Behavioral Health, 10th Combat Support Hospital, Baghdad, Iraq 

†

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814

‡

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

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

Avenue NE, 4th Floor, Washington, DC 20002
580

Combat and Operational Behavioral Health

INTRODUCTION

The US military has made significant contributions 

to medical relief efforts for many devastating civilian 

events around the world. More recently, military psychiatrists and allied mental healthcare professionals 

have played major roles in these relief operations. This 

chapter outlines general principles of disaster psychiatry and illustrates the application of these principles 

via the response of military psychiatry to recent mass 

casualty disasters.

The field of disaster psychiatry continues to evolve 

and inform the conceptualization of disasters and their 

behavioral health consequences. Knowledge of the 

proper psychiatric interventions for times of disaster 

is essential. Although generally well-trained in war or 

battlefield psychiatry and the application of PIES (proximity, immediacy, expectancy, simplicity) principles, 

some military psychiatrists, like many of their civilian 

colleagues, are less familiar with the care of traumatized 

patients outside the sphere of standard inpatient or 

office psychiatric settings. Most psychiatrists may be 

more experienced with the management of conditions 

such as acute stress disorder or posttraumatic stress 

disorder (PTSD) in the office than with management of 

symptoms in the austere and disrupted postdisaster environment. The treatment of disaster-related behavioral 

health conditions can challenge psychiatric concepts 

such as those related to intrapsychic determinants of 

mental disorders1 and psychiatrist–patient boundaries (eg, cohabiting a tent with a patient).2

 Although 

knowledge about individually experienced trauma, 

such as rape and automobile accidents, along with 

that of war psychiatry, informs the basic principles of 

disaster psychiatry, psychiatric reactions to disasters 

where there are often acute, unexpected, and collectively experienced large-scale traumatic events may be 

different. Much has been learned in recent years as a 

result of experience following the September 11, 2001, 

(9/11) attacks, the devastating Indian Ocean tsunami 

of 2004, and Hurricane Katrina in 2005. The participation of military psychiatrists in relief teams responding 

to these events has provided a unique opportunity to 

practice disaster plans, assess the existing framework of 

disaster psychiatry knowledge, and consider possible 

modifications for advancement. 

This chapter will outline the historical background 

for the current principles of disaster psychiatry. Descriptions of military psychiatric response to the 9/11 

attack on the Pentagon, the Indian Ocean tsunami, and 

Hurricanes Katrina and Rita will illustrate not only 

the application of principles of disaster psychiatry but 

also what military psychiatrists may expect in disaster 

situations and how they can best assist in relief and 

recovery. Finally, areas for future research and training 

emphasis will be identified. 

HISTORICAL BACKGROUND

Substantial empirical data regarding medical and 

surgical needs at times of catastrophe have been accumulated. However, relatively little is known about 

mental health needs and appropriate psychiatric services. Nonetheless, the nature and extent of mental 

health needs of populations affected by a disaster and 

the appropriate psychiatric response has been well 

articulated in reports regarding a variety of natural 

and man-made disasters, wars, and public health 

emergencies. 

In disasters, many experience grief and depression, 

anxiety, and somatic and dissociative reactions.3–6

Disaster stress reactions may mimic physiological 

symptoms anticipated by a specific type of disaster 

event; for example chest tightness and nausea because 

of anxiety may follow the explosion of a truck carrying 

chlorine gas. This phenomenon complicates assessment and care of disaster-affected populations and 

necessitates the collaborative work of psychiatrists 

with their medical counterparts. Among people with 

preexisting mental disorders, anxiety and somatic reactions are compounded by fears regarding community 

disruption, availability of care, and availability of 

medication supplies. 

Psychological reactions to disaster, resulting in 

presentation for treatment, are well documented in the 

literature. For example, during the Persian Gulf War 

(1990–1991) about 40% of Israeli civilians near Scud 

missile attacks reported symptoms consistent with 

a chemical weapons’ explosion despite the absence 

of any such exposure.7

 A similar phenomenon was 

observed in the 1995 sarin gas attack on the Tokyo 

subway system.8–10 In a cross-sectional assessment of 

182 survivors from the 1995 Oklahoma City bombing 6 months after the disaster, North and colleagues 

showed elevated rates of PTSD (15% predisaster and 

34.3% postdisaster) and depression (12.6% predisaster 

and 22.5% postdisaster).11 Five emergency rooms in 

lower Manhattan near the World Trade Center collapse 

experienced a surge in patient care in the aftermath of 

the 9/11 disaster. Of the 950 patients examined during the first 48 hours in these emergency rooms, 14% 

reported cardiac, neurological, and psychiatric problems.12 In the months following the World Trade Center 
581

Disaster Psychiatry

destruction, a survey of Connecticut, New Jersey, and 

New York residents showed nervousness, worry, sleep 

problems, and increased smoking and alcohol use as 

a result of the attacks.13

The terrorist anthrax attacks in Washington, DC, 

during November 2001 again demonstrated the need 

for psychological, emotional, and behavioral healthcare of the affected populations. During the 2 weeks 

following the anthrax attacks on the Hart Senate Office 

Building, 1,129 patients with symptoms and concerns 

of anthrax exposure visited the emergency room of 

Inova Fairfax Hospital, located in nearby northern 

Virginia. Of these patients, only two were diagnosed 

with inhalational anthrax.14 The reactions of civilians 

to disasters are fairly similar to those documented 

among troops as early as World War I.15 Historically, 

psychiatric reactions (such as those noted above) have 

been divided along the time phases of a disaster 

(predisaster, disaster, and postdisaster), with each 

phase having its own characteristics with differences 

essentially determined by the nature and duration of 

the disaster.16 Thus, the emotional and behavioral consequences of disasters may cause considerable disruptions in the health and functioning of individuals and 

societies along a significant timeline. Investigations 

in the fields of social science, psychology, psychiatry, 

and public health have provided useful information to enhance resilience, promote effective disaster 

behaviors, and mitigate mental disorders following 

traumatic exposures. These have been summarized 

by Ursano, Fullerton, and Norwood6; and Ritchie, 

Watson, and Friedman.17 Three broad mental health 

intervention areas that are informed by the empirical 

evidence are: (1) community support, (2) education, 

and (3) definitive care (Table 35-1). These domains of 

intervention areas are consistent with long-standing 

TABLE 35-1 

ESSENTIAL DOMAINS OF DISASTER MENTAL HEALTH INTERVENTIONS

Community 

Support

Basic Needs: provide safety, security, water, food, shelter/housing, transportation, contact and/or communication with family and friends

Psychological First Aid: minimize further harm; reduce psychological arousal and physical pain; mobilize 

support; maintain families and facilitate their reunion; provide information and education; foster communication about risks; contemplate need for translators

Needs Assessment: assess current status; know predisaster circumstances; consider silent populations like 

children and the disabled; think of needs on three levels: (1) populations, (2) groups, and (3) individuals

Monitoring: listen to those affected; gauge the level of basic needs that are met; measure psychological 

vital signs like attitudes, hope, expectations, and substance misuse; monitor and dispel rumors

Fostering Resilience and Recovery: encourage social interaction; allow regular activities such as school 

and work as far as possible; enhance coping skills; strengthen role system; suggest community action to 

decrease helplessness and instill hope; build on existing community and organizational fabric; encourage protective community rituals (speeches, memorial services, funerals) to reduce distress and enhance 

cohesion 

Education Outreach and Information Dissemination: ensure wide dissemination of practical information and easyto-do instruction through media and trusted local leaders; inform the public clearly and repeatedly about 

recommendations and the rationale behind them; educate about risky behaviors and signs and symptoms 

of abnormal functioning; be available at common gathering places; make informal services as well as 

referral to formal services available; use the language of the affected people 

Providing Consultation and Training: transfer needed skills to existing community organizations to improve their ability to meet psychological needs; be available to and educate public officials and religious, 

civic, and business leaders; encourage local participation in recovery efforts

Definitive 

Care

Triage and Clinical Assessment: stabilize and refer cases of mental disorder or dysfunction; screen highly 

vulnerable populations; hospitalize to avoid harm

Treatment: reduce or eliminate symptoms; improve functioning; use psychopharmacy and psychotherapy 

(individual, family, and group interventions); apply multidisciplinary approach coordinating care with 

clergy, spiritual healers, counselors, and employers

Adapted from: Ritchie EC, Friedman M, Watson P, Ursano R, Wessely S, Flynn B. Mass violence and early mental health intervention: a 

proposed application of best practice guidelines to chemical, biological, and radiological attacks. Mil Med. 2004;169(8):575–579.
582

Combat and Operational Behavioral Health

psychiatric conceptualizations of trauma and response 

such as those of Pierre Janet,18 Sigmund Freud,19 and 

Ivan Petrovich Pavlov.15

The appropriate balance of community support, 

education, and definitive care may enhance individual, 

group, or community capacity to integrate traumatic 

experiences, thereby reducing depression, anxiety, 

somatization, and dissociation. The benefit of interventions along these lines will vary depending on the 

type of disaster as well as its timing and intensity. Also, 

many of these efforts (eg, support and education) may 

be conducted by nontraditional mental healthcare providers, highlighting the importance of liaison among 

mental healthcare providers and disaster rescue workers including volunteers. 

Self-triage and self-soothing can also be enhanced 

by community support, education, and definitive care. 

Psychoeducation can help reduce somatization by 

explaining (and normalizing) the impact of traumatic 

exposure on personal psychology, spirituality, and 

physiologic function. Knowledge and understanding of stress reaction may boost the ability of affected 

individuals to contain their anxiety, curb fear, and 

mobilize psychological defenses in response to distress 

by assisting survivors in making sense of the disaster 

and their emotional responses to it. Support and education may reduce disaster-related chaos by providing 

instruction and may thus minimize “compensation 

syndromes” by advocating for postdisaster assistance 

and community rebuilding programs. Educational 

and support programs can guide survivors with preexisting mental illness to definitive care centers for 

medication refills, reevaluation, and hospitalization (or 

other services as indicated). These mental health interventions, when sustained and tied to surveillance and 

outreach efforts, may lessen the conversion of minor 

and short-lived emotional symptoms into more serious 

and long-lasting mental health problems. Community 

support, education, and definitive care (when clearly 

available to those who require it) all serve to enhance 

community ability to integrate frightening and devastating experiences into cognitive, emotional, and 

behavioral schemes. From a cognitive and neurobiological perspective, this integration may be viewed as 

the accumulation of “safety memory,” which inhibits 

the expression of fear memory.20

“Project Liberty,” a government-funded entity set 

up after 9/11, illustrates the benefits of the provision of 

support, education, and definitive care. This program, 

which provided counseling, education, and outreach 

services to an estimated 1.2 million individuals during the 27 months following 9/11 in the area around 

“ground zero” in New York City, is an example of successful community support, education, and definitive 

care interventions. Project Liberty was particularly 

effective in facilitating survivors’ return to predisaster 

functioning and guiding those survivors with more 

serious problems, such as depression and PTSD, to 

definitive care.21,22

An emerging area of concern in disaster psychiatry has been the mental health of disaster workers. 

Although the evidence is somewhat mixed,23,24 health 

problems appear to disproportionately affect disaster 

workers exposed to psychologically traumatizing exposures.25–29 Traumatic exposures may have lasting effects on volunteers and rescuers and can diminish their 

mission effectiveness. Traumatic exposures in military 

disaster relief and humanitarian assistance operations 

can include: “a) dead bodies, b) orphaned or abused 

children, c) uncertainty regarding mission . . . [objectives] and d) unclear chain of command.”30(p63) Every 

disaster response plan should include mental health 

interventions for the affected population and also 

consider the emotional, behavioral, and mental health 

needs of rescuers. A psychiatrically informed plan for 

the support of rescuers can improve mission effectiveness by enhancing worker ability and willingness to 

report to duty.31,32 In this era of tremendous advances 

in medicine, including control of infectious diseases 

and emergency surgical provisions by disaster workers, 

and given the recognized health burden of long-term 

psychiatric illness, the refinement of disaster psychiatric 

interventions would seem a natural next step in reducing disaster-related morbidity and mortality.

RECENT MISSIONS

Military psychiatrists have supported various disaster relief efforts in the past several years. Among 

these were the response at the Pentagon following the 

9/11 attack, the mission in Southeast Asia following 

the 2004 tsunami, and the relief operations on the US 

gulf coast after Hurricanes Katrina and Rita, both in 

2005. Military disaster mental health interventions 

for these catastrophes were tailored to enhance safety 

and security, mitigate negative long-term psychiatric 

consequences, ameliorate suffering, and address clinically significant psychiatric reactions. Where possible, 

research and process improvement procedures were 

established to gather and document lessons learned. 

These operations were facilitated greatly by the readiness of military psychiatrists to respond. The extent to 

which responders were successful depended largely 

on their military psychiatric training, experience with 

the practice of caring for war-traumatized soldiers, and 
583

Disaster Psychiatry

access to consultants at national centers of excellence 

in trauma response and disaster psychiatry such as 

the Psychiatry Department at the Uniformed Services 

University of the Health Sciences, located in Bethesda, 

Maryland. 

The September 11, 2001, Attack on the Pentagon

American Airlines Flight 77 crashed into the Pentagon at 9:43 am edt on September 11, 2001. It was 

followed by a rapid, comprehensive, and sustained 

rescue and recovery response. As part of this response, 

all military services located near the crash scene dispatched mental healthcare teams to the Pentagon. One 

rapidly assembled stress management team arrived 

from Walter Reed Army Medical Center (WRAMC). 

Other crisis management teams arrived from Andrews, 

Bolling, and Keesler Air Force bases. A psychiatric 

intervention team came from the National Naval 

Medical Center in Bethesda.33–36 The teams worked 

with other support personnel, including members of 

the American Red Cross, Salvation Army personnel, 

various church volunteers, and Department of Defense 

(DoD) and fire department chaplains.34

Soon after the attack, the DiLorenzo Clinic at the 

Pentagon was designated as the headquarters for the 

disaster response. There, on September 12th, more 

specific plans were developed for the mental health 

support of personnel at the Pentagon, and the Army 

was assigned the lead for this mental healthcare effort. 

Because the Pentagon did not have in-house mental 

health services for its occupants (beyond a threeperson employee assistance program and a single 

chaplain), Army and Air Force assets were focused 

on the Pentagon while Navy assets where charged 

with supporting the Arlington Annex, Marine Corps 

headquarters,34 which was a few hundred yards from 

the crash site.

As observed in other disasters, distressed, sometimes anxious or panicked survivors visited the various 

organized clinics for assistance and guidance early 

after the crash. To address the growing need for social 

and mental health services, a family assistance center 

was established on September 13th at the Sheraton 

Crystal City Hotel, which was a short drive from the 

Pentagon. This facility provided assistance to families 

of Pentagon personnel as well as families of passengers 

and crew on Flight 77. Many Air Force mental health 

personnel, joined by WRAMC mental health team 

members, supported the mission of this center, including grief counseling, until it was closed 2 weeks after 

the October 11th memorial service because demand 

for services had declined.36

Consistent with the initial planning, the Air Force 

established teams that specifically served the personnel falling under the various deputy chiefs of staff in 

the Pentagon. These teams rotated in the DiLorenzo 

Clinic generally for 2-week periods until December 

10th.36 The Army divided its charge into an “inside” 

and an “outside” mission. The “inside” mission included the support of Pentagon personnel while the 

“outside” mission focused on the large population of 

first responders encamped on the lawn surrounding 

the Pentagon. The WRAMC mental health response 

was based on the accepted premise that most adverse 

mental health consequences following disasters are 

“subclinical” (ie, transient and normal responses to 

trauma).33 Hence, WRAMC mental health support 

often took the form of promoting awareness of basic 

needs such as sleep, food, water, and family contact. 

It involved modified debriefings through informal 

conversations and outreach through monitoring of 

reactions to traumatic exposure among Pentagon employees and responders, particularly high-risk groups 

such as casualty assistance officers and healthcare 

workers. This approach allowed for the delivery of 

support while minimizing the stigma associated with 

mental health service utilization. When warranted, 

referral for clinical services was offered for formal 

evaluation and treatment.33

In addition, the WRAMC Psychiatry Consultation 

Liaison Service (PCLS) team contacted and lent support 

to attack survivors who were admitted to local civilian 

hospitals. Using a novel and flexible approach adapted 

from critical incident stress debriefing models, but with 

a more targeted emphasis on the observed psychological state of each injured survivor, the WRAMC PCLS 

team approach helped reduce psychological symptoms, prevent the development of psychopathology, 

facilitate compliance with medical care, speed recovery, 

and arrange social support for the 18 attack survivors 

from the Pentagon who required lengthy hospitalization37 (Exhibits 35-1, 35-2, and 35-3). 

The “therapeutic debriefing” approach advocated 

mental health contact with all disaster patients and 

normalization of responses to the disaster with bedside 

techniques such as cognitive reframing.37 Here the 

goal was to help patients integrate their memories in 

a way that would prevent the disaster experience from 

“overwhelming” their defenses and that would minimize long-term morbidity.37 “Therapeutic debriefing” 

included the use of relaxation breathing, distraction, 

humor, and creative visualization to speed the return of 

a sense of agency and mastery to the patient. Addressing the quality of sleep, pain control, and satisfaction 

with medical treatment was also emphasized.37 The 

support provided to the Pentagon was sustained for 

weeks while psychiatric clinical services and gradu-
584

Combat and Operational Behavioral Health

ate medical education continued at many of the commands from which the mental health intervention 

teams came.33 Psychiatry residents involved in this 

response reported that their education was enhanced 

due to their participation in the rescue and recovery 

operations. The potential benefit of including residents 

in disaster plans has been echoed by other psychiatry 

training programs affected by Hurricane Katrina.38

Particularly traumatic during the early days of the 

response to the Pentagon attack were the work of the 

groups that helped in the recovery of the remains of 

the dead in the Pentagon.39 A descriptive report on 

the effect of recovering human remains on 10 military healthcare workers showed that mental health 

responses were quite varied and included acute but 

short-lived—in the order of days—restless sleep, nightmares, and flashbacks. Mission clarity and expectations were cited as ways to enhance coping.40

In summary, the military response to the Pentagon 

attack was rapid; military-specific efforts that were 

integrated through a series of ongoing planning efforts 

began immediately after the attack. Sustained mental 

health outreach efforts helped maximize support for 

the survivors and rescue workers. The support effort 

was enhanced by the multidisciplinary composition 

of the responders, which included psychiatrists, social 

workers, and chaplains. The “therapeutic debriefing” 

described by Wain et al42 stands out as a promising 

modification of the critical incident stress debriefing 

model applied in a psychiatry consultation liaison setEXHIBIT 35-1 

GOALS OF PSYCHIATRY CONSULTATION 

LIAISON SERVICE FOR DISASTER 

INJURED 

	 •	 Liaison between medical staff, patients, commands, family, and friends.

	 •	 Facilitate medical treatment.

	 •	 Reduce psychological-psychiatric morbidity.

	 •	 Maintain a flexible evaluation and treatment

approach.

	 •	 Recognize and reinforce patient’s adaptive

defense mechanisms.

	 •	 Advocate for patient’s needs.

	 •	 Educate patients and staff.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):20.

EXHIBIT 35-2 

TREATMENT GOALS OF “THERAPEUTIC 

DEBRIEFING” 

	 •	 Establish support.

	 •	 Make debriefing a routine preventive measure.

	 •	 Emphasize environmental safety.

	 •	 Normalize responses and feelings including

survivor guilt.

	 •	 Reframe loss by recognizing the injured

patient’s significant sacrifice.

	 •	 Help the patient consolidate a narrative of

what occurred.

	 •	 Console the patient.

	 •	 Identify and reinforce healthy coping mechanisms.

	 •	 Teach patient mastery techniques using imagery, relaxation, or humor.

	 •	 Teach the patient that he or she can be in

control.

	 •	 Encourage the patient to use social supports.

	 •	 Normalize sleep patterns and dietary intake

if medical condition permits.

	 •	 Clarify patient’s medical concerns.

	 •	 Educate on the pitfall of self-medication with

substance abuse.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):20.

ting. This PCLS approach, which is used with returning 

injured soldiers at WRAMC, may have contributed 

to the lower-than-historically observed initial rates 

of PTSD among battle-injured soldiers and deserves 

further study in disaster response.41,42

Scrutiny of the response to the Pentagon attack 

points to some weaknesses in terms of coordination 

and planning of response efforts, as well as mission 

ambiguity.33,34,36 Mental healthcare teams that arrived 

at the Pentagon did not coordinate their initial efforts with the on-scene commander of the disaster 

response.34 Each service and each mental health organization came with its own theoretical perspective, 

response plan, and set of priorities, complicating the 

response effort. Many have suggested that developing 

a joint doctrine of disaster response, perhaps along 

the same lines as the Federal Emergency Management Agency (FEMA) National Incident Management 

System, and drilling this plan would be a worthy 

future consideration.33,34,36,43 Also, the lack of military 
585

Disaster Psychiatry

administrative support was viewed as contributing to 

some of the difficulties with coordination.33 This lack of 

administrative support may have also contributed to 

the missed opportunity by military providers to fully 

integrate the civilian assets into combined plans.33,34

Inclusion of administrative support for disaster mental 

health response teams should also be considered. 

The December 26, 2004, Southeast Asia Tsunami

A powerful earthquake struck the Indian Ocean basin on December 26, 2004. The aftermath was a tsunami 

that affected many coastal countries, particularly Indonesia, Thailand, and Sri Lanka. Estimates placed the 

number of dead and missing at over 250,000 people. 

The affected people, even if physically unharmed, 

faced profound grief, loss, and guilt.44 The US military 

responded to this disaster by organizing Operation 

Unified Assistance. The magnitude of the disaster was 

so great that even highly capable and independent 

nongovernmental organizations (NGOs) needed the 

assistance of the US military to reach the devastated 

areas.45 The US military mission was subdivided into 

two groups: one was destined for Sri Lanka and the 

other to Indonesia. A third group from the Armed 

Forces Research Institute of Medical Sciences led the 

assessment of needs in Thailand and coordinated the 

delivery of assistance in that country.46

Soon after the tsunami struck, an advance team was 

dispatched to the region, which helped coordinate 

the arrival of US military assets with the respective 

US embassies and other local and international aid 

agencies. In addition to military members, the group 

to Indonesia deliberately included civilian volunteers 

involved with Project HOPE (Health Opportunities 

for People Everywhere), an NGO, to enhance the 

prospects of meeting the mounting needs of the affected people there.47,48 This group was dispatched to 

Banda Aceh, Indonesia, on USNS Mercy in early 2005, 

while the other groups were air-lifted to Sri Lanka and 

Thailand. The group in Sri Lanka eventually worked 

in the northeastern corner of the island. Once in Thailand, the third group began the task of assessing the 

damage in Thailand’s six coastal provinces affected 

by the tsunami.

As is established practice with disaster relief and 

humanitarian assistance operations, relief work entailed providing as much care as possible in situ and 

only bringing back to USNS Mercy patients who could 

not be treated ashore. All operations were in the “spirit 

of cooperation, collaboration, mutual respect, teambuilding and team participation, trust, interdependency and consensus-building.”49(p33) Although only the 

USNS Mercy included mental healthcare providers, all 

three groups considered the mental health needs of the 

affected populations as well as the disaster responders. For example, when choosing the housing location 

for the relief team in Sri Lanka, planners considered 

the psychological benefits of distance from the major 

concentration of affected people and physical devastation, allowing team members respite from constant 

traumatic exposure.50 Although the team in Sri Lanka 

provided many interventions that can be considered 

beneficial to improving mental health, they avoided 

specific psychological counseling and formal evaluation as it was deemed that these services could not be 

provided in a culturally relevant manner.50

Although the care provided by the team sent to Sri 

Lanka did not involve formal mental health interventions, the mental healthcare team on USNS Mercy

specifically planned for and engaged in the provision 

of mental health services in Banda Aceh, Indonesia. 

And although the team in Thailand did not directly 

provide mental health services, its rapid needs assessment alerted Thai officials to the poor preparedness of 

hospitals for meeting the mental health needs of the 

affected population. This prompted Thai authorities 

to organize and deploy mental health teams to the 

disaster-affected areas and consider changes in their 

EXHIBIT 35-3 

PSYCHIATRY CONSULTATION LIAISON 

SERVICE LESSONS LEARNED IN THE 

RESPONSE TO THE SEPTEMBER 11, 2001, 

ATTACKS 

	 •	 Psychiatric consultation liaison services may

need to be exported after a disaster.

	 •	 All disaster patients should be seen by mental

health providers as a standard protocol.

	 •	 Responses of disaster patients should be

reframed as normal responses to abnormal 

events.

	 •	 Mental health providers should establish an

early therapeutic alliance with other healthcare providers and patients.

	 •	 Patient’s mature psychological defenses

should be supported.

	 •	 Mental health resources should remain available to patients irrespective of their current 

medical status.

Adapted from: Wain HJ, Grammer GG, Stasinos JJ, Miller 

CM. Meeting the patients where they are: consultation-liaison 

response to trauma victims of the Pentagon attack. Mil Med. 

2002;167(9 suppl):21.
586

Combat and Operational Behavioral Health

disaster plans that originally did not include mental 

health elements.46 The assessment team in Thailand 

also reported on other facets of disaster response 

relevant to mental health, such as availability of basic 

needs, and found them to be well provisioned.46

A lesson learned in Operation Unified Assistance 

was the value of telecommunications. Through datasharing networks and communication links, the mental health team on the USNS Mercy was supported by 

a virtual group of disaster mental health experts from 

around the globe. These links enabled the team to 

assess the needs of the affected population and plan 

a response. Once it became clear that children were 

going to be the focus of the team, the same links were 

invaluable in accessing the latest literature, consulting 

with experts, and developing an intervention plan.51,52

With support from consultants, the mental health team 

aboard USNS Mercy was able to implement a program 

that provided over 80 hours of training in 85 content 

areas, which reached over 200 child-service staff 

members and 1,200 teachers in Aceh Province.53 The 

data and communication links continue to enhance 

the effectiveness of the mental health intervention in 

Aceh Province as they remain in use by mental health 

providers in the disaster-affected areas.53

One study examining rescuers who responded 

to the tsunami disaster provides some evidence to 

suggest that certain preventive measures—teaching 

rescuers about expected traumatic exposures, the 

range of psychological responses, and appropriate 

interventions—can reduce the incidence of negative 

consequences among members of this group. In this 

study, surveys were used to assess participant health 

before and 3 months after the mission. Although the 

small sample size precluded statistically significant 

conclusions regarding changes from baseline in overall 

health status, depression, posttraumatic stress disorder, or risk behaviors, responders tended to view 

favorably and find helpful the mental-health–related 

briefings and “just-in-time” training they received on 

the eve of their deployment.30

Thus, Operation Unified Assistance rapidly applied 

validated methods of disaster response. The effort also 

involved some new components, such as virtual access to global information resources and field experts. 

This mission illustrated the potential for successful 

cooperation between military personnel and civilian 

rescuers. Policies for these types of missions were later 

enumerated in DoD Directive 3000.05, Military Support 

for Stability, Security, Transition, and Reconstruction Operations.

54 Some areas that require further investigation 

include those that pertain to clarification of the optimal 

training for prevention of psychological trauma among 

disaster workers. One possibility might be the expansion of “just-in-time” training along the same lines as 

“Battlemind,” a training developed for troops before 

deployment to combat.55,56

Hurricanes Katrina and Rita in 2005

Hurricane Katrina struck the coast of Louisiana and 

Mississippi on Monday, August 29, 2005. As a result 

of the hurricane’s winds, torrential rains, and massive 

waves, an area the size of the United Kingdom was 

severely affected. In the aftermath, hundreds of thousands of people remained away from their homes in 

temporary shelters. Thousands of others less fortunate 

were stranded in a city that would soon be flooded 

because of breaches in levees. The contaminated 

waters pouring into New Orleans flooded hospitals, 

community mental health centers, pharmacies, and 

physicians’ offices alike, forcing closure of facilities 

and total displacement of healthcare professionals 

and patients in the four parishes of Jefferson, Orleans, 

Plaquemines, and St Bernard.57–59 Many persons with 

chronic medical conditions, including those most 

vulnerable because of psychiatric conditions, were left 

without care, medication, medical supplies, or support services. Under normal circumstances, Charity 

Hospital’s Crisis Intervention Unit managed about 600 

patient encounters each month. These numbers predicted a high post-Katrina demand on mental health 

services.60 This potential was identified early on by 

military disaster psychiatrists and communicated to 

planners and caregivers.61,62

The National Guard mobilized 48 hours before Hurricane Katrina made landfall. The military response, 

which eventually involved more than 60,000 active 

duty and National Guard members, accelerated its 

activities within hours of Hurricane Katrina’s landfall 

despite the presence of half of the Louisiana National 

Guard in Iraq.57,63,64 A shelter was established at the Superdome before the hurricane and a medical treatment 

facility was organized at the convention center 1 day 

after Katrina made landfall. A field hospital was also 

established at Louis Armstrong International Airport. 

By mid-September, Army, Air Force, and Navy medical teams were in and around New Orleans working 

with the Coast Guard, the US Public Health Service, 

the Environmental Protection Agency, the Centers 

for Disease Control and Prevention (CDC), and the 

Louisiana Department of Health and Hospitals.57 The 

first 72 hours following Katrina’s landfall were the 

most hectic. It was during this time that thousands 

of people were evacuated from the Louis Armstrong 

International Airport under some of the most distressing conditions.65

Health surveillance by the CDC, which commenced 
587

Disaster Psychiatry

on September 9th (with the assistance of the military), 

revealed no outbreaks of disease or hazardous environmental exposures as of September 25th. Early surveys 

noted 42 cases of intentional injuries among the 2,018 

cases of injuries reported.66 The communication of accurate news regarding outbreaks of disease and contamination, as well as education about risks through 

printed material and the media, were in line with 

disaster mental healthcare practices that likely calmed 

public fears of exposure and curbed the propagation 

of rumors. The rescue of city residents from rooftops 

kindled hope and strengthened survivors’ trust in the 

arrival of assistance. The hope for outside assistance, at 

least in terms of augmented medical operations, was 

realized through the Navy ship USNS Comfort. The 

Comfort supported relief efforts at Pascagoula from 

September 9th through September 20th and at New 

Orleans from late September to October 8th. Navy 

medical personnel and volunteers from Project HOPE 

with experience from the Indian Ocean tsunami helped 

triage and treat nearly 2,000 patients.67 However, the 

confusion regarding the responsibility of recovering 

human remains and safe travel routes, and the subsequent graphic media coverage, could not have helped 

allay people’s worries and sense of helplessness and 

abandonment.57,65

As the situation in the city stabilized and some 

degree of order was restored, the mental health 

burden became more apparent. Hurricane Katrina 

had caused the deaths of over 1,000 people by early 

estimates68; this would rise to over 1,400 in Louisiana 

once more accurate counts were available.69 The dead 

included two police officers who died by suicide.70

The news of deaths combined with the realities of 

scattered families and friends, community destruction, loss of social supports and healthcare, economic 

devastation, and numerous uncertainties distressed 

people profoundly, particularly those with existing 

mental illness. The burden of stress and dysfunction 

was brought to attention by a CDC survey in October 

2005, which showed that 56% of the respondents had 

a chronically ill family member and only 35% were 

employed, in contrast to the 73% who were employed 

before Katrina.71 Nine hundred New Orleans police officers and about 500 firefighters who completed a CDC 

survey during October and November 2005 reported 

mental health problems with symptoms of PTSD and 

depression, with depression affecting more than a 

quarter of each group (26% of police officers and 27% 

of firefighters).72

Over half of female caregivers living in FEMA trailers or hotels responding to a February 2006 survey 

scored at levels consistent with clinically diagnosable 

depression, anxiety, or other psychiatric disorders.73 It 

was not surprising that the New Orleans Coroner’s Office reported increased suicide rates from 9 per 100,000 

per year to 26 per 100,000 per year in the months from 

Katrina to the end of 2005.74 These consequences were 

exacerbated by the disruption of mental health services 

at large medical centers like Tulane University and 

Louisiana State University Health Sciences Center, 

including problems with methadone clinic patient 

records.59,75 Response to Katrina survivors was further complicated by Hurricane Rita, which followed 

3 weeks later.

As problems became more evident, programs were 

organized with the support of local, state, federal, and 

military organizations. Social workers at Louisiana 

State University at Baton Rouge arranged for the 

care of special-needs children displaced by the two 

hurricanes; Public Health Service staff streamlined 

credentialing and pharmacy processes for displaced or 

volunteer physicians.76 FEMA funding allowed for the 

start of Project Recovery in Mississippi and supported 

Louisiana Spirit mental health counselors.58,70 Project 

Recovery, which was spearheaded by the Substance 

Abuse and Mental Health Services Administration 

(SAMHSA), provided assistance and education to 

over 1,000,000 people, resulting in more than 10,000 

referrals to mental health and substance abuse services. 

Another SAMHSA program, the Katrina Assistance 

Project, conducted thousands of counseling sessions.58

Despite these efforts, the pre-Katrina burden of chronic 

mental illness in the city, including substance use problems, may have prolonged the “duress” experienced 

by survivors.70 Fortunately, psychiatric teaching and 

treatment programs in New Orleans, borrowing a 

page from the disaster response literature, were able 

to return quickly to the city by reestablishing communications, minimizing uncertainty, and applying 

academic flexibility.77 Disaster response and recovery 

in the Gulf Coast still continues, as do efforts to quantify the psychological burden of this disaster and find 

more effective disaster response paradigms. 

SUMMARY

In disaster psychiatry, vast areas of knowledge and 

practice are by necessity evidence-informed rather 

than evidence-based. Military psychiatric observation and experience form the basis of much of today’s 

understanding of population response to disaster and 

mass violence. Considerable knowledge exists with 

regard to the psychological effects of disasters, but 

only a smaller body of empirical evidence supports 
588

Combat and Operational Behavioral Health

current disaster response practices. Difficulties in 

the conduct of studies examining relevant questions 

in this field largely stem from the nature of the traumatizing event; few disasters are clearly anticipated 

and still fewer are slow to unfold. Further efforts 

by military and civilian disaster researchers must 

include rigorous longitudinal studies with baseline 

predisaster characterization of populations followed 

by comprehensive health surveillance and ongoing 

recharacterization of the disaster-affected populations. Measurements of symptoms and functioning 

before and after mental health interventions with 

control population comparisons (if ethical) will help 

quantify the efficacy of intervention programs and 

help separate cause from effect and modifiers from 

mediators. 

Another area of focus may be the education of 

disaster psychiatrists. Much is learned and lost in the 

field of disaster response as a result of the infrequency 

of large-scale tragedy. Disaster psychiatry training 

programs may help preserve the gains made in disaster psychiatry and function as institutional memories 

and resources to be called upon in times of need. Such 

training programs should emphasize and develop 

models for cooperation and coordination among the 

various agencies such as FEMA, the National Center 

for PTSD, SAMHSA, Uniformed Services University 

of the Health Sciences, National Institutes of Mental 

Health, and Project HOPE. Disaster response programs 

must also strive to more effectively incorporate various 

professionals (eg, psychiatrists, emergency medical 

technicians, public health workers, and community 

politicians) into disaster preparation, response, and 

recovery efforts. 

Specific areas for consideration by the military psychiatric establishment beyond the support of academic 

centers and research in this area include:

	 • 	 the development of a common disaster response doctrine, perhaps along the same 

lines as the National Incident Management 

System;

	 • 	 inclusion of disaster psychiatry in psychiatry

residency training programs and possible 

involvement of residents in disaster relief efforts;

	 • 	 furtherintegration of psychiatry consultation

liaison services in the medical care of disaster 

survivors to reduce stigma and enhance outreach; and

	 • 	 further development of the concepts of stress

inoculation and resilience to find ways to 

protect disaster workers. 

Direct military correlates may be found in the aims 

of the “Battlemind” program, as discussed in the attachment to Chapter 4, Combat and Operational Stress 

Control, in this volume.

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Acad Psychiatry. 2007;31(3):200–204.
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Chapter 36

TERRORISM AND CHEMICAL, 

BIOLOGICAL, RADIOLOGICAL, 

NUCLEAR, AND EXPLOSIVE WEAPONS

ROSS H. PASTEL, PhD,* and ELSPETH CAMERON RITCHIE, MD, MPH†

INTRODUCTION

TERMINOLOGY

RISK COMMUNICATION AND PERCEPTION

Communicating With the Public

Risk Perception

Mass Media

TRIAGE AND ISSUES OF DIFFERENTIAL DIAGNOSIS

Psychological Symptoms

Estimating Psychological Casualties

ACUTE EFFECTS

Mass Panic

Distress and Outbreaks of Multiple Unexplained Symptoms

Mental Disorders

LONG-TERM EFFECTS

Distress and Chronic Outbreaks of Multiple Unexplained Symptoms

Mental Disorders

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army; Chief, Division of Traumatic Brain Injury, Research Directorate, Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury, 1335 East-West Highway, Suite 900, Silver Spring, Maryland 20910; formerly, Assistant Professor, 

Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†

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

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

Avenue NE, 4th Floor, Washington, DC 20002
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INTRODUCTION

Chemical, biological, radiological, nuclear, and 

explosive (CBRNE) agents have gained increased international attention in the last 20 years. In 1992 Boris 

Yeltsin, the Russian president, admitted for the first 

time that the Soviet Union had continued to develop 

an offensive biological warfare program following 

the Soviet Union’s ratification of the Biological and 

Toxin Weapon Convention in 1972.1 In 1995 the world 

was stunned by two major terrorist attacks. In March 

the Aum Shinrikyo cult carried out a large-scale sarin 

attack on the Tokyo subway system. In April two 

home-grown American terrorists, Timothy McVeigh 

and Terry Nichols, attacked the Murrah Federal Building in Oklahoma City, Oklahoma, with a large truck 

bomb. Early in the new millennium on September 

11, 2001, the terrorist group al Qaeda attacked the 

Pentagon and the twin towers of the World Trade 

Center. Although the anthrax mail attacks followed 

within the week, they were not recognized until 

October, when the first victim fell ill. In the midst of 

these terrorist attacks, an emerging infectious disease outbreak caused by a new contagious disease 

called severe acute respiratory syndrome (SARS) 

appeared and caused widespread death and illness 

around the globe, including in China, Taiwan, Hong 

Kong, Singapore, Vietnam, and Canada. Although 

not a terrorist attack, the SARS epidemic resembles 

what might happen following a terrorist attack with 

a contagious disease such as smallpox.

CBRNE weapons are no longer weapons only of 

states; they have become available to terrorists as well. 

Many experts believe that a large-scale attack with 

CBRNE weapons is not a matter of if, but of when. 

Therefore, it is critical that mental healthcare practitioners become aware of the possible psychological 

consequences following a CBRNE attack. 

The psychological effects differ from other medical effects in that personnel do not need to be physically exposed to these agents to exhibit symptoms. 

Psychological effects can cause symptoms that may 

mimic the prodromal (or early) symptoms of CBRNE 

agents. Fortunately, the acute and long-term effects 

after CBRNE attacks have no apparent unique psychological disorders, but rather seem to exist on a 

continuum with effects seen after natural disasters or 

high explosives.2 Psychophysiologic effects, typically 

syndromes of medically unexplained symptoms, will 

likely dominate the long-term picture,3 and treatment 

may be difficult because of patient resistance and difficulties with doctor–patient relationships.4

This chapter will not be a comprehensive review of 

the literature; rather, it will introduce the clinician to 

potential problems resulting from CBRNE attacks. The 

chapter will briefly cover some unique aspects of such 

attacks, which can amplify the psychological effects, 

before reviewing acute and long-term effects.

Terminology

Terminology has an important effect on perception. Having a name for something presupposes an 

understanding. Terminology can be positive, neutral, 

or negative, depending on the connotations and context. One important collective behavior phenomenon 

has variously been called mass hysteria, epidemic 

hysteria, and mass psychogenic illness.5–7 Unfortunately, these terms have a pejorative connotation. For 

example, hysteria comes from the Greek word hystera, 

meaning uterus. Thus, when “mass hysteria” is used 

to describe an event involving medically unexplained 

physical symptoms, the immediate presupposition is 

that mostly females are involved. The common connotation for hysteria presupposes an overemotional 

response to an event, that is, a pejorative connotation. 

Use of “mass hysteria” by media, medical personnel, 

or public officials can lead to a negative perception of 

medical personnel and public officials by people affected by an event and vice versa. Similarly, in “mass 

psychogenic illness,” psyche refers to the mind and 

genic refers to genesis or creation. The connotation is 

that symptoms are “all in the head” and thus not real. 

A preferred term is “outbreak of multiple unexplained 

symptoms” (OMUS).7 Although clumsy, this term 

is relatively neutral. OMUS is also descriptive—the 

symptoms are real but unexplained, rather than “all 

in the head.”

Another common term used in CBRNE events is 

“worried well.” This terminology presupposes that 

the “worried well” are not suffering a real medical 

effect from a CBRNE exposure, but are simply worried that they might be ill. However, after a CBRNE 

event, many people with unknown exposures may be 

symptomatic—distressed and in pain. How can they 

be “well?” Again, “worried well” is a pejorative term 

and should be discarded. In the 1950s a more useful 

term, “disaster fatigue,” was used. This term was based 

on the military experience with combat exhaustion 

or battle fatigue (now called combat stress reaction). 

In World War II, battle fatigue was originally called 

“war neurosis” or “psychoneurosis” (which also had 

a negative connotation for soldiers). 
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Panic is another commonly used term, often used in 

reference to the general public, that is, a “mass panic.” 

In the strict sense, mass panic means an acute fear 

reaction marked by loss of self-control and followed 

by nonsocial and unreasoning flight.8 Flight can be a 

normal reaction to the presence of an immediate danger. It becomes a mass panic only when large numbers 

of people stampede without regard to others in an 

attempt to escape danger. Thus, to describe a panic 

following the anthrax attacks in 2001 or the New York 

City outbreak of West Nile virus in 1999 is inaccurate 

because there was no mass exodus from any city, nor 

was there an explicit danger from which to escape. A 

more accurate term would be “mass anxiety.”

Terrorism and CBRNE incidents (whether in warfare or in terrorism) are most typically mass casualty 

events (MCEs). However, MCEs vary widely both in 

the number and severity of casualties and the ability of the local environment to respond to the event. 

One group has proposed a useful terminology that 

categorizes MCEs into emergencies, disasters, and 

catastrophes based on the demand characteristics 

(number of people in need of rescue, shelter, or medical treatment) of the event and the locally available 

response capacity.9 Disasters are events in which 

the demands are in excess of the locally available 

response capacity (eg, the 2001 World Trade Center 

attack). Although emergencies may have high demand characteristics, they are not disasters because 

the locally available response capacity can handle 

the demand (eg, the 2001 attack on the Pentagon). 

Catastrophes occur when the event not only overwhelms the local response capacity, but also causes 

substantial damage to the infrastructure supporting 

the response system (eg, the 1995 Kobe earthquake 

in Japan).

Persistent idiopathic (medically unexplained) 

symptoms that drive patients to seek medical care4

typically fall within syndromes, including chronic 

fatigue syndrome, fibromyalgia, and multiple chemical sensitivity. These syndromes have overlapping 

symptom clusters and may be identified more by the 

specialty of the physician providing treatment than by 

the patient’s symptoms.

Risk Communication AND Perception

Communicating With the Public

In a CBRNE event, it is likely that the extent of the 

danger will not be known immediately, especially for 

chemical, biological, radiological, and nuclear (CBRN) 

weapons. Public health authorities and public officials 

will attempt to calculate the extent of the threat, and 

inform the media and the public. New York City Mayor 

Rudolph Giuliani was extremely effective following 

the events of September 11, 2001, and demonstrated the 

value of daily or twice-daily scheduled briefings with 

the media and the public. Much has been published on 

principles of health communication, including having 

a consistent message delivered by a knowledgeable 

and credible official, listening and responding to the 

concerns of the public, and avoiding the appearance 

of defensiveness or concealment. 

After any toxic accident or terrorist attack, many 

people will feel anxious about the potential health 

effects of a CBRN release. Such anxieties may be 

multiplied if devastating descriptions of the potential 

aftermath appear in the media. Following the 2001 

events, fears were exacerbated by media suggestions 

that in an anthrax attack, “your next breath may kill 

you.” Public officials should provide accurate hazard 

communication and workable measures that can be 

taken to protect individuals and families. According to 

one risk communication approach, risk equals hazard 

plus outrage.10 Hazard is the scientifically based risk 

assessment, but outrage is made up of nonquantifiable 

factors related to the public’s concern and perception of 

the event. Outrage following an attack with weapons 

of mass destruction will significantly influence both 

acute and long-term psychological effects. 

The US Army Center for Health Promotion and Preventive Medicine has more detailed information and 

training courses available (see the Center’s Web site: 

http://usachppm.apgea.army.mil/risk/). The Centers 

for Disease Control and Prevention has developed a 

course on emergency risk communication training (see 

the CDC’s Web site: http://www.cdc.gov/cdcynergy/

emergency/). 

Risk Perception

Risk perception is an important driver of the outrage 

component in risk communication. CBRN weapons 

involve a number of factors that can increase the perception of risk. Many CBRN weapons are invisible 

and odorless (radiation, biological agents, and some 

chemical agents), which leads to uncertainty about 

both exposure and amount of exposure. In many 

cases, exposure is not known until the patients become 

symptomatic. However, these agents may initially 

induce nonspecific symptoms (eg, fatigue, headache, 

nausea, dyspnea, dizziness, and muscle and joint 

ache). Regardless of illness induced, chemical agent 

and radiation exposures will also increase the fear of 

the long-term effects of the exposure.

In the risk literature, a number of factors have been 
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shown to increase the perception of risk, including 

potentially fatal illness, involuntary exposure (lack of 

control), a catastrophic event, presence of an unknown 

perpetrator, delayed detection and reaction by authorities, and potential effect on future generations.11,12

Fear of radiation, in particular, is prevalent, largely 

because of ignorance and misinformation. Thoughts 

and images typically associated with radiation are 

death, cancer, sterility, and fear for future generations. A number of factors may further amplify risk 

perception: scapegoating, distrust of governmental 

and industrial experts, and news media hype and 

misinformation.

Mass Media

The acute and long-term consequences of terrorism 

and CBRNE events are certainly shaped by risk perception. Risk perception, at least in part, is shaped by the 

mass media. Mass media has played an important role 

in various OMUS situations.13 Media are an important 

risk amplifier because they select and frame risk messages to inform the public, and intensive reporting (or 

media hype) can create continuing waves of news.13

The power of the media can be seen in studies that 

followed both the 1995 Oklahoma City bombing and 

the events of September 11, 2001. In a study of over 

2,000 middle-school children surveyed 7 weeks after 

the Oklahoma City bombing, both emotional exposure 

and television exposure were significantly related to 

posttraumatic stress symptomatology.14 When children 

with no direct (felt or heard the explosion) or emotional 

(knew someone killed or injured) exposure to the 

bombing were divided into high and low television 

exposure, children with high television exposure had 

significantly higher posttraumatic stress scores.14 A 

telephone survey study done 3 to 5 days after September 11 found that 44% of the people surveyed had one 

or more substantial stress symptoms, including sleep 

difficulties, irritability and anger, difficulty concentrating, and disturbing thoughts, memories, and dreams.15

The people responding to this survey were not present 

at the event; therefore, much of what they knew was 

presumably based on media reporting. 

In a contagious disease outbreak, information 

becomes extremely important. The public is eager 

for information and needs to know what precautionary measures should be taken. In Hong Kong, most 

respondents to a survey reported actively seeking 

SARS information on a daily basis, and relied more on 

mass media (television, newspapers and radio) than 

on medical professionals, friends, or the Internet.16

Substantial misinformation and false beliefs persisted 

among Hong Kong adults even at an advanced stage 

of the SARS epidemic, despite constant media and 

public service announcements.17 Recommended measures were not practiced uniformly. Many people did 

not understand transmission routes; only one third 

of respondents avoided direct contact by touch with 

contaminated objects (fomites), and less than one 

half practiced at least five of the seven recommended 

precautions. 

Triage and Issues of Differential Diagnosis

An important lesson learned from the Israeli Scud 

missile experience is the importance of a separate 

stress center at hospitals, so that psychological casualties can be removed from the emergency room and 

taken to a less stressful environment. Only recently 

have neuropsychiatric casualties been included as a 

triage category.18 When Israel was attacked with Scud 

missiles during the Persian Gulf War in 1991, large 

numbers of people reported to the emergency room 

for treatment.19,20 Studies reported that approximately 

70% to 80% of the patients in the early attacks had 

stress-related symptoms. 

Psychological Symptoms

Many symptoms commonly seen following a 

CBRNE incident (fatigue, nausea, vomiting, headaches, 

and anorexia) are common in combat21 and can be induced by acute radiation sickness (ARS) and chemical 

agent exposure, or during the prodromal syndrome of 

exposure to various biological agents and toxins.22 Because many CBRN agents are invisible, many soldiers 

may experience symptoms that they blame on CBRN 

exposure, regardless of actual exposure or dose of 

exposure. These patients are not “worried well.” They 

are worried—possibly with good reason—but they are 

not well if they are in distress and pain. 

Some CBRN agents may directly induce psychological effects in addition to medical effects (eg, nerve 

agents can induce anxiety).23 In other cases, symptoms 

may precede signs; that is, patients exposed to pulmonary agents may initially present with respiratory 

distress without measurable physical signs.24 Symptomatic ambulatory cases with mild or perceived exposures will present difficulties for CBRN event triage.

Unfortunately, most disaster exercises for CBRNE 

or other incidents include few psychological casualties. Without proper training based on actual CBRNE 

accidents, incidents, and attacks, healthcare providers will be unprepared for the sudden onslaught 
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

of patients presenting with mild or psychological 

symptoms who will arrive at the hospital before the 

severely wounded.

Estimating Psychological Casualties

Based on historical experience in World War II, 

military medical planners can get a rough estimate of 

battle fatigue or combat stress casualties, based on the 

number of wounded in action (WIA) expected from 

different types of battles.25,26 In World War II, the ratio 

of combat stress casualties to WIA was in the range of 

1:10 to 1:2.25,26 The civilian psychological casualty (PC) 

to WIA ratio for the first Israeli Scud missile attack was 

16:1 (if PCs are combined with unjustified atropine 

injections) or 8:1 (if only the PCs are included). In the 

1987 radiological contamination accident in Goiânia, 

Brazil, where no explosion occurred, the PC to WIA 

ratio was 500:1 (with WIA defined as anyone contaminated either externally or internally), or 2,500:1 

(with WIA defined as those individuals requiring close 

medical surveillance). 

Both examples involve civilians of two foreign nations, so extrapolation to US citizens or military personnel is difficult. The available data suggest that it is 

unlikely that the PC to WIA ratio following a CBRNE 

attack or incident will resemble the 1:10 to 1:2 range 

seen in World War II battles. The low end of the range 

may resemble World War II statistics, but the high end 

could go much higher, depending on the characteristics 

of the CBRNE attack. Most importantly, it is time to 

ensure that training for disaster and CBRNE incident 

should involve large numbers of psychological casualties, not the typical token few. 

Acute Effects

Mass Panic

The common image of behavior during or after a 

disaster is that of mass panic, described as “highly 

disorganized flight by hysterical individuals who 

have stampeded at the sight of actual or potential 

danger.”27(p68) During the Cold War, civil defense planners feared that a mass panic would follow a nuclear 

attack. However, studies of disasters and wars over 

the last 50 years show that disorganized flight (mass 

panic) is very rare.28–30 The few occasions when it did 

occur were very circumscribed and were characterized 

by limited escape routes with the possibility of entrapment, a perception of collective powerlessness, and a 

feeling of individual isolation.27,29,31 The most frequent 

historical examples of mass panic are in cases of fires, 

mine collapses, and sinking ships. Mass anxiety is not

mass panic.

In the initial use of chlorine gas on the Western front 

by Germany in 1915, “a full-blown, blind, contagious 

panic swept portions of the line.”32(p91) However, no 

panic occurred farther out on the line where there was 

little or no gas. In the next six gas attacks over the following 2 months, no mass panics occurred, although 

protective equipment was rudimentary and not widely 

available. Only four other gas panics were documented 

in World War I. 

Most victims of the Tokyo sarin subway attack were 

office workers going to their jobs in central Tokyo. Despite the crowded conditions of the morning rush hour 

and the limited escape routes, there were no reports of 

mass panic. One fireman reported a “perplexing silence” 

at the accident scene—no talking, just the coughing of 

the victims as they awaited medical assistance.33

Distress and Outbreaks of Multiple Unexplained 

Symptoms 

Perceived exposure to a CBRNE agent can result in 

the appearance of symptoms that may be hard to differentiate from mild symptoms expected from actual 

exposure. Thus, an OMUS can occur independently 

or in conjunction with a CBRNE event. However, in 

a CBRNE event, not all symptomatic casualties have 

been exposed to a toxic agent.34 Symptoms of psychological origin can also occur in casualties actually 

exposed to a CBRNE agent and may make treatment 

more difficult (victims finding out they have been exposed to a lethal disease such as anthrax or smallpox 

are unlikely to remain calm). Regardless of the actual 

exposure, it is important to pay attention to the patient’s symptoms of pain and distress while attempting 

to discern actual exposure.

The US military has experienced several OMUS incidents. In World War I, outbreaks of gas neurosis (gas 

hysteria) occurred, in which some soldiers experienced 

symptoms of gas poisoning (eg, dyspnea, coughing, 

and burning of skin) without clinical exposure to gas.35

In one incident, 500 battle-tested troops drifted into 

medical aid stations over a 1-week period following 

desultory gas shelling. They exhibited chest pain, fatigue, dyspnea, coughing, husky voice, and indefinite 

eye symptoms, all consistent with chemical exposure.36

However, the divisional gas officer found no evidence 

of gas inhalation or burning. 

More recently, in 1988, 1,800 male military recruits 

were evacuated from barracks due to an epidemic of 

coughing, dyspnea, and chest pain that broke out at a 

training center.37 The symptoms were consistent with 
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Combat and Operational Behavioral Health

exposure to a chemical agent or toxin. Recruits and 

medical personnel suspected an airborne toxin, but 

none was detected. These examples of OMUS demonstrate that a perceived exposure can induce symptoms 

resembling an actual exposure.

The Goiânia radiation incident was a dramatic 

example of a co-occurrence of OMUS and a CBRNE 

event. Over 125,000 people demanded to be screened 

for radiological exposure following the news of radiological contamination.38 Screening identified only 

249 persons with any radiological contamination, but 

5,000 of the first 60,000 people screened had symptoms 

consistent with radiation sickness (vomiting, diarrhea, 

and/or rashes around the face and neck). None of the 

symptomatic persons were contaminated.

Chemical Warfare Agents

The Israeli experience with 18 Scud missile attacks 

during the Persian Gulf War involved both the effects of missile explosions and, at least initially, the 

perception of a possible nerve agent attack. One study 

of patients arriving in the emergency departments of 

11 local hospitals in Israel19 found that approximately 

332 of the 773 casualties (43%) were psychological 

casualties and an additional 209 (27%) had injected 

themselves with atropine because they feared the 

missiles contained nerve agent. After the first Scud 

attack, there were 365 casualties: 172 psychological 

casualties (47%), 171 cases of unjustified atropine 

injections (47%), and only 22 cases of physical injury 

(6%). Another study20 looked at patients reporting 

to the emergency department of a Tel Aviv hospital 

within 8 hours of a Scud attack. Of the 103 patients 

admitted, 70 had psychological distress (68%) and 19 

had unjustified atropine injections (18%); only 9 had 

direct injuries (9%). All these findings were among 

civilians, not soldiers. 

After the 1995 sarin attack in the Tokyo subway,33,39

over 5,500 people visited 280 medical facilities the day 

of the attack and the following week. Of these, 1,046 

were admitted as patients. Saint Luke’s International 

Hospital saw the most patients: 641 patients on the 

first day and 349 in the following week.39 Of the 641 

patients admitted to the emergency department on the 

first day, 111 were admitted to the hospital (4 severe 

cases, 107 moderate cases), and 530 mild cases were 

observed for 6 hours and then released. The patients 

with mild cases suffered mainly from eye problems. It 

is difficult to determine from the literature how many 

of the mild cases were psychological casualties.

Biological Agents

In 1994 two outbreaks of plague occurred in India: 

a bubonic plague outbreak in Maharashtra state, followed by a pneumonic plague outbreak 1 month later 

and 500 km away in Surat.40 Of the 5,000 suspected 

cases of plague, there were 167 confirmed cases and 55 

deaths.41 Unfortunately, no data are readily available 

on psychological reactions or rates of such reactions. 

However, there were observable effects on behavior. 

The local media fueled the anxiety with exaggerated 

reports.41,42 An estimated 400,000 to 600,000 people fled 

Surat, including hospital staff, private medical practitioners, and municipal workers.43,44 In Delhi, 1,200 km 

from Surat, people fashioned masks from available 

materials, and many bought and hoarded tetracycline, 

an antibiotic used to treat plague.45

In 2001, after the September 11th attacks and before 

the first of 23 anthrax cases,46 the media had already 

reported increased purchases of gas masks and ciprofloxacin (“cipro,” used to treat anthrax). After the 

anthrax mail attacks, there were increased patient 

requests for ciprofloxacin and anecdotal reports of 

increased prescriptions.47 Hospitals reported their already busy emergency rooms were filled with people 

anxious about anthrax, many demanding treatment.

The outbreak of SARS, a new and emerging infection, created much fear and anxiety. In Beijing, schools 

and universities were closed, hundreds of companies 

closed their doors, and some surrounding villages shut 

themselves off from contact with others.48 Rumors of 

neighborhoods being quarantined led to stockpiling of 

food.49 Although officials asked people to avoid travel, 

thousands of businesspersons, migrant workers, and 

college students left Beijing. In Taiwan, 160 doctors and 

nurses quit work at various hospitals, fearing both the 

disease itself and the inadequacy of infection control 

measures.50 SARS patients often spent hours in isolation between contacts with staff and were deprived 

of family visits, leading to complaints of sadness, 

anxiety, boredom, loneliness, and nonspecific anger 

and frustration.51,52 Fear and anxiety often waxed and 

waned with fever.51

One study measured the psychosocial effects of 

SARS on hospital staff in a Toronto hospital using 

questionnaires.53 Almost two thirds of the respondents 

reported concerns for their own or their family’s health. 

Factors associated with increased concerns were perception of a greater risk of death from SARS, living with 

children, personal or family lifestyle affected by SARS 

outbreak, and being treated differently by other people 

because of working in a hospital. Emotional distress 

was found in almost 30% of all responders and in 45% 

of nurses, who were most at risk for infection. Factors 

identified for significant association with emotional 

distress were being a nurse, part-time employment 

status, lifestyle affected by SARS outbreak, and ability 

to do one’s job affected by precautionary measures.
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Radiological Agents

The Three Mile Island (TMI) accident in Pennsylvania in 1979 demonstrated the importance of 

psychological effects following a CBRNE incident. 

According to the president’s commission that studied 

the accident, the only medical effect documented was 

mental distress.54 There were no cases of ARS, and the 

estimated exposure doses for people living within 10 

miles of TMI were approximately the dose of an average chest radiograph, much lower than the annual 

background radiation dose.55 Populations exhibiting 

the most distress were TMI workers, families with 

preschool-age children, and those living within 5 miles 

of TMI. Studies of TMI workers reported no long-term 

effects, only short-term acute effects. TMI personnel reported nausea, stomach troubles, headaches, 

diarrhea, sleep disturbances, and loss of appetite in 

greater frequency than did the control group. These 

symptoms are also common to the ARS prodrome, but 

TMI personnel were not exposed to radiation doses 

that would cause ARS.

Unlike the TMI accident, the 1986 Chernobyl accident in Ukraine did release significant amounts of 

radiation. Approximately 135,000 people were evacuated from a 30-km zone in the first 2 weeks after the 

accident. Most of these people had to be permanently 

relocated. In addition, an estimated 600,000 to 800,000 

“liquidators” were brought in to handle the emergency situation and subsequent cleanup operations.56

Although over 200 cases of ARS were recorded, the 

primary health effect was widespread psychological 

distress.57,58

In the 1987 Goiânia incident, two scavengers removed a cesium-137 teletherapy unit from an abandoned radiotherapy institute.59 While dismantling the 

unit, they accidentally ruptured the source capsule 

that contained radioactive cesium-137 powder. When 

the accident became public, the perceived threat of 

radiation exposure caused over 120,000 people (approximately 10% of the city’s population of 1.2 million) to be screened over a 6-month span for possible 

contamination.60 Residents and others in the city at 

that time felt sufficiently at risk that they took time 

off from work or came on weekends to wait in line to 

be scanned.38,61 Approximately 5,000 (8%) of the first 

60,000 people screened presented with symptoms that 

mimicked ARS (eg, rash around neck and upper body, 

vomiting, diarrhea), but none of these individuals 

were contaminated.38 Only 249 people had measurable 

radiological contamination.

Explosives

Acute psychological effects were reported in 50% of 

bomb-injured patients in one study.62 Another study 

reported that approximately 12% of the casualties 

presented with emotional distress, with another 6% 

presenting with medical problems (eg, angina, diabetes, headache, or asthma).63

Mental Disorders

Chemical Warfare Agents 

Most patients from the Tokyo sarin attack who were 

admitted to a hospital remained hospitalized for a few 

days. Some reported sleep disturbances, nightmares, 

and anxiety. Whether these symptoms were due to 

acute stress disorder or to exposure to nerve agent is 

unknown. In studies done 1 month after the event, 

nearly 60% of casualties reported suffering from 

postincident symptoms, including fear of using the 

subway, sleep disturbances, flashbacks, depression, 

nightmares, irritability, headaches, malaise, physical 

tension, and emotional lability and irritability.33,39

Follow-up questionnaires at 3- and 6-month intervals 

showed little decrease in the percentage reporting 

symptoms. Unfortunately, it is difficult to determine to 

what extent these symptoms were psychological effects 

and to what extent they may have been sequelae to the 

cholinergic effects of sarin exposure. Because most of 

the casualties from Saint Luke’s International Hospital 

were mild cases (suffering mainly eye symptoms), it 

is possible that many of the postincident symptoms 

were psychological.

Radiological Agents

Most of the 20 hospitalized Goiânia patients suffered from depression and anxiety.64 The 11 victims 

most seriously affected were moved to one hospital, 

where they were kept confined and isolated because 

of immunosuppression, and the medical personnel 

treating them wore protective masks. Both measures 

increased stress in patients. Uncertainty about future 

health effects also increased stress, as did the lack of 

information concerning the duration of their treatment 

and the long-term prognosis.

Nuclear Weapons

Of all CBRNE agents, nuclear weapons have the 

greatest destructive impact—they are the quintessential weapons of mass destruction. The atomic weapons 

dropped on Hiroshima and Nagasaki caused incredible devastation, outbreaks of local fires, and large 

numbers of dead, dying, and injured people.65 In interviews done after the war, approximately two thirds 

of survivors described psychological disturbances of 
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Combat and Operational Behavioral Health

intense fear, emotional upset, or depression. However, 

only a single incident of an apparent mass panic was 

reported at Hiroshima: a large group of frightened 

people in a park pressed some victims into a river, 

and several died.66

During the following weeks, survivors continued to 

witness the sight of severely injured people suffering 

from burns and blast injuries. In addition, there were 

outbreaks of ARS. The continued exposures to the 

devastation and human suffering served as a constant 

reminder to survivors and reinforced the psychological 

impact of the original event.65

LONG-TERM EFFECTS

Distress and Chronic Outbreaks of Multiple Unexplained Symptoms

Although acute OMUS has been widely studied, 

the possibility of long-duration and large-scale OMUS 

syndromes has only lately been suggested.67 In recent 

years, a number of different chronic syndromes (eg, 

chronic fatigue syndrome, environmental somatization syndrome, multiple chemical sensitivity syndrome, and sick building syndrome) have appeared, 

all characterized by multiple nonspecific symptoms 

(eg, fatigue, headaches, sleep disturbances, nausea, 

dizziness, muscle and joint pains, and difficulties with 

memory and concentration) that are not connected 

with specific infectious or toxic agents.68–70 In each of 

these syndromes, the patient attributes an invisible 

contaminant or infectious agent as the cause for the 

symptoms.

Military Experience

The military has seen several chronic OMUS syndromes, including Agent Orange syndrome, atomic 

veterans syndrome, and Gulf War syndrome.3 Agent 

Orange syndrome began when the media publicized 

an association between exposure of Vietnam veterans 

to Agent Orange and a reported epidemic of cancer 

and children born with birth defects. Epidemiological 

studies done by the Centers for Disease Control and 

Prevention found no evidence of increased incidence 

of cancer or birth defects in this population.71–73 However, an increased prevalence of depression, anxiety, 

alcohol abuse or dependence, and posttraumatic 

stress disorder (PTSD) was demonstrated in Vietnam 

veterans compared with subjects who had not fought 

in Vietnam.71 Another study found that symptoms of 

psychological distress were strongly associated with 

self-reported herbicide exposure. This group presented 

with more symptoms than were found in Air Force 

personnel actively involved in aerial spraying of herbicides.74 This suggests that Agent Orange syndrome 

might be more related to a perception of exposure than 

to actual exposure.

An estimated 200,000 Department of Defense personnel (both military and civilian) observed the early 

US above-ground nuclear tests.75 The external doses 

received by these “atomic veterans” averaged about 

0.5 rem, with many receiving no dose and only 1% 

receiving a dose greater than 5 rem (the maximum annual occupational dose). Several case studies of atomic 

veterans reported long-term psychological distress.76,77

Initially, troops at the Desert Rock V test seemed to go 

through the experience with equanimity,78 but many 

years later, an anecdotal study found that veterans 

reported vivid recollections of an atmosphere of tension and fear at the test sites and thought they had 

been ill-prepared.76

A cluster of functional somatic symptoms was reported in atomic veterans and dubbed the “radiation 

response syndrome.”77 The syndrome has two components: (1) a core belief that radiation had caused 

physical harm, and (2) functional somatic symptoms 

that appeared to be an expression of this belief. The 

radiation response syndrome belief system included 

the views “that men were dying, that doctors are of 

little help, that one doctor may exist who could help, 

that the government is to blame for their illness, and 

that people think they are crazy for blaming exposure 

to ionizing radiation for their illnesses.”77(p128) Radiation 

response syndrome resembles delayed-onset PTSD, 

but rather than reexperiencing the trauma as in PTSD, 

the veterans are preoccupied with radiation and its 

effect on their lives. 

Chemical Warfare Agents

Three years after World War I, approximately one 

half of gassed veterans claimed subjective complaints 

in medical examinations.79 When there were no objective findings, no compensation or pensions were 

paid, nor were these complaints included in statistics 

of permanent disabilities. There were reports of large 

numbers of men who had recovered from acute gas 

poisoning and had good physical examinations, but 

suffered from serious sequelae, most particularly 

of easy fatigability and difficulty breathing on exertion.80 This condition was variously known as effort 

syndrome, disordered action of the heart, and neurocirculatory asthenia. Chronic gas cases often involved 

acute attacks of breathlessness at night accompanied 

by nightmares, and patients usually reported insomnia 

and unrefreshing sleep.80
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

A long-term study of sarin patients who had been 

hospitalized at Saint Luke’s Hospital found that 

somatic and psychological symptoms continued for 

5 years after the incident.81 A high rate of medically 

unexplained physical symptoms was reported. Eye 

symptoms, fatigue, muscle stiffness, and headache 

were all reported by more than 10% of the study 

population.

Biological Agents

Puzzling long-term effects were seen in the survivors of the 2001 anthrax attacks. Newspapers reported that survivors continued to exhibit symptoms 

of fatigue, shortness of breath, chest pains, memory 

problems, nightmares, and rage 6 to 12 months after 

their illnesses.82 Only one of the inhalational anthrax 

survivors was well enough to return to work at the 

time of the study. In the one published study of anthrax 

survivors 1 year after the attack, many of the survivors 

reported reduced health-related quality of life and 

psychological distress.83

Radiological Agents

No long-term psychological stress in TMI workers 

has been reported.84 However, TMI residents, compared to controls, displayed a significant amount of 

stress on several measures (performance; self-reported 

measures of anxiety, depression, and somatic complaints; physiological measures of urinary norepinephrine, epinephrine, and cortisol; disturbed sleep; 

and changes in immune system parameters) for up to 

6 years after the accident.85–87 The TMI symptoms were 

not the result of exposure to radiation but to perceived 

radiation threat, demonstrating that fear of exposure 

to radiation can cause significant distress and stress 

symptoms that can mimic symptoms of actual radiation exposure. 

The large number of people (~10,000) who lived or 

worked within 300 meters of the contaminated area 

in Goiânia exhibited fear, psychosomatic reactions, 

fear about the future, insecurity, and doubt about the 

effectiveness of government remedial measures.88 A 

public opinion poll conducted 6 months after the incident88 found that two thirds of both affected Goiânia 

residents and a control group living away from the 

contamination believed that Goiânia was still contaminated. Research conducted 3 years later showed that 

stress parameters were still increased and performance 

decreased both in nonirradiated individuals with perceived exposure (those living within 1 km of the area 

where contaminated waste from the incident had been 

stored) and in irradiated individuals from Goiânia.89

A variety of psychoneurological syndromes have 

been reported as sequelae of Chernobyl in the Russian 

literature.90–92 These syndromes are characterized by 

multiple unexplained physical symptoms including 

fatigue, sleep and mood disturbances, headaches, 

impaired memory and concentration, and muscle or 

joint pain. These syndromes were reported in liquidators who both had and had not experienced ARS.90,92

No significant correlations were found among physical 

symptoms, radiation dose, and physical examination 

data.92

Nuclear Weapons

Survivors of Hiroshima and Nagasaki were severely 

stigmatized, especially those with severe burns that resulted in scarring and keloids. Lifton described a “neurasthenic survivor syndrome” characterized by “persistence of symptoms of withdrawal from social life, 

insomnia, nightmares, chronic depressive and anxiety 

reactions and far-reaching somatization . . . in addition, 

fatigue, emotional lability, loss of initiative, and generalized personal, sexual and social maladaptation.”93(p504) 

A study of over 7,000 Nagasaki atomic bomb patients 

done 15 years later showed long-term psychological 

effects in approximately 7%, with the majority complaining of fatigue, lack of spirit, poor memory, and 

introversion.94 These symptoms were twice as common 

in survivors who had shown ARS symptoms and were 

related to severity of ARS symptoms.

Mental Disorders

Chemical Warfare Agents

PTSD has been reported in American World War II 

veterans exposed to mustard agent while participating in field trials and chamber tests.95 According to 

follow-up studies of the Tokyo sarin attack, conducted 

3 and 5 years after the accident by the National Police 

Agency and the National Research Institute for Police 

Science, reporting of somatic complaints—eye strain, 

weakened eye sight, and easy fatigability—remained 

relatively stable from the acute stage through both 

follow-up periods.33 PTSD symptoms still reported by 

14% to 18% of studied survivors included flashbacks, 

fear of the subway, intense distress at exposure to 

reminders of the attack, and avoidance of thinking 

about the attack. 

The casualties seen at Saint Luke’s were surveyed 

at 2, 3, and 5 years, using a questionnaire that asked 

about 14 physical symptoms, 8 eye symptoms, and 11 

psychological symptoms (symptoms of avoidance, hyperarousal, and reexperiencing).81 The most common 

symptoms across all time periods were eye symptoms: 

eye strain (33%–39%), dim vision (23%–26%), and 
602

Combat and Operational Behavioral Health

difficulties focusing (17%–21%). Physical symptoms 

(tiredness, fatigue, muscle ache, headache) were also 

common. Most of the psychological symptoms remained stable over the three time periods, with rates 

of 10% to 16% still being reported at the 5-year point 

for memory difficulties, depressed mood, avoidance of 

accident reminders, flashbacks, and fear in the subway 

or at the attack site. PTSD frequency, as determined 

by criteria in the Diagnostic and Statistical Manual of 

Mental Disorders, 4th Edition,

96 remained stable, with 

2% to 3% of patients meeting the criteria during the 

three time points. The incidence of partial PTSD (one 

symptom from each category) ranged from 7% to 9%. 

Because of the persistence of physical symptoms, a 

modified set of PTSD criteria (adding at least one 

medically unexplained physical symptom to the diagnosis) were developed, and 10% to 14% of patients met 

these criteria. The physical symptoms were reported 

to deteriorate following flashbacks and to improve 

during psychiatric therapy. The victims continued to 

be stressed by lack of government support, limited 

resources available for medical follow-ups, and a feeling of stigmatization.

Biological Agents

Several infectious disease outbreaks have been 

reported to cause both PTSD and a decreased healthrelated quality of life. For example, the majority of survivors of an outbreak of Legionnaires disease reported 

fatigue, neurologic symptoms, and neuromuscular 

symptoms 17 months after diagnosis.97 Health-related 

quality of life was impaired in seven of eight dimensions, and 15% of patients experienced PTSD. Similarly, 

survivors of acute respiratory distress syndrome have 

also reported PTSD and decreased health-related quality of life.98,99 Because most category A biological warfare agents cause acute respiratory distress syndrome, 

similar long-term effects should be expected.

Radiological Agents

A study conducted 8 years after the Chernobyl accident found that 44% of 1,412 Latvian liquidators had 

mental-psychosomatic disorders: depression (neurotic 

depression and brief depressive reaction), physiologic 

malfunction arising from mental factors, or unspecified disorders of the autonomic nervous system.100The 

actual numbers of mental-psychosomatic disorders 

might have been higher, but anxiety, PTSD, and sleep 

disturbances were not studied because of the coding 

scheme used.101 Two other studies of Chernobyl exposure found PTSD and PTSD symptoms.102,103

An epidemiologic study of over 4,700 Estonian liquidators found an increase in suicide, but no increases 

in cancer, leukemia, or overall mortality.104 Suicide 

accounted for almost 20% of mortality in the liquidator cohort. Reasons for the increased suicide rate are 

not currently known. However, data from Vietnam 

veterans with PTSD have demonstrated an increased 

risk for traumatic deaths, including suicide.105 Other 

studies demonstrating a variety of mental health disorders in Chernobyl liquidators support the speculation 

that fear of radiation might cause depression, PTSD, 

and other disorders associated with increased rates 

of suicide. The primary toxic agent appears to be fear, 

rather than radiation.

Explosives

Long-term psychological consequences after terrorist attacks with explosives have been reported. After 

the Oklahoma City bombing, 45% of the survivors 

suffered a postdisaster psychiatric disorder, including 34% with PTSD.106 Another study reported PTSD 

in 50% of the patients 6 months after a bombing.107

PTSD patients had a lower mean injury severity score 

(1.2) than did patients without PTSD (6.6). Nearly one 

in five civilian survivors of terrorist attacks (18%) in 

another study suffered from PTSD, while another 13% 

suffered from major depression.108 When broken down 

by severity of injury, PTSD was present in 31% of the 

severely injured, but in only 11% of the uninjured and 

8% of the moderately injured. The adjusted prevalence 

ratio for PTSD (severely injured/others) was 4.2. Similarly, major depression occurred in 22% of the severely 

injured, but in only 9% of the moderately injured or 

uninjured.108

Summary

Mass panic is not likely to occur in CBRNE incidents. Although mass panic can occur in situations 

involving limited escape routes, it will still probably 

be a rare event. Psychological effects are likely to cause 

large numbers of casualties following attacks using 

CBRNE weapons. Initial presentation may resemble 

combat stress casualties or may include a variety of 

nonspecific symptoms, such as difficulty breathing, 

dizziness, fatigue, headache, and sleep disturbances. 

Triage and differential diagnosis may be challenging 

in the initial stages. The number of psychological casualties could increase based on possible amplification 

of risk perception by mass media reporting. Unlike 

most physical injuries or illnesses caused by CBRNE 
603

Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

agents, psychological effects can be contagious. Given 

the history of postcombat syndromes, long-term effects 

are also very likely, and will be difficult to diagnose 

and treat. These chronic OMUS syndromes will also 

be greatly influenced by risk perception and mass 

media reporting. 

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Chapter 37

OPERATION IRAQI FREEDOM 05-07 

MEDICAL CIVIL–MILITARY 

OPERATIONS: LESSONS LEARNED IN 

HUMANITARIAN ASSISTANCE

JEFFREY S. YARVIS, PhD*

INTRODUCTION

BACKGROUND

PARTNERING WITH NONGOVERNMENTAL ORGANIZATIONS AND GOVERNMENTAL ORGANIZATIONS

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington, DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland
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INTRODUCTION

The primary mandate of Task Force 30th Medical 

Brigade (TF 30) is force health protection. During 

Operation Iraqi Freedom (OIF) 05-07, TF 30 saved the 

lives of an unprecedented 96% of the wounded soldiers 

entering its facilities. Also historic was the way in 

which the task force commander employed behavioral 

health assets and their unique skills for the brigade’s 

civil-military operations. 

Medical brigades, with their organic clinical operations section and civil-military operations staff, represent a robust public health team capability unsurpassed 

by even the public health teams organic to a civil affairs 

brigade. Nearly half of the casualties seen in coalition 

hospitals were Iraqi; to transition these medical cases 

back to the Iraqis, Iraqi military and civilian medical 

capabilities must be enhanced.1 TF 30 Medical CivilMilitary Operations (CMO) joined together with the 

Department of State, Multi-National Force–Iraq (MNF–

I), nongovernmental organizations (NGOs), private 

companies, and the Focused Stabilization Task Force of 

the Multi-National Corps–Iraq (MNC–I) to accomplish 

this goal. TF 30 also facilitated humanitarian assistance 

to vulnerable populations in Iraq. 

In fiscal years 2005 and 2006, TF 30 assisted in 

securing more than $70 million to support humanitarian needs, including establishing emergency health 

services; enhancing water treatment and sewage 

plants, clinics, hospitals, and schools; and facilitating 

agricultural projects through effects-based planning 

with local and regional host-nation government officials. These efforts bolstered the legitimacy of the 

local medical officials, opened lines of communication 

between local individuals and local leaders with the 

Iraqi national government, created access to care, and 

promoted livelihoods. Due to the highly fluid nature 

of the internally displaced person (IDP) population in 

Iraq, TF 30 also supported ongoing preventive medicine operations for humanitarian assistance for IDPs. 

This chapter will discuss the medical civil-military 

lessons learned by TF 30 during OIF 05-07.

BACKGROUND

 The US military routinely executes medical humanitarian missions. These missions encompass 

everything from medical support, to civic action, to 

capacity development or enhancement projects, to 

major theater wartime operations. The public affairs 

benefit of military medical forces providing support to 

another nation in conflict seems apparent. Assisting the 

injured, sick, and wounded, and providing access to 

care to displaced peoples seems beneficial. However, 

as Ritchie and Mott2

 point out, many pitfalls are associated with providing assistance. Past literature on the 

pitfalls of military humanitarian assistance was largely 

concerned with the ethical issues of providing care that 

cannot be sustained by the host nation, resulting in 

“doing more harm than good.” This harm is often associated with the medical rules of engagement that are 

tied to the amount of resources the US military brings 

to support troops in a theater of operations. However, 

often overlooked are how the medical humanitarian 

assistance missions are tied to the strategic end state of 

an operation and how these missions may contribute 

to or detract from a mission.3

To frame military humanitarian assistance missions, it is necessary to go back to the purpose of all 

operations: to create a secure environment in which 

political and economic development can proceed. 

Therefore in Iraq, the end state of all missions, to 

include medical civil-military missions, is to create 

legitimate local and provincial Iraqi governments 

capable of continuing political and economic development. Furthermore, to stabilize the Iraqi government, 

the effect of the insurgency must be minimized. Insurgency is both a political and a military phenomenon. 

Insurgents will be frustrated if the government has a 

competent and capable administration that dispenses 

services and effectively coordinates a multitude of political, economic, and security policies. In Iraq, access 

to and delivery of medical care represents a tangible 

reminder that the government is functioning. These 

functions are also exploited by the insurgency. If the 

insurgency or those sponsoring it control serviceoriented ministries, then the Iraqis will believe that it 

is the insurgency that is providing this care to them. 

In other words, healthcare is something that can be 

utilized by both the US military and the insurgency. 

The perceived Iraqi government response to the 

medical needs of its people is thus a key variable in 

achieving US political-military objectives. 

President George W Bush recognized the importance of healthcare in achieving US political-military 

objectives when he said, 

America is now threatened less by conquering states 

than we are by failing ones....The United States 

should invest time and resources into building international relationships and institutions that can help 
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manage local crises when they emerge....We will 

use our economic engagement with other countries 

to underscore the benefits of policies that generate 

higher productivity and sustained economic growth, 

including...investments in health and education that 

improve the well-being and skills of the labor force 

and population as a whole.4

Tommy G Thompson, the former US Secretary 

of Health and Human Services, noted that military 

missions must include medical strategies. He stated 

that the “[m]ost effective arsenal against terrorists 

[contains]: education, compassion, and medicine.”5 He 

also said that the “[b]est chance to defeat the terrorists 

[is] by enhancing our medical and humanitarian assistance.”5

 History demonstrates the effectiveness of 

such strategies. During World War II, the US employed 

military humanitarian assistance in the Philippines. 

It has continued to do so in places such as Haiti and 

Bosnia because of a moral mandate in support and 

sustainment operations.2

The military operations other than war and peacetime engagement projects that represented the bulk 

of military humanitarian missions in the 1990s were 

inherently different than the missions occurring 

today in Iraq and Afghanistan. In Iraq, for example, 

the war began with kinetic fighting—attacking the 

enemy with weapons and destroying infrastructure 

along the way. As the United States approached the 

transition phase of operations during OIF 05-07, 

efforts were refocused on building projects. The 

various projects were undertaken to restore basic 

health services and address public health concerns 

to mitigate the health effects that were the result of 

the kinetic fight. 

Now as the shift continues to the nonkinetic fight, 

the aim is to preserve existing structures, develop 

capacities, and target key structures critical to transitioning the health “battlespace.” After three to four 

rotations in Iraq, medical civil-military operations 

were incorporated into all transition operations from 

the start and in all levels of planning—strategic, operational, and tactical. Waiting until the kinetic fight 

is over to plan and execute civil-military projects is 

not a workable concept.6

 Simultaneous integration of 

civil-military operations represents a shift in the operational effort following combat operations to a nonkinetic main effort. As the transition phase proceeded, 

the civil dimension became a part of the main effort. 

Following security gains, constructive engagement to 

repair damage and build on security success must begin in earnest. This is where longer-term success and 

true transition to civil control will become possible. 

The civil dimensions noted in Ritchie and Mott2

—rule 

of law; facility/critical infrastructure assessment and 

repair; critical needs assessment (health, safety, and 

so forth); and local governance/leadership—all had 

to be focused. In addition, the TF 30 medical civilmilitary operations included nontraditional actors in 

the planning and execution process, such as NGOs 

and international organizations.

As mentioned earlier, medical civic action programs 

(MEDCAPs) and other medical military humanitarian assistance projects have apparent benefits such 

as “winning the hearts and minds.” However, the 

contrary was true in Iraq; the apparent benefits of 

“tailgate” medicine were not realized because these 

missions were not tied to lines of operation and the 

strategic political-military objectives. Furthermore, 

the value to US medical personnel was not apparent. 

The need to transition patients back to an independent and capable host nation medical system was 

burdened by MEDCAPs. The medical civil-military 

end state defined by the XVIII Airborne Corps during 

OIF 04-06 was defined as: “To conduct coordinated 

cooperative medical engagements at the provincial 

level to strengthen governance and transition lines of 

operation in support of campaign plan and overall US 

objectives in Iraq.”7No clear end state was identified in 

this mission statement. Past operational civil-military 

operations and plans did not effectively develop governance capacity in provinces. Furthermore, no standing 

organizations existed for coordination and support 

to medical civil-military operations at the national 

level. By OIF 05-07, it was clear that what was needed 

were fundamental changes in behavior, structure, and 

organization to address gaps in medical civil-military 

staffing and skill sets at the operational and strategic 

level. Inattention to these gaps led to inconsistent and 

“stovepiped” MEDCAPs that offered little long-term 

benefit and could not be quantified in terms of measures of effectiveness.

To implement the national strategy at the transition 

phase of operations in Iraq to achieve the politicalmilitary objectives set forth by the commander of the 

MNF–I, the following seven assumptions were made 

by the US medical civil-military operations team:

1. Increased governance capacity building and 

assistance is necessary to develop sustained 

capability of provincial governments. 

2. Existing organic civil affairs public health 

teams will maintain current capability in 

provinces until their efforts are tied to the 

operational main effort, which when established will represent fully coordinated, joint 
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medical civil-military teams. 

3. A need exists to develop a formalized mechanism for coordinating provincial activities 

and support at the Department of State and 

MNF–I. 

4. Capability to provide enhanced health support to provincial governments must persist 

beyond elections. 

5. The Iraqi national government will need to 

support increased medical outreach at the 

provincial and district levels. 

6. Coalition resources necessary to support any 

new medical civil-military operations efforts 

will be available. 

7. Medical civil-military efforts can be tailored 

to meet the needs and security situation 

existing in each province. Substantial capability of provincial governments will be 

developed in 2 years, allowing transition to 

more traditional US Agency for International 

Development (USAID), international organization, governmental organization, and NGO 

assistance delivery mechanisms to provincial 

and local governments for an additional 2 

years. 

Given these assumptions, the following mission 

statement for medical civil-military operations was 

developed:

• To assist Iraq’s provincial director generals 

of health with developing a transparent and 

sustained capability to promote public health 

and provide provincial administration necessary to meet the basic health needs of the 

population. 

• To provide timely and relevant assessments 

of health infrastructure and political developments in the Ministry of Health at the local 

level, and to promote Coalition governance 

and capacity development goals.

To implement the mission statement, the following 

eight tasks were identified: 

1. Facilitate achievement of Coalition goals in 

Iraq by enhancing the capabilities of the Iraqi 

health sector from the district level within 

the Ministry of Health and the battalion level 

within the Ministry of Defense. 

2. Promote health reform at the provincial 

level. 

3. Assist local ministry representatives and Iraqi 

Army surgeons with developing a comprehensive strategy that results in a capable and 

accountable local government. 

4. Assist provincial governments with identifying and prioritizing the needs of their citizens 

and with addressing those needs via the Iraqi 

government, Coalition, donor, and NGO 

resources. 

5. Assess health capabilities of provincial governments and develop a joint plan of action 

to increase these capabilities, with emphasis 

on sustainability. 

6. Assist provincial governments in developing 

short- and long-term goals for public health 

programs, and assist with their implementation.

7. Coordinate with other major subordinate 

commands to synchronize medical governance efforts with stability operations. 

8. Coordinate with civil affairs assets to assess 

health sector developments at the local level, 

and to advocate Coalition goals and objectives. 

These tasks were augmented with some of the 

peacetime concepts for civil-military operations noted 

in Ritchie and Mott2—train, coach, and mentor local 

government medical entities to develop their capacity to: 

• develop core competencies and standards of 

care; 

• establish effective linkages with ministries and 

central government; 

• help Iraqi health officials plan and prioritize 

direction and activities; 

• prepare critical needs lists, identify funding 

needs, and identify resources; and

• determine facility staffing requirements and 

assist medical officials to address these with 

their next higher minister or officer. 

The G-5 (civil-military operations officer) of TF 

30 also addressed systemic gaps through resource 

development activities for the MNC–I. Specifically, 

TF 30: (a) coordinated support by donors and NGOs; 

(b) communicated with stakeholders via effective 

public affairs and information operations activities; 

(c) provided and enhanced the delivery of provincial 

and municipal health services to include emergency 

medical services; (d) developed subordinate medical civil-military operations working groups; and 

(e) involved host-nation medical contacts in medi-
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cal reconstruction activities to ensure the cultural 

relevance of all TF 30 projects. All of these efforts 

had to be observable in some meaningful way, 

therefore qualitative and quantitative measurements of success against established benchmarks 

were provided.

The involvement of Iraqi healthcare officials in TF 

30’s medical civil-military operations planning seems 

obvious, however, it had been routinely ignored by 

previous rotations. Upon implementation of the TF 30 

medical civil-military engagement strategy, Iraqis were 

part of meetings at all levels of planning. This involvement was key to the paradigm shift from MEDCAP as 

the main thrust of medical humanitarian assistance 

to a more comprehensive process called “cooperative 

medical engagements.” Cooperative medical engagements are specific humanitarian assistance opportunities led by Iraqi civilian or military medical personal 

for which US involvement is incidental to the overall 

engagement. Each cooperative medical engagement 

must focus on assisting the Iraqi medical system and 

the Iraqi Security Forces to provide for its civilian 

population. The projects must advance operational 

security goals; improve access (to regions and to the 

people); reinforce security and stability; and generate 

good will to enhance the US ability to shape the operating environment. Projects must be humanitarian in 

nature and must compliment the strategic goals and 

objectives of the Ministry of Health. Addressing the 

medical rules of engagement and misuse of MEDCAP, 

cooperative medical engagements do not allow for 

direct care to the Iraqi people unless it is a life, limb, or 

eyesight issue. The corps surgeon is the coordinating 

and approving authority for all cooperative medical 

engagements.

On August 18, 2005, then Secretary of Defense 

Winkenwerder stated that, “[t]he primary goal of the 

US Governmentin matters of world health is to build 

capability and capacity so that societies may address 

their healthcare needs.” Cooperative medical engagements promote this concept. Initial reconstruction 

efforts had been designed to create entire healthcare 

systems for, and not with, the Iraqis. According to the 

Department of State,7

 $786 million from international 

and US sources was provided for health-sector development. However, few substantial gains were made 

in terms of transitioning healthcare back to the Iraqis 

or increasing access to care. TF 30’s goals were more 

modest: building on existing platforms, identifying 

medical systems that could assist with the transition 

to the host nation through partnerships with the Iraqi 

Security Force and TF 30 facilities, or assisting medical 

systems key to stabilizing Iraq. Department of Defense 

Directive 3000.5 states, “Integrated civilian and military efforts are key to successful stability operations.”8

Executing this directive meant implementation at the 

local and regional levels, and allowing lower-level officials to communicate needs in a culturally acceptable 

way with the National Ministry of Health. Such open 

lines of communication and systemic cooperation 

across the country enhanced the legitimacy of all the 

health officials involved. Involving Iraqis through 

cooperative medical engagements addressed issues 

created by MEDCAPs. Ritchie and Mott2 describe 

pitfalls of peacetime engagement projects. Some of 

the pitfalls that they identified—short-term focus, 

inadequate planning, disruption of local healthcare, 

and raising expectations for care—were all real problems that undermined long-term political-military 

objectives in Iraq. For instance, many medical civil 

affairs public health teams conducted “a MEDCAP 

a week,” without any apparent reason. In addition 

to the problems discussed by Ritchie and Mott,2

MEDCAPs also created parallel systems, vacuums 

of care when medical assets were moved around the 

battlefield, and resentment among Iraqi officials who 

often did not have an opportunity to vet these projects, 

determine if there was need for US interventions, or 

simply have the means to sustain US efforts once care 

was withdrawn. TF 30 and the corps surgeon’s office 

were determined to achieve small, sustainable, and 

observable efforts. 

Small sustainable humanitarian assistance projects 

created tangible results, increasing the legitimacy of 

Iraqi medical care and governance with potential for 

growth of Iraqi systems in a culturally relevant way. 

Using Natsios’ “Nine Principles of Reconstruction 

and Development”9 and considering the dimensions 

of nation building, TF 30 had highly successful cooperative humanitarian assistance operations, engaging 

Iraqis at the tactical, operational, and strategic levels 

(Exhibit 37-1).

These nine principles should guide medical planners in the targeting and execution of medical CMO 

and humanitarian assistance missions. Such planning 

is consistent with the effects-based planning conducted 

by military planners representing the full spectrum 

of battlefield operating systems and is not limited to 

medical planners. When employing these principles, 

the objectives of all CMO efforts should be to gain 

targeted effects that support the mission of the higher 

command, the commander’s stated lines of operation, 

and the national strategy for the intervention for Iraq. 

It is also important, however, to understand that these 

concepts represent a departure from civil-military 

doctrine.10
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Combat and Operational Behavioral Health

EXHIBIT 37-1

NINE PRINCIPLES OF RECONSTRUCTION AND DEVELOPMENT

In 2005, Natsios1 delineated nine principles that guide the US foreign assistance community, which includes the US 

military, in the provision of aid to a variety of war-torn countries:

In a time of increasing collaboration between the two organizations [military and USAID], it is important that 

the military gain a better understanding of how USAID [US Agency for International Development] and development agencies generally approach their work, and how the two communities can beneficially build on 

this cooperation. . . .When a foreign assistance agency adheres to the Nine Principles, this greatly enhances the 

likelihood of success. Conversely, failure to take the Nine Principles into account when designing and managing a program increases the risk of program failure. . . . Just as a particularly skilled battlefield commander can 

violate one or two of the principles of war and still prevail, a development officer may violate one or two of the 

development principles and still succeed. But generally development agencies ignore these principles at great 

risk, particularly in countries like Iraq, Afghanistan, and Sudan, where major reconstruction efforts are under 

way.1(p5)

This table presents the nine principles for successful collaboration between the US military and other agencies, and 

the US military experience in Iraq with the utilization of the principles. The first two columns are from the Natsios 

article; the third column delineates how TF 30 interpreted and employed the “Nine Principles” in Iraq.

Principle Description Experience in Iraq

Principle 1: Ownership—

Build on the leadership, participation, and commitment 

of a country and its people.

The first principle of development 

and perhaps the most important is 

ownership. It holds that a country 

must drive its own development 

needs and priorities.

Leadership, participation, commitment of host 

nation.

Activities should enhance legitimacy of host 

nation.

Principle 2: Capacity 

Building—Strengthen 

local institutions, transfer 

technical skills, and promote 

appropriate policies.

Capacity building involves the 

transfer of technical knowledge 

and skills to individuals and 

institutions so that they acquire the 

long-term ability to establish effective policies and deliver competent 

public services.

Activities that enhance legitimacy of local 

professionals through accredited training 

models and certification programs.

Activities that allow self-sustaining operational capability such as training in use of 

budgets and logistical systems.

Activities that promote personal accountability 

and ownership of product and process.

Principle 3: Sustainability—Design programs to 

ensure their impact endures.

The core of the sustainability principle is that development agencies 

should design programs so that 

their impact endures beyond the 

end of the project.

Impact must endure, for example: TF 30 created the first self-sustaining Iraqi medical 

association in Iraq.

Risk if ignored: alienation of local population.

Principle 4: Selectivity—

Allocate resources based on 

need, local commitment, and 

foreign policy interests.

The selectivity principle directs US 

bilateral assistance organizations 

to invest scarce aid resources based 

on three notions: humanitarian 

need, the foreign policy interests of 

the United States, and the commitment of a country and its leadership to reform.

Needs assessment plus political-military 

objectives need not be expensive or time 

consuming.2

 Example: disease nonbattle 

injuries (DNBIs) at Iraq Security Force camps 

increased during the Ramadan holiday. Targeted Iraqi camps (nodes) were given handwashing campaign posters and water-testing 

strips for under $50/camp. In 2 months, 

DNBI from food- and water-borne sources 

went from approximately 300 Iraqi soldiers 

per month to zero. Lesson learned: did not 

have to create an entire preventive medicine 

program to address some immediate shortand potentially long-term problems.3

 (Exhibit 37-1 continues)
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

Principle 5: Assessment—

Conduct careful research, 

adapt best practices, and 

design for local conditions.

One of the most important tasks a 

development agency must undertake before designing and implementing a program is to conduct a 

comprehensive assessment of local 

conditions.

Research best practices, design for local conditions.

Nongovernment orgnizations (NGOs) may 

already have this information. Example: 

International Medical Corps has been doing 

medical humanitarian assistance for nearly 

30 years in Iraq.

Principle 6: Results—Direct 

resources to achieve clearly 

defined, measurable, and 

strategically focused objectives.

The principle of results is an outgrowth of the assessment principle. It means that before a donor 

agency even enters a particular 

country, it first determines its strategic objectives.

Results measured by standards, indicators, 

and effectiveness. 

Measures of standards; qualitative or quantitative. Example of qualitative standards: 

increased use of host-nation ambulances to 

clear battlefield and increased transportation of Iraqi casualties directly to host-nation 

facilities.

Performance (process) indicators: decreased 

length of stay by Iraqi patients at targeted US 

facilities (nodes) by as much as 70% in one 

year’s time.

Impact indicators: increased host-nation care 

for burn patients through capacity enhancement projects with Iraqi hospitals.

Measures of effectiveness: combination of key 

indicators, interdependent and multisectoral; 

more useful in longer missions; useful to 

determine transition criteria; need to partner 

with civilian agencies to do these right.

Principle 7: Partnership—

Collaborate closely with

governments, communities, 

donors, nonprofit organizations, the private sector, 

international organizations, 

and universities.

The partnership principle is a 

central element of USAID’s business model and holds that donors 

should collaborate closely at all 

levels with partner entities, from 

local businesses and private voluntary organizations to government 

ministries.

Collaborate not only with the health attaché 

and host-nation minister of health, but also 

NGOs and international organizations. 

Principle 8: Flexibility—

Adjust to changing conditions, take advantage of 

opportunities, and maximize 

efficiency.

Development assistance is fraught 

with uncertainties and changing circumstances that require 

an agency to continuously assess 

current conditions and adjust its 

response appropriately.

Adjust to changing circumstances.

Be aware of cultural, political environment.

Principle 9: Accountability—Design accountability and transparency into 

systems and build effective 

checks and balances to guard 

against corruption.

There are two important aspects 

to the accountability principle: 

donors should work to fight corruption in the countries where 

they operate, and donors must also 

ensure that the actual programs 

they implement are transparent 

and accountable.

Transparency (within security restrictions).

Avoid corruption.

Perception is everything.

(1) Natsios A. Nine principles of reconstruction and development. Parameters. 2005:5–20. (2) Bonventre G. Capacity-building in the health 

sector. Presentation to the Combatant Command Surgeons Conference. December 2005. Washington, DC. (3) Yarvis JS. Social workers as 

civil affairs officers: medical civil affairs in Iraq. In: Actionable strategies for caring for our warriors, veterans and our country. Presented 

at the 112th Annual Meeting of Association of Military Surgeons of the United States (AMSUS). San Antonio, Tex. November 2006.

Exhibit 37-1 continued
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Combat and Operational Behavioral Health

PARTNERING WITH NONGOVERNMENTAL ORGANIZATIONS AND 

GOVERNMENTAL ORGANIZATIONS

TF 30 could not achieve optimal results without 

coordinating and synchronizing efforts with NGOs 

such as the International Medical Corps and Assisting Marsh Arabs and Refugees, and US governmental 

organizations such as USAID. These organizations are 

experienced in managing the second-order effects of 

combat and have substantive relationships in Iraq that 

often began well before OIF. Lacking a Commander’s 

Emergency Response Program of its own, TF 30 relied 

on the resources of the MNC–I as well as the NGOs. In 

turn, the NGOs relied on the technical expertise, security capability, and networking ability of the military 

to effectively develop partnerships between the Iraqi 

military medical community, Iraqi civilian medical 

community, and the Coalition medical community 

to accomplish humanitarian assistance missions. For 

example, TF 30 facilitated the identification and movement of over $60 million in humanitarian assistance 

medical supplies for Iraqi hospitals and primary 

healthcare centers from Humanitarian AssistanceKuwaitand US donors (via the Denton Amendment11). 

TF 30 was the lead on medical issues for the MNC–I 

Humanitarian Assistance Working Group, working 

to match the needs of the Iraqi medical systems with 

available medical supplies and to focus the medical 

efforts being conducted by agencies working in the 

health sector. This coordination by the TF 30 CMO staff 

gave visibility to the “ground truth” from the tactical 

level of the health sector, thereby giving actionable 

intelligence to the health attaché for the US Department of State as it coordinated with the Iraqi National 

Ministry of Health. 

The partnerships were not just focused on the 

delivery of tangible medical goods. Tangible goods, 

although extremely important in terms of demonstrating that Iraq can provide for its own people, are 

but one of many issues. Partnering with NGOs also 

involved sharing technical expertise and systems that 

enhance health promotion and delivery of services. 

Some of the enduring projects were the creation of 

three burn centers and a national trauma-training 

center, with an approximate cost of $2 million. These 

programs would allow Coalition hospitals to train 

and share expertise with their Iraqi counterparts 

while simultaneously developing the capacities of key 

Iraqi facilities. This will enable the Iraqis to gradually 

take over healthcare for critical neighborhoods and 

thus allow Coalition forces to transition out of caring for seriously ill and wounded Iraqi citizens and 

soldiers. An example of success in the area of Iraqi 

capacity was evidenced in their ability to “clear” or 

evacuate their own casualties from operational and 

civilian areas independent of Coalition evacuation assets. For example, during rotation 05-07, Iraqi medical 

facilities took over the health “battlespace,” increasing the clearing rate from 41% to 81% and caring for 

casualties directly without the help of the Coalition 

medical assets, meaning the Iraqis were now clearing 

81% of their casualties themselves. Another example 

of success was the decrease in the “length of stay” of 

Iraqi military and civilians in US medical facilities. 

Length of stay was defined as the number of days 

occupying a bed. In 7 months of capacity building, 

the length of stay in US beds decreased by an average of 6 days. This significant decrease occurred because Iraqi hospitals could now accept an increased 

number of patient transfers due to better Iraqi facilities, evacuation assets, and trained providers. Such 

capacity-building indicators were now being used 

by the MNC–I surgeon as measures of effect toward 

operational and strategic goals.

NGOs were well established in all 18 Iraqi provinces and therefore had relationships and credibility with 

the host nation. Because NGOs are neutral they can 

reach less approachable members of the health sector 

in the Iraqi Ministry of Health. NGOs must maintain 

the appearance of neutrality to be effective; military 

partnerships with them are less formal and not used 

as part of a military public affairs campaign. While 

humanitarian assistance activities make for good 

photo opportunities, the best public affairs stories 

come from programs that actually succeed. The worst 

example of health sector failures are structures that 

were built by the United States for Iraq, but sit empty 

or are used for other purposes by the enemy. Such 

failures can undermine US information operations. 

Typical focused humanitarian assistance partnership 

programs in the health sector are successful because 

the projects involve local contractors and workers, 

train local officials to staff programs and facilities, and 

are typically resourced at a degree that the community 

can maintain with its current level of financial, natural, 

and human resources. Furthermore, US medical CMO 

projects were linked to other civil-affairs projects to 

make them more comprehensive. TF 30’s preventive 

and veterinary assets were heavily involved in sewer, 

water, electricity, and trash (SWET) projects. When 

SWET projects augment humanitarian efforts, the 

insurgency was diminished in those “Beladiyahs,” or 

Iraqi districts. The key lesson learned from the NGO 

partners is that it takes much more than money and 

infrastructure development to be successful. 
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

SUMMARY

TF 30 had highly successful civil-military operations and successfully transitioned its operations to 

the 3rd Medical Command for OIF 06-08. Recognizing 

the importance of CMO and humanitarian assistance 

in stability, security, transition, and reconstruction operations, the 3rd Medical Command deployed a more 

robust CMO capability to capitalize on the successes 

of TF 30. However, to date very few Army medics 

are trained in humanitarian assistance, and there is 

no proponent in the Army Medical Department for 

medical CMO or humanitarian assistance. The civil 

dimensions of war must be planned for. To facilitate 

medical planners’ cognizance of the importance of 

CMO, doctrine and courses must be developed to 

meet needs of the operational commanders on today’s 

battlefields. 

REFERENCES

1. Swann S, Berry T. Task Force 30th medical brigade commander’s overview: OIF 05-07. Presented at: The Medical 

Service Corps Conference; November 2006; Grassau, Germany.

2. Ritchie EC, Mott R. Military humanitarian assistance: the pitfalls of good intentions. In: Beam TE, Sparacino LR, eds. 

Military Medical Ethics. Vol 2. In: Textbooks of Military Medicine. Washington, DC: US Department of the Army, Office 

of The Surgeon General, Borden Institute; 2004: Chap 25.

3. Ritchie E, Mott R. Caring for civilians during peacekeeping missions: priorities and decisions. Mil Med. 2002;167(3 

suppl):14.

4. Bush GW. In the National Security Strategy of the United States of America. September, 2002. Available at: http://georgewbush-whitehouse.archives.gov/nsc/nss/2002/index.html. Accessed July 28, 2010.

5. Thompson TG. The cure for tyranny. The Boston Globe. October 24, 2005. Available at: http://www.boston.com/news/

globe/editorial_opinion/oped/articles/2005/10/24/the_cure_for_tyranny/. Accessed July 28, 2010.

6. Bonventre G. Capacity-building in the health sector. Presented at: The Combatant Command Surgeons Conference; 

December 2005; Washington, DC. 

7. Bowersox J. Health sector update. Presented at: Task Force 30th Medical Brigade Commander’s Conference; December 

2005; Baghdad, Iraq.

8. Department of Defense. Military Support for Stability, Security, Transition and Reconstruction (SSTR) Operations. September 16, 2009. DoD Directive 3000.05. Available at: http://www.dtic.mil/whs/directives/corres/pdf/300005p.pdf. 

Accessed July 28, 2010.

9. Natsios A. Nine principles of reconstruction and development. Parameters. Autumn, 2005. Available at: http://www.

carlisle.army.mil/usawc/parameters/Articles/05autumn/natsios.pdf. Accessed July 28, 2010.

10. Department of the Army. Civil Affairs Operations. Washington, DC: DA; 2000. Field Manual 41-10.

11. Information on the Denton Amendment is available at: http://www.usaid.gov/our_work/cross-cutting_programs/

private_voluntary_cooperation/dentonguidelines.html. Accessed July 26, 2010.
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Combat and Operational Behavioral Health
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Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

Chapter 38

BEHAVIORAL HEALTH ISSUES IN 

HUMANITARIAN AND MILITARY 

RELIEF OPERATIONS: THE SPECIAL 

PROBLEM OF COMPLEX EMERGENCIES

THOMAS F. DITZLER, PhD*

INTRODUCTION

OPERATIONAL Behavioral health IN CONTEXT: THE HUMANITARIAN 

SPACE AND ITS PLAYERS

The International Community

Nongovernmental Organizations

Military Support to Other Players

PRINCIPLES AND PRACTICE OF CIVIL-MILITARY COLLABORATION IN Behavioral health

Security Needs and Information Sharing

Practical Considerations 

SPECIAL Behavioral health CONSIDERATIONS IN COMPLEX HUMANITARIAN ENVIRONMENTS

Factors Influencing Survivor Psychic Distress

Psychic Ground Effects 

Environmental Threats

PRINCIPLES OF Behavioral healthCARE IN HUMANITARIAN ENVIRONMENTS

Acute Phase

Reconsolidation Phase

SUMMARY

*Director of Research, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859
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Combat and Operational Behavioral Health

INTRODUCTION

The provision of timely, effective, and culturally 

competent disaster behavioral health services is critical 

in all phases of a disaster response. Historically, disaster management and humanitarian assistance planners 

have divided events into three general categories: (1) 

natural, (2) technological, (3) and complex. Natural 

disasters include common geological and meteorological events such as floods, cyclonic storms, earthquakes, 

volcanic eruptions, and tsunamis. For those directly affected, these events can be catastrophic, but they do not 

constitute meaningful political threats for the public 

at large. The same may be said for most technological 

emergencies, such as the Bhopal, India, chemical accident of 1984, or for catastrophic infrastructure failure, 

such as the Chernobyl nuclear reactor meltdown in the 

Soviet Union in 1986. These disasters are often the result of human error, but they do not generally represent 

acts of political intention or willful malice. Local teams 

of trained personnel typically provide the response to 

these events, with regional or national assets deployed 

as required. However, in very large or regional natural 

disasters, such as the December 26, 2004, Indian Ocean 

tsunami, or in complex emergencies involving politically mediated security and logistical problems, such 

as the conflicts in Somalia or the former Yugoslavia, 

the operating environment may require an integrated 

multinational civil-military response.1

A number of recent events have provided opportunities to examine the capacities and limitations of civilmilitary collaboration in disaster response in general,2

and in the provision of behavioral health support in 

particular.3 Because of the organizational and logistical 

burden of large-scale and complex emergencies, civilian and military behavioral health providers must have 

a sound working knowledge of the shared operating 

space and the players who help shape the context of 

services. This chapter will consider (a) the humanitarian 

space and its players, (b) benefits and challenges to effective civil-military collaboration, (c) special behavioral 

health considerations in complex environments, and (d) 

principles with demonstrated utility in helping affected 

populations return to predisaster functioning. 

Operational Behavioral health In Context: The Humanitarian Space and Its Players

Knowledge of the organizational and logistical aspects of integrated disaster response is critical to the 

efficacy of behavioral health services. The working 

environment is often referred to as the “humanitarian space”; it has been described in functional terms 

as an environment with the independence, flexibility, 

and freedom of action necessary to gain access and 

provide assistance to beneficiaries in a humanitarian 

emergency. For many civilian operators, including 

international and nongovernment organizations 

(NGOs), humanitarian space is achieved through acceptance of and adherence to the humanitarian principles of impartiality, neutrality, and independence as 

modeled by the International Committee of the Red 

Cross (ICRC).4

 Specifically, this means that aid is given 

regardless of race, creed, or nationality; aid is not used 

to further a particular political or religious position; 

and humanitarian and relief agencies do not act as 

tools of a state or policy.

Because military organizations responding to disasters are by definition not impartial, neutral, or independent, concern has arisen over the use of the term 

”humanitarian” in reference to military support in 

some contexts. The United Nations (UN) Inter-Agency 

Standing Committee provides useful guidance on this 

issue in a reference paper, Civil-Military Relationship in 

Complex Emergencies.5

 In part, the committee recommends that military efforts should be termed “relief” 

instead of “humanitarian.” The difference in terminology is not just academic: the security and logistical 

support provided by the military can be critical to 

the success of the overall humanitarian effort; however, civilian humanitarians express concern that the 

perception of their affiliation with the military could 

negatively affect their security and ability to access 

vulnerable groups. 

Well-orchestrated civil-military responses can offer 

great benefits, but such efforts take careful planning, 

a clear understanding of roles of civilian and military 

personnel, and effective communication between the 

two groups. This coordination is especially important 

in behavioral health services because of the profound 

effect of sociocultural issues in the acceptability of 

care. A central theme of disaster behavioral healthcare 

is the need for cultural competence in the delivery of 

services. Especially in large-scale disasters, it is critical 

for providers to know the context of services: what 

other agencies and activities are involved, how the 

range of services is coordinated, and what personnel 

and programs are available.

The first task for military personnel is to understand 

the types of organizations and personnel who share the 

environment—the “players.” Personnel arriving on 

site should expect to find the humanitarian operating 

space shared by a range of “actors” (the acceptable 

generic reference in much of the literature in applied 

social and behavior science in political environments, 

such as terrorism, area studies, and complex disas-
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Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

ters, especially when the mix includes a broad range 

of groups—in this case, active belligerents, military 

personnel, civilian agencies, and international organizations) presenting highly diverse organizational 

cultures and roles, as well as the affected population. 

In addition to various host nation assets, the key actors in a large-scale humanitarian response frequently 

include donor governments and agencies, UN operational agencies, NGOs, the International Red Cross 

and Red Crescent Movement, other international and 

regional organizations, and the media. Some of these 

organizations may provide acute behavioral health 

services, but the goal of many is the development of 

long-term, self-sustaining programs as an integrated 

part of capacity building and development. Successful behavioral health service is directly related to the 

physical, social, psychological, and spiritual support 

provided by these programs.

The International Community

Major donors in the international community 

include the European Community Humanitarian 

Office, Japanese International Cooperation Agency, 

Australian Council for International Aid, United 

Kingdom Department for International Development, US Agency for International Development, 

and Canadian International Development Agency. 

UN agencies, funds, and programs are also much 

in evidence. Although no agency has a primary behavioral health mandate, many UN activities make 

meaningful contributions to behavioral healthcare 

through pursuit of physical security, stability, 

sanitation, shelter, child development programs, 

and other essential support. Among these, the UN 

Development Program works in poverty reduction, 

development goals, democratic governance, crisis 

prevention, information and communication technology, human immunodeficiency virus/acquired 

immunodeficiency syndrome (HIV/AIDS) response, 

and landmine action in 166 countries. The UN High 

Commissioner for Refugees (UNHCR) has a mandate 

under international law to protect and assist refugees as specified in the 1951 Refugee Convention.6

Focused on provision of food, shelter, and other basic 

necessities, this support is especially important in 

environments where the affected groups may include 

refugees, internally displaced persons, or migrants, 

a situation that can bring additional distress even 

in stable environments. UNHCR has approximately 

5,000 staff in 120 countries with a current caseload 

of over 20 million people worldwide.

The World Food Program, the largest provider of 

food aid in the UN system, responds to both emergency needs and long-term economic and social development goals. In 2004, the program fed 113 million 

people in 80 countries. Operating in over 140 countries, 

the UN Children’s Fund prioritizes girls’ education, 

early childhood development, immunization, protection from violence and exploitation, HIV/AIDS services, health and nutrition programs for children and 

pregnant women, and children’s rights. In recent years 

the program has also worked for the demobilization 

and reintegration of former child combatants through 

community-based efforts.7

The UN established the World Health Organization 

(WHO) in 1948; its constitutional objective is “the attainment by all peoples of the highest possible level 

of health.” In disasters, WHO provides medical assessments and supplies and trains healthcare workers 

as part of building capacity. WHO is staffed by some 

3,500 health experts, other experts, and support staff 

on fixed-term appointments, working at the Geneva, 

Switzerland, headquarters; in six regional offices; and 

in countries around the world. WHO actively pursues 

relations with NGOs to promote its policies, strategies, 

and activities.

A common feature of complex humanitarian 

emergencies (CHEs) is psychic trauma caused by the 

failure to maintain basic human rights. UNHCR, the 

secretariat for all UN human rights bodies, ensures 

that human rights are “mainstreamed” into all other 

UN activities. In addition to national capacity building, 

UNHCR maintains a field presence of human rights 

monitors and observers. 

International organizations established by treaties 

also work closely with the UN and other actors. The 

International Organization for Migration, established 

in 1951 to assist with the movement of displaced 

persons in Europe, is the leading intergovernmental 

organization in the field of migration and now operates worldwide with 120 member states and offices in 

over 100 countries. This organization works closely 

with governmental, intergovernmental, and nongovernmental partners in managing the movement 

of migrants, resettling refugees to third countries or 

returning them to places of origin, and countering trafficking of people. The International Red Cross and Red 

Crescent Movement is the world’s largest humanitarian network, with a presence and activities in almost 

every country. The Movement has three distinct entities: (1) the Geneva-based ICRC directs and coordinates 

international relief efforts in situations of conflict and 

promotes and strengthens humanitarian law (Geneva 

Conventions) and universal humanitarian principles; 

(2) the International Federation of Red Cross and 

Red Crescent Societies acts as the official representative of the member national societies and directs and 

coordinates the international assistance efforts of the 

individual member societies; and (3) the individual 
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Combat and Operational Behavioral Health

National Red Cross and Red Crescent Societies provide a range of auxiliary disaster, development, and 

capacity-building services to the national authorities 

in their own countries. Although not officially a part 

of the UN, the Movement has observer status at UN 

headquarters in New York City. 

Nongovernmental Organizations 

The term “NGO” defines a very diverse group 

with respect to size, style of management, and type of 

operations. The World Bank defines NGOs as “private 

organizations that pursue activities to relieve suffering, 

promote the interests of the poor, protect the environment, provide basic social services, or undertake community development.”8

 Tens of thousands of NGOs 

exist; many consult to governments and the UN, and 

some have a meaningful influence in world affairs.

According to Hall-Jones,9 the NGO sector now represents the eighth largest economy in the world. NGOs 

are generally funded by grants or private donations, 

although some receive large donations from governments. The groups may be national (indigenous) 

or international and are typically staffed by skilled 

professionals such as physicians, nurses, logisticians, 

engineers, and lawyers. NGOs are sometimes classified 

by their orientation (religious or secular); mission types 

(operational or advocacy); specific interests (medical 

care, child protection, food distribution); or operating 

area (community based, national, or international). 

Their size varies from small community-based groups 

to very large international organizations with equally 

large budgets. 

Many NGOs have been working in particular locations for many years and have vast knowledge of 

the areas and access to the local population. InterAction is the largest alliance of US-based international 

development and humanitarian NGOs, with more 

than 160 member organizations.10 The largest of these, 

in terms of financial assets, is currently the Bill and 

Melinda Gates Foundation, with an endowment of 

$28.8 billion.9

Military Support to Other Players

In recent years the military forces of many nations 

have deployed in response to humanitarian crises. 

These missions involve various forms of logistical 

and security support to protect civilian aid workers 

and ensure that relief reaches the populations in need. 

Types of military support can be conceptualized as 

belonging to five general service clusters, all of which 

have security as a central theme11:

1. Direct assistance: the face-to-face distribution 

of goods and services (these services often 

embrace a meaningful security component).

2. Indirect assistance: activities such as transporting relief goods or relief personnel (at 

least one step removed from the population). 

3. Infrastructure support: general services 

such as road repair, airspace management, 

or power generation that facilitate relief but 

are not necessarily visible to or solely for the 

benefit of the affected population. 

4. Peacetime missions: responses to large-scale 

natural disasters (eg, the Indian Ocean tsunami).

5. Training and exercises conducted in a region 

with no hostile intent. 

The UN’s Guidelines on the Use of Military and Civil 

Defence Assets in Disaster Relief,

1

 originally released in 

1994 and revised in December 2005, is the principal 

document specifying the obligations and limits of 

military support in humanitarian relief. Because the 

original document was developed at an international 

conference in Oslo, Norway, it is generally referred to 

as the “Oslo Guidelines.” Under these guidelines, UN 

military and civil defense assets in humanitarian space 

are under UN control. 

Other peace operations or support missions include 

a range of tasks undertaken by military forces that may 

not be under UN command, including peacekeeping, peace enforcement, peace building, and other 

operations with forces deployed under parameters 

that dictate a minimum necessary use of force. In 

some circumstances, the humanitarian mission may 

exist alongside traditional combat missions, including 

behavioral health services for detainees, as in Iraq and 

Afghanistan. 

Principles and Practice of Civil-Military Collaboration in Behavioral health

The practice of civilian aid workers sharing the 

humanitarian space with the military is not new. Much 

of the recent interest in civil-military collaboration, 

however, may be traced to the success of Operation 

Provide Comfort in 1991, when NGOs and the military, 

working toward a common goal, achieved unprecedented success in providing humanitarian relief for the 

Kurds of northern Iraq.12 Since that time, many senior 

military training institutions have developed curricula 

dedicated to civil-military issues. Civilian and military 
623

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

organizations differ greatly in their respective cultures, 

but each group possesses knowledge, skills, and assets that in collaboration create a synergy neither can 

achieve independently.

The coordination of these skills and assets, however, 

can be a critical challenge. Bessler and Seki13 have 

provided a useful overview of common problems in 

the development of civil-military collaboration in the 

humanitarian space They point out, for example, that 

civilian humanitarians may express concern over the 

militarization of aid, especially in the area of military 

civil affairs projects designed to “win the hearts and 

minds” of the populace. These efforts are often a key 

part of the reconstruction process and have great 

pragmatic value; however, they can also create the perception that humanitarians might be used as de facto 

force multipliers or field operators of the local government. Humanitarians note that the perception of a 

military affiliation may compromise their principles 

of impartiality and neutrality, with a negative effect 

on the security of their staff or their ability to access 

affected populations. Given such problems, military 

and civilian workers must have a clear understanding of each other’s needs to create a pragmatic and 

principled response. 

Security Needs and Information Sharing

McHale11 offers useful general guidance on security and informational requirements of civilian and 

military actors in the humanitarian space. Although 

specific needs of humanitarian actors vary widely, civilian humanitarians commonly seek military support 

for the following:

	 •	 security in the area to allow humanitarians to

conduct operations, although usually not to 

the extent of one-on-one protection of their 

staff;

	 •	 reaction forces to assist personnel in danger,

possibly requiring one-on-one security and 

evacuation of humanitarian staff;

	 •	 access to airfields, ports, and facilities if these

are not readily open for humanitarian use;

	 •	 communication technology;

	 •	 logistical transport of materials and possibly

personnel;

	 •	 emergency medical support and possible

medical evacuation of personnel; and 

	 •	 emergency infrastructure repairs.

McHale advises military operators in the humanitarian space to avoid classifying information unless 

necessary for security of operations or personnel. The 

military can often share with NGOs the following 

information:

	 •	 details on the security situation to inform humanitarian risk assessment, including areas of 

ongoing military action, banditry, or general 

instability;

	 •	 status of air and sea points of debarkation and

lines of communication; 

	 •	 checkpoint locations and pass-through procedures, which greatly reduces the chances 

of accidental injuries to humanitarian staff;

	 •	 location of unexploded ordnance, mines, and

mine action activities;

	 •	 information on population movements, conditions, and activities;

	 •	 types of humanitarian (relief or support) projects planned by military; and

	 •	 poststrike information, including location of

persons in need and unexploded ordnance.

Civilian humanitarian organizations are often hesitant to share information with the military, concerned 

over the perception of alignment with military intelligence. However, military personnel have suggested 

that security and efficacy is improved for both partners 

when NGOs offer the following information: 

	 •	 location of humanitarian staff and operations,

which lessens the chance of accidentally 

targeting areas with ongoing humanitarian 

operations or humanitarian staff;

	 •	 locations for possible evacuation of humanitarian staff if necessary; and

	 •	 a complete list of humanitarian projects, to

avoid competition and duplication.

Practical Considerations 

Because effective behavioral health services are an 

integral part of the overall disaster response, providers must be familiar with the coordination mechanisms and position themselves to be an ongoing and 

integrated part of the response. The most common 

administrative mechanism for coordination is the 

civil-military operations center (CMOC). The US Department of Defense defines a CMOC as 

an ad hoc organization, normally established by the 

geographic combatant commander or subordinate 

joint force commander, to assist in the coordination 

of activities of engaged military forces, and other 

United States Government agencies, nongovernmental organizations, private voluntary organizations, and regional and international organizations. 
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Combat and Operational Behavioral Health

There is no established structure, and its size and 

composition are situation dependent.14

The Center for Excellence in Disaster Management 

and Humanitarian Assistance agrees that the physical 

structure of the CMOC and the liaison arrangement 

best suited for the mission are determined on a caseby-case basis, outlining four principal approaches to 

liaison placement (Figure 38-1).11 Civil and military 

leaders benefit from a careful consideration of perceptions, accountability, the need for transparency, and 

how these issues may affect the security of civilian 

humanitarian staff and beneficiaries. The center also 

offers a number of operating principles obtained from 

successful CMOC endeavors (Exhibit 38-1).11

Figure 38-1. Civil-military coordination: four approaches to 

liaison arrangements. Collocation: humanitarian agencies 

and military units operate from within the same compound. 

The perception that civilian actors may be affiliated with 

the military can have negative security implications for the 

civilian humanitarian agency staff. For this reason, collocation is rarely used and should never be used in a complex 

emergency. Liaison exchange: liaison officers are assigned 

to and work in the offices of the other unit or agency. Limited exchange: liaison officers maintain an office in their 

own unit or agency but travel to the other actor’s office to 

conduct business. Interlocutor: liaison officers maintain an 

office in their own unit or agency and travel to a neutral 

site to conduct business, such as a United Nations or local 

governmental office. This is often the most secure option for 

civilian humanitarian agency staff operating in an insecure 

environment.

Civ: civilian LO: liaison office Mil: military

Mil

Should never 

be used in a 

complex 

emergency

Collocation Liaison 

Exchange

Mil

LO

Limited 

Exchange

Civ

LO

Mil

LO

Interlocutor

Civ

Mil

Neutral 

site

Civ

LO

Civ

LO

EXHIBIT 38-1

OPERATING PRINCIPLES LEARNED 

FROM SUCCESSFUL CIVIL-MILITARY 

OPERATIONS CENTERS

	 •	 Remember that coordination is personality and

perception driven.

	 •	 Have respect for other actors and their operations;

your personality and how you are perceived will 

dramatically affect whether coordination occurs.

	 •	 Have meetings chaired or co-chaired by civilian

actors.

	 •	 Understand the roles, responsibilities, and constraints of the other humanitarian actors.

	 •	 Understand that nongovernmental organizations

(NGOs) vary in their degree of comfort in working with the military; some NGOs will never be 

comfortable working with the military.

	 •	 When possible, work to establish areas of common

responsibility.

	 •	 Establish open communications and sharing of

information.

	 •	 Avoid classifying information unless necessary.

	 •	 Respond in a timely manner to requests for information or assistance.

	 •	 Understand that civilian actors may be hesitant to

share information with you, especially in an open 

forum.

	 •	 Ensure that communications equipment (radio,

mobile phones, e-mail) is compatible. 

	 •	 Offer assistance when possible; understand that

offers may be rejected.

	 •	 Know the market prices for local goods and services.

	 •	 Do not drive up prices by overbidding.

	 •	 Work with civilian actors to build consensus in

operations.

	 •	 The collaborative process may benefit from a third

party (eg, the US Office for the Coordination of 

Humanitarian Affairs) through which to share 

information.

Adapted from: McHale S. The International humanitarian 

community: overview and issues in civil-military coordination. Paper presented at: Combined Humanitarian Assistance Response Training; June 29, 2006; Marine Corps 

Bases Japan.

Special Behavioral health Considerations in Complex Humanitarian Environments

Equipped with an understanding of the players and 

a strategy for coordinating services, behavioral health 

providers can next consider important contextual issues 

that affect service delivery. Among the more important 

of these issues is how the psychic environment of CHEs 

differs from that of natural or technological emergencies. Although a CHE has several definitions, the UN 

Inter-Agency Standing Committee characterizes such a 
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Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

situation as 

a humanitarian crisis in a country, region or society 

where there is total or considerable breakdown of 

authority resulting from internal or external conflict and which requires an international response 

that goes beyond the mandate or capacity of any 

single agency and/or the ongoing United Nations 

country program.15

Many recent CHEs originated in the 1940s and 

1950s, when the historical colonial powers began divesting themselves of overseas outposts. This trend 

accelerated at end of the Cold War, as the world experienced a dramatic rise in struggles for autonomy 

among newly liberated groups. These struggles often 

emerged along ethnic or religious lines, accompanied 

by a volatile mix of social, political, economic, and 

cultural variables that fueled internal conflicts. Humanitarian disasters that have emerged from these 

conflicts approximate civil wars and are labeled 

CHEs. CHEs are typically characterized by politically 

mediated excess mortality and morbidity; loss of civil 

police and judicial processes; massive displacement 

of people within the country (internally displaced 

persons) or across borders (refugees); destruction of 

critical infrastructure; and widespread damage to civil 

society and economies. The UN Office for Coordination of Humanitarian Affairs adds that 

[r]esponders typically face the need for a large-scale, 

multi-faceted humanitarian response in which delivery of assistance is hindered or prevented by 

political/military constraints, including significant 

security risks for humanitarian aid workers.16

Frequently, CHEs emerge from a weak or failed 

political infrastructure confronted by catastrophic 

economic distress or a natural disaster. The disaggregation of the former Yugoslavia and the Rwandan 

genocide of 1994 are illustrative of CHEs at the state 

level. The specific targeting of civilians to terrorize, 

displace, and create psychological distress is often a 

military goal. Garfield and Neugut note that World 

War I produced civilian casualty rates of approximately 14%; in World War II the rate had risen to 67%. By 

the 1990s the rate of casualties among noncombatants 

reached 90%.17

Factors Influencing Survivor Psychic Distress 

Behavioral health providers should understand the 

ways in which the anarchic aspects of CHEs create 

psychic environments that differ greatly from those 

typically associated with natural or technological 

disasters. Any individual’s subjective experience 

of psychic distress is a product of the complex interactions between the personal characteristics of 

the survivor and characteristics of the traumatizing 

event. Survivor characteristics may include a history 

of previous trauma, personality organization, physical health, availability of psychosocial support, and 

material resources. 

The two principal characteristics of the traumatizing event itself are the gradient of exposure and the 

magnitude of personal loss and impact. The gradient 

of exposure defines how much trauma survivors were 

exposed to: how “close” it was and how many times 

they were exposed. The magnitude of personal loss 

and impact concerns the comprehensiveness of the 

event: Did the survivor hear about it, read about it, 

see it on electronic media, or witness it personally? 

Did it happen to someone they know? A loved one? 

Did they experience it personally? How many times? 

In general, the more directly and persistently an individual is affected, the higher the risk of meaningful 

behavioral health problems. In complex emergencies 

where losses result from intentional, human-mediated 

violence, the emotional proximity, comprehensiveness, 

and persistence of the trauma can be devastating to 

survivors and their greater communities. 

Psychic Ground Effects

Measured by the gradient of effect and magnitude of 

personal loss, CHEs expose survivors to physical, emotional, and environmental sources of psychic trauma 

that are persistent and highly interrelated. Specific 

sources of distress may include persecution, oppression, marginalization, detention, incarceration, torture, 

witnessing atrocities, and separation from loved ones. 

In natural or technological disasters, emergency relief 

personnel and assets are limited largely by logistical 

constraints. In addition, the immediate cause of the 

threat is usually time-limited (eg, cyclonic storm, 

earthquake), so survivors can begin the response and 

recovery process in a fairly short time. CHEs, however, 

often involve an ongoing threat of armed aggression, 

including hostile resistance to both military humanitarian support and civilian aid workers. 

Even following the official cessation of hostilities, 

threats in a CHE may extend into the “postconflict” 

environment for both survivors and responders. In 

the aftermath of a complex emergency, survivors may 

know not only victims, but also perpetrators. After the 

Rwandan genocide of 1994, aid workers frequently 

encountered Tutsi survivors who returned to their 

home areas only to encounter the very people who 

had killed members of their families.18 Retributive 
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Combat and Operational Behavioral Health

violence can also persist long after the official “peace” 

has been declared. 

In addition to ongoing physical and psychic threats 

to their safety and autonomy, survivors in CHEs often 

experience meaningful material deprivation, including 

loss of home, personal possessions, important records, 

economic and material resources, employment, social 

position, or authority. These problems are exacerbated 

by the loss of customary social, psychological, spiritual, 

and cultural institutions that could otherwise provide 

support.

Among the most distressing of behavioral health 

issues in CHEs is gender-based violence. Especially in 

CHEs involving ethnic conflict, sexual violence against 

women and girls is often a planned and systematic 

military weapon designed to humiliate, induce terror, 

and destabilize communities. Although reliable statistics are difficult to obtain, a large body of information 

obtained from NGO and international organization 

investigations documents the problem. Concerning the 

protracted conflict in Sudan, for example, the Watchlist 

Project notes that gender-related violence

connected to conflict, including sexual slavery 

of women and children, rape by military forces, 

forced prostitution and forced marriage, is known 

to be a widespread problem in Sudan. No statistics 

are available. Children, especially girls from these 

areas, are victims of sexual exploitation, sexual 

slavery, forced marriage, rape and other forms of 

violence after abduction by . . . militias and opposition groups.19

Similarly, Roque reported,

In Bosnia, for example, public rape of women and 

girls preceded the flight or expulsion of entire Muslim populations from their villages, and strategies 

of ethnic cleansing included forced impregnation

In Rwanda, Hutu extremists encouraged mass 

rape and sexual mutilation of Tutsi women as an 

expression of contempt, which sometimes included 

intentional HIV transmission.20

In addition to the trauma of the violence itself, 

survivors of gender-based violence may also experience social rejection from their own group. In many 

traditional collectivist societies, family, tribe, or other 

group affiliation largely determines the sense of self 

and social role. Forcing women to bear the children of 

their enemies disrupts the social fabric of community 

organization. Gourevitch has described a Tutsi woman 

who had survived the Hutu massacre in Rwanda 

commenting on her relationship with the restored 

government: 

And they would say, “If they killed everyone 

and you survived, maybe you collaborated.” To a 

woman who was raped 20 times a day, day after 

day, and now has a baby from that, they would 

say this.18

This circumstance might be thought of as an interethnic, multigenerational psychic insult A successful 

clinical response to such a problem would require an 

exceptionally well-resourced, culturally embedded, 

long-term commitment. UN-sponsored programs for 

the reintegration of former child combatants may provide a heuristic model for program development. 

Environmental Threats

Environmental threats, both direct and indirect, 

negatively affect survivors’ subjective sense of safety 

and security and are a major source of psychic distress. 

In addition to active armed conflict, direct threats 

may be represented by the loss of secure shelter or 

the presence of landmines and unexploded ordnance. 

Indirect threats often involve destroyed or degraded 

infrastructure, including utility and public health assets associated with transportation, power generation, 

water, sanitation, and basic health services. For many, 

living circumstances are austere and overcrowded. 

These problems often have the effect of forcing traumatized people to live in close proximity to others 

who are equally distressed, and with whom they may 

have to compete for scarce resources. The effects of 

this situation are especially deleterious for the most 

vulnerable people. Groups at high risk include children 

(especially unaccompanied minors), pregnant and 

lactating women, the elderly and infirm, the chronically and persistently mentally ill, displaced persons, 

and refugees. 

During complex emergencies, the definition of 

“high-risk group” may evolve through the life span 

of the emergency. In general, anyone who is physically or psychologically vulnerable may be thought of 

as a high-risk individual, but because of the political 

nature of CHEs, high-risk groups may be determined 

by social, religious, educational, or political affiliation. 

For example, during many long-term CHEs such as the 

civil war in Mozambique (1975–1994), male adolescents became vulnerable to kidnapping and induction 

into irregular militias or paramilitary groups because 

of the depletion of older male soldiers lost in the fighting. Social and medical risks are often reflected in a 

high incidence of drug and alcohol abuse, domestic 

violence, and related pathology. These aspects of the 

psychic environment of CHEs have meaningful implications for behavioral health providers attending to the 
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Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

needs of both civilian survivors and military personnel operating in theater. Little doubt exists that the 

severity and persistence of human-mediated trauma 

in complex emergencies carries a much higher risk of 

long-term psychic distress than the trauma of natural 

or technological disasters.21

The most common behavioral health diagnoses 

among survivors of CHEs include anxiety disorders, 

especially acute or posttraumatic stress disorder, and 

mood disorders, especially depression. These conditions are often accompanied by a range of somatic complaints including body pains, sleep disturbances, and 

restlessness. Neglect of one’s own health is common, 

as are substance use disorders. Apart from diagnosable 

disorders, however, the single greatest source of psychic distress is typically the problem of loss and grief. 

Loss and grief are axiomatic to human experience, but 

in CHEs the sheer magnitude of loss coupled with the 

absence of usual support structures can present a special clinical challenge for practitioners. The successful 

resolution of grief is an essential part of the recovery 

process; unresolved grief can be a rate-limiting factor 

in the successful return to predisaster functioning for 

both individuals and communities at large. 

Although the response to acute grief is unique 

to each person, a number of descriptive models of 

bereavement and mourning have been advanced to 

describe common themes.22–26 For a vast majority of 

survivors, the early grieving process includes preoccupation with persons or things lost and feelings of 

profound sadness, loneliness, fear, powerlessness, anger, anxiety, and despair. A central component of grief 

is the need to engage the mourning process to achieve 

appropriate levels of relief, resolution, reintegration, 

and return to functioning. In mourning, the reality of 

the pain is consciously identified and openly expressed 

with some degree of support seeking, psychological 

unburdening, and reestablishment of equilibrium. In 

unmourned loss, however, the reality of the pain is denied or suppressed, and the pain tends to remain fresh. 

The bereaved have a critical need for timely support to 

properly mourn their losses. Not grief itself, but grief 

that is unmourned, is associated with the development 

of more serious psychological problems; these may 

include pathological grief responses, depression, and 

posttraumatic stress disorder. These serious psychological problems are especially significant in complex 

emergencies, where the scale of destruction and social 

disorder creates cumulative risks at the same time 

that it precludes the ability of survivors to engage the 

normal mourning process in a timely way. 

Despite the intensity of their experiences, some of 

the bereaved may initially fail to seek help because 

they are overwhelmed or immobilized by the shock 

and magnitude of their losses. Other survivors may 

actually decline help in an effort to preserve their 

sense of autonomy, competence, or dignity. Because 

social customs, religious practices, and traditional 

rituals exert great influence on the mourning process, 

behavioral health support should be integrated into 

other support and recovery activities provided by 

local providers and organizations. If possible, service 

providers should seek collaborative relationships with 

local traditional healers. 

Principles of Behavioral healthCare in Humanitarian Environments

Because of cultural and logistical problems, many 

traditional Western behavioral health interventions 

may be of limited use in disasters requiring a multinational response, especially complex emergencies. 

The most effective behavioral healthcare strategies 

pursue integration of sociocultural, medical, and 

psychological assets, ideally involving collaboration 

among relevant organizations. Practitioners are often 

less invested in direct clinical care for individuals and 

small groups and more focused on supportive and 

facilitative activities.

 The WHO Department of Mental Health and 

Substance Dependence offers some general behavioral health service principles that have demonstrated 

utility across a range of disasters and cultures.27 If 

circumstances permit, predisaster preparation should 

include a plan that identifies specific tasks, responsible 

personnel, and detailed communication and coordination strategies for key actors and agencies. If the key 

actors include international organizations, the leadership should be reminded that, to the degree possible, 

staff (including managers) should be hired from the 

local community. This practice increases the cultural 

competence of care and sets the stage for the development of long-term, self-sustaining programs.

Acute Phase

In the acute phase of a complex emergency, the 

crude mortality rate generally rises after loss of basic 

needs, including security, food, water and sanitation, 

and access to primary and public health services. 

Disaster behavioral health workers note that the reestablishment of these basic services is also essential in 

helping survivors recapture a sense of autonomy and 

efficacy in their environment. The process is enhanced 

by dissemination of information about relief efforts, 

including location of aid organizations and, when 
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Combat and Operational Behavioral Health

possible, information concerning the location of relatives. For survivors with behavioral disorders, whether 

disaster-induced or not, basic behavioral healthcare 

is best provided through general health services or 

through community-based primary healthcare resources within the health sector. In addition, providers 

should ensure the availability of essential medications 

for persons with acute psychiatric emergencies. 

During complex emergencies, when the acute 

phase may be protracted, many survivors respond 

well to the principles of “psychological first aid.”28

Credentialed providers can also use psychological 

first aid materials to provide on-the-job training 

and supervision in core psychological care skills for 

existing healthcare providers, social service workers, 

and community leaders. This training expands the 

cadre of service providers available to the community 

while facilitating the integration of behavioral health 

into primary healthcare for the longer term. Also 

useful is the creation of community-based support 

and self-help groups to provide emotional support 

and enhance coping strategies, especially in grief 

management. Other helpful efforts, when possible, 

include encouraging the reestablishment of normal 

religious and cultural activities, specifically including orphans, those who have lost partners, and those 

without families. 

One of the most practical behavioral health priorities is reopening schools. Schools normalize life 

for children and provide opportunities for them to 

interact with others in a familiar environment. Children in school are also much less likely to become 

involved in criminal or other high-risk behavior, and 

less likely to become victims of child exploitation, a 

tragically common occurrence following large-scale 

disasters. With children in a secure environment, 

other family members are freed to attend to pressing 

needs. Schools are also an accessible, low-visibility 

platform for disseminating behavioral health and 

social services information in an environment that is 

culturally confluent and preserves self-esteem. Uncomplicated, empathic information should focus on 

normal reactions, give practical advice, and provide 

specific information about availability and location 

of behavioral health and social service resources. 

These self-empowerment techniques provide immediate practical relief as they establish templates for 

self-sustaining, locally managed programs that can 

eventually serve the medium- and long-term needs 

of the community. 

Reconsolidation Phase

 In the reconsolidation phase, survivors often face a 

lengthy period of adjustment to the losses created by 

the disaster. Especially in response to very large-scale 

events, the enormity of the losses often predicts a rise in 

the most serious behavioral health problems, including 

posttraumatic stress disorder, depression, and suicidal 

thoughts. To meet the long-term needs of survivors, behavioral health services must be organized, sustained, 

and integrated into the local community. 

The US Department of Veterans Affairs National 

Center for Posttraumatic Stress Disorder29 recommends that following disasters, long-term tasks for 

behavioral health providers should include public 

education, screening, and where indicated, referral and 

treatment. Educational activities include programs on 

enhancing self-care and coping techniques, and providing information about social, financial, legal, and 

medical services. These activities help survivors normalize their reactions to trauma and develop healthy 

forms of coping. Screening seeks to identify those at 

increased risk for negative psychological outcomes. 

Survivors with a prior history of psychiatric illness, 

psychological trauma, or substance use disorders are 

particularly vulnerable, as are members of historically 

marginalized or disenfranchised groups. Survivors 

typically have a brief interview with a behavioral 

health provider and complete a risk-assessment questionnaire. Where appropriate, the screening process 

may rely on informal sources, including aid workers, 

friends, or family members. Based on screening assessments, survivors can be referred to counseling for 

specific problems, such as alcohol abuse or complicated 

bereavement, or to more medically or psychiatrically 

based interventions. 

A principal behavioral health challenge of the reconsolidation phase is the establishment or reinvigoration 

of sustainable economic support programs to respond 

to the long-term consequences of the disaster’s impact. 

Especially for survivors whose predisaster livelihoods 

depended on subsistence work, the ability to generate income is a critical link to emotional recovery. 

In disasters involving a multinational response, the 

success of these programs requires a high degree of 

collaboration among public and private programs 

from both the host nation and donor countries. Because of the sensitivities that invariably accompany 

humanitarian aid, the host government must be able 

to exercise maximum administrative influence over 

the community’s return to predisaster functioning. 

Andrew Natsios, former director of the US Agency for 

International Development, describes the concepts of 

local ownership, capacity building, and sustainability 

as the “iron triad” of all successful reconstruction and 

development projects, an observation that generalizes 

well to behavioral healthcare.30
629

Behavioral Health Issues in Humanitarian and Military Relief Operations: The Special Problem of Complex Emergencies

SUMMARY

health services typically occurs during the emergency 

phase of the response. However, evidence shows that 

the need for behavioral health services actually goes 

up over time, so that the most pressing needs often 

surface after the assets available in the acute period 

have diminished. The best strategy for responding 

to this problem is to ensure that local planners and 

other leadership are aware of the circumstance and 

that providers invest maximum effort in the establishment of culturally competent, indigenously managed 

programs. Behavioral health providers should initiate 

training and supervision of local personnel early in 

the response to ensure long-term behavioral health 

support. 

Successful behavioral health service in the humanitarian space demands a high level of clinical expertise 

in an environment fraught with meaningful challenges. 

To meet these challenges, providers must develop 

skills in fields ranging from cultural anthropology to 

diplomacy, logistics, economics, and organizational 

behavior. The successful integration of these skills is 

rewarded with the development of timely, efficacious, 

and self-sustaining behavioral health services to help 

those in need. 

Established principles and evolving research in 

the reconstruction and development fields inform the 

civilian and military humanitarian response communities, including behavioral health providers. In the 

humanitarian space, it is critical for behavioral health 

providers to know the key players, their respective 

roles, typical tasks, and relationships to each other. 

In part, this knowledge requires an understanding of 

the host culture, the challenges and opportunities of 

civil-military collaboration, and the best mechanisms 

to share resources and expertise among contributing 

groups. These knowledge sets permit practitioners to 

function as behavioral health force multipliers through 

their identification and support of community-based 

psychosocial and educational programs, the development of information networks, and collaboration 

with traditional healers and other local assets. The 

most effective practitioners also understand how the 

psychological ground effects in complex emergencies 

differ from those in natural and technological disasters, and how those differences affect the potential 

for psychological trauma and disability, especially in 

response to grief.

The greatest impetus and funding for behavioral 

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13. Bessler M, Seki K. Civil-military relations in armed conflicts: a humanitarian perspective. Liaison. 2006;3:4–10.

14. US military glossary. About.com: US military Web site. Available at: http://usmilitary.about.com/od/theorderlyroom/l/

blglossasry.htm. Accessed December 15, 2009.

15. United Nations Inter-Agency Standing Committee Web site. Available at: http://www.humanitarianinfo.org/iasc/

content/default.asp. Accessed December 15, 2009.

16. US Office for the Coordination of Humanitarian Affairs. OCHA Orientation Handbook of Complex Emergencies. New York, 

NY: UN; 1999. Available at: http://www.reliefweb.int/library/documents/ocha__orientation__handbook_on__.htm. 

Accessed December 15, 2009.

17. Garfield RM, Neugut AI. The human consequences of war. In: Levy BS, Sidel VW. War and Public Health. New York, 

NY: Oxford University Press; 2000: 27–38.

18. Gourevitch P. We Wish to Inform You That Tomorrow We Will Be Killed With Our Families. New York, NY: Picador USA; 

1998: 304–308.

19. Watchlist Project. Watch List on Children and Armed Conflict. New York, NY: Women’s Commission for Refugee Women 

and Children; 2003. Available at: http://www.womenscommission.org/pdf/wl_sd.pdf. Accessed December 15, 

2009.

20. Roque H. Addressing gender-based violence: if not now, when? The United Nations Chronicle [serial online]. 2002;39(3). 

Available at: http://www.un.org/Pubs/chronicle/2002/issue3/0302p77_gender_based_violence.html. Accessed 

December 15, 2009. 

21. Ditzler TF. Psychic Trauma in Complex Emergencies: Sources and Interventions. Health Emergencies in Large Populations 

2005: A Training Course for the Management of Health Intervention in Armed Conflict [CD-ROM]. Honolulu, Hawaii: DoD 

Center for Excellence in Disaster Management and Humanitarian Assistance and International Committee of the Red 

Cross; 2005.

22. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry. 1994;151(6 suppl):155–160.

23. Engel GL. Grief and grieving. Am J Nurs. 1964;64:93–98.

24. Kübler-Ross E. On Death and Dying. New York, NY: Macmillan; 1969.

25. Bowlby J. Attachment and Loss. Vols 1–3. New York, NY: Basic Books; 1979.

26. Westphal R. Dynamic grief model. Paper presented at: Shea-Arentzen Nursing Symposium; “Navigating New Frontiers 

of Nursing Practice: The Challenges of Health Care Reform,” La Jolla, Calif. March 20–24, 1995; La Jolla, Calif. 

27. World Health Organization, Department of Behavioral Health and Substance Dependence. Behavioral Health in Emergencies: Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors. Geneva, Switzerland: WHO; 2003. 

Available at: www.who.int/whr/en. Accessed December 15,2009.

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ncptsd.va.gov/. Accessed December 15, 2009.
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29. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder. Secondary behavioral health treatment following disasters. National Center for PTSD fact sheet. Available at: http://www.ncptsd.va.gov/. Accessed 

December 15, 2009.

30. Natsios AS. The nine principles of reconstruction and development. Parameters. 2005;Autumn:4–20.
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

Chapter 39

POPULATION-BASED PROGRAMS AND 

HEALTH DIPLOMACY APPROACHES OF 

THE US PUBLIC HEALTH SERVICE

JON T. PEREZ, PhD*; JEFFREY COADY, PsyD†; KEVIN McGUINNESS, PhD‡; and MERRITT SCHREIBER, 

PhD§

INTRODUCTION

THE INDIAN OCEAN TSUNAMI AND RELIEF EFFORTS

THE MERCY MODEL: “LEADERSHIP OF THE OPEN HAND”

THE US PUBLIC HEALTH SERVICE MERCY MISSION: “GO WEST AND DO 

GOOD THINGS”

Initial Assessments and Collaboration

Program Development and Delivery

Final Preparations and One Last Hurdle

SUMMary

ATTACHMENT 1: EARTHQUAKE DISASTER RELIEF

ATTACHMENT 2: THE MERCY MODEL

*Captain, Scientist Corps, US Public Health Service; Team Leader, US Public Health Service Disaster Mental Health Team II, Department of Health and 

Human Services, 801 Thompson Avenue, Suite 300, Rockville, Maryland 20852

†

Commander, Scientist Corps, US Public Health Service; Deputy Team Leader, US Public Health Service Disaster Mental Health Team II, Department 

of Health and Human Services, 233 North Michigan Avenue, Suite 600, Chicago, Illinois 60601

‡

Captain, Scientist Corps, US Public Health Service; Director and Medical Psychologist, HRSA/BCRS National Health Service Corps, Ready Responder 

Program, Department of Health and Human Services, c/o La Clinica de Familia, 510 East Lisa Drive, Chaparral, New Mexico 88081; formerly, Senior 

Clinical Scientist, Health and Human Services, US Department of Justice, Bureau of Prisons, Federal Correctional Institution La Tuna, New Mexico

§

Captain, Scientist Corps, US Public Health Service (Inactive Reserve Corps); Senior Program Manager, Center for Public Health and Disasters, University of California at Los Angeles Center for the Health Sciences, 1145 Gayley Avenue, Suite 304, Los Angeles, California 90024; Operations Lead, 

USPHS Mental Health Team II
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Combat and Operational Behavioral Health

Go to the people 

Live with them 

Learn from them 

Care about them 

Start with what they know 

Build with what they have 

But with the best leaders 

When the work is done 

The task accomplished 

The people will say 

“We have done this ourselves” 

—Lao Tzu (700 BC)1

INTRODUCTION

The Commissioned Corps (Corps) of the US Public 

Health Service (USPHS) is an all-officer corps of approximately 6,000 members.2

 The Corps is capable 

of providing highly trained and mobile healthcare 

professionals to carry out programs that promote the 

health of the nation and, when needed, furnish health 

services and expertise in times of war or other national 

or international emergencies. 

As demonstrated in its healthcare relief response to 

the Indian Ocean tsunami of December 26, 2004, the 

Corps provided distinct leadership approaches and 

methodologies that proved useful to that extraordinary 

international effort. Several of the key leadership precepts and approaches are now known as the “Mercy

model” and constitute an important guide for USPHS 

health diplomacy efforts worldwide.3

THE INDIAN OCEAN TSUNAMI AND RELIEF EFFORTS

The Indian Ocean tsunami, also known as the 

“Sumatra tsunami,” was the result of a massive earthquake, with a magnitude of at least 9.0 on the Richter 

scale, that occurred when the India tectonic plate 

subducted beneath the Burma plate.4 Waves reached 

a height of 35.5 feet, and killed an estimated 230,000 

people, 168,000 in Indonesia alone. (When earthquakes 

occur in landmasses above sea level, their initial effects 

are felt immediately and precautions can be taken in 

anticipation of follow-on tremors and structural collapse. Attachment 1 to this chapter provides a description of land-based earthquake disaster relief.) 

Operation Unified Assistance (OUA) was an 

unprecedented undertaking to support victims of 

a massive natural disaster. The USNS Mercy sailed 

from San Diego on January 5, 2005, less than 3 days 

after being ordered to assist, and arrived in Banda 

Aceh, Indonesia, on February 6, 2005. From that point 

through to its departure on April 29, 2005, the ship 

and crew treated over 17,500 patients in the region. 

It brought together an untested capability (the USNS 

Mercy as a humanitarian service platform) and an 

untested mix of uniformed and civilian personnel to 

accomplish an overarching humanitarian mission that 

was not clearly defined until well into its eventual 

execution. 

The OUA teams were sent into an area of extraordinary human devastation where there was active 

military conflict, devastated healthcare infrastructure, 

and an uncoordinated mix of governmental and 

nongovernmental organization (NGO) programs 

with widely divergent approaches and capabilities. 

Logistics of ship-to-shore lift, security, unknown 

length of time on station, limited understanding of 

and commitment to population-based programs by 

key leadership personnel, and initial relief agency 

reticence to accept US help, limited preliminary 

activities and very nearly stopped them completely. 

Ashore, the Mercy team was met with suspicion by 

many who questioned the sincerity of the overall US 

commitment to tsunami relief and, in particular, the 

team’s commitment. It was in this environment that 

the eventual collaborations, programs, and successes 

were achieved, and it was the Mercy leadership approach that helped build them. 

Although not especially unique or groundbreaking 

in many of its individual specifics, the overall intervention approach developed and implemented by 

the USPHS behavioral healthcare team was seen as a 

marked advance for behavioral health programming 

in multinational relief efforts. The people and agencies 

of Aceh Province embraced this approach, as well as 
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

the larger international relief community supporting 

them. It significantly altered the view of the United 

States’ ability to work in an integrated, international 

behavioral health relief effort. 

At its most basic level, the Mercy model represents 

a public health leadership approach, not a program 

or a product. That approach is composed of specific 

knowledge, attitude, and collaboration precepts that 

guide efforts to create teams and programs. Relief 

personnel face operational environments that vary 

in nature, severity, and complexity. The basic Mercy

approaches have proven themselves to help relief 

leadership maximize what resources are available, 

and mobilize systems far larger than the coordinating team itself to create large-scale, population-based 

recovery programs. 

The precepts are highly adaptable to international 

and domestic systems. In its tsunami relief form, the 

Mercy model was composed of 21 general precepts that 

fostered collaborative interaction among diverse organizations and stakeholders (detailed in Attachment 2 to 

this chapter). Most recently, virtually the same precept 

set was used with substantial success in the Hurricanes Katrina/Rita (in 2005) response where it was 

shared with the Louisiana Department of Education 

and ultimately directly contributed to the successful 

development of a psychosocial recovery program for 

over 200,000 displaced schoolchildren.5

The Mercy model precepts have been applied most 

effectively to facilitate delivery of population-based 

behavioral health interventions. However, they have 

also been adapted for use across an array of disciplines 

from biomedical engineering to primary care medicine. 

Given the scope of hazards that the United States faces 

in the world as a nation, in which very large numbers 

of the population may develop enduring mental health 

consequences as a result of disaster exposure,6 Mercy

model percepts are particularly needed.

The Mercy model is designed to effect large-scale, coordinated change in damaged or fragmented systems 

following major disasters by providing collaborative 

leadership to help the system regain operational status. 

The model is called “Leadership of the Open Hand,” 

in deference to the Lao Tzu quotation that opened this 

chapter. It details the means and methods to work in a 

response environment where US agencies are neither 

completely in control nor have the resources to effect 

unilateral action or mission accomplishment. Instead, 

the strategy in such cases is to increase response impact 

through effectively harnessing collaborations with 

other agencies, forces, NGOs, international organizations, and even nations. 

This is accomplished by 

	 •	 addressing, first and foremost, public health

and system-level interventions;

	 •	 providing essential health system leadership

support for damaged systems during highly 

chaotic and difficult times;

	 •	 seeking and promoting collaborative approaches, not unilateral action;

	 •	 assessing system needs rapidly and determining the best placement of limited resources to 

maximize system effects;

	 •	 partnering with the most promising and resourceful agencies;

	 •	 providing partner agencies with capacitybuilding tools;

	 •	 working with partner agencies from program

conception through implementation; and

	 •	 accomplishing it all in time frames measured

in days, not weeks or months.

In Indonesia, the model was utilized to help coordinate relief agencies and the Indonesian government’s 

disaster relief effort to provide specific infrastructure 

and program support for children’s services. Through 

this effort an array of population-based services was 

created in the posttsunami relief environment that 

was eventually delivered to all 200,000 school-aged 

children in Aceh Province. Equally important, the 

approach taught local agencies methods to independently develop and deliver their own programs 

without any outside support. 

In the post-Katrina recovery efforts, the Mercy

model was used to help the Louisiana Department of 

Education regain its operational footing and create a 

statewide system of behavioral health interventions 

for students affected by the hurricane. In Indonesia, 

the process, from initial conception to implementation, 

was completed in just 9 days. In Louisiana, it took 12 

days. There were seven officers directly assigned to 

population-based operations in Indonesia; there were 

four officers assigned to the Louisiana Department of 

Education. This chapter will focus more specifically 

on the Indonesian mission, but the reader should 

understand it represents many missions with similar 

leadership challenges. 

Far from a closed fist, “my-way-or-the-highway” 

leadership approach, the Mercy approach is openhanded leadership, designed to help pull people 

and systems back up and forward following major 

THE MERCY MODEL: “LEADERSHIP OF THE OPEN HAND”
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Combat and Operational Behavioral Health

catastrophic disruption. It utilizes the leadership 

approaches described in the WICS (“wisdom, intelligence, and creativity, synthesized”) model by Robert 

Sternberg,7 to achieve this collaborative partnership 

for the common good. Future relief situations will 

have many of the associated leadership challenges 

present in the OUA response, as well as others not 

even imagined here. Thus, understanding the transitions from chaos to clarity, and suspicion to collaboration are critical to understanding the ultimate 

mission successes. In particular, decisions were made 

and approaches were adopted at several key junctures 

that, if carried out differently, would have resulted in 

mission failure. For future planning, it is important 

to fully appreciate how fragile the situations were 

and how easily the missions could have failed. It is 

the team’s belief that the leadership approach embodied in the open-handed Mercy model precepts 

contributed to these significant transitions and was 

critical to the ultimate successes of the international 

team missions. 

Another important aspect of the leadership approach involved the OUA team aboard the USNS 

Mercy and around the world working to support novel 

programming outside of their traditional operating 

spectrum. International relief organizations, many of 

which had never worked with or were suspicious of 

US uniformed services support, were also of critical 

importance because these organizations provided 

many of the resources that were crucial to successful 

program implementation. Also, research and program 

institutes from around the world provided significant 

amounts of information, often in real-time, via email 

and other digital technologies in support of the team’s 

training efforts, despite the significant time zone differences.8

In a related Department of Health and Human 

Services effort, a team at the Centers for Disease Control and Prevention Emergency Operations Center 

facilitated the use of the novel, rapid mental health 

triage platform—PsySTART (psychological simple 

triage and rapid treatment)—that enabled use of a 

population-based rapid triage platform in an affected 

area. This work began empirical validation of this 

non–symptom-based approach to rapidly determine 

levels of risk in mass casualty events. When the results 

of the PsySTART triage “tags” are aggregated to form 

population estimates, they can be used as a common 

metric for Mercy model population approaches using 

evidence-based risk indicators.9.10 The Mercy model 

and the PsySTART rapid mental health triage system 

are now key competencies of a training initiative for 

new federal disaster response assets—the USPHS 

Disaster Response Teams—created after Hurricane 

Katrina.

The Mercy model approach did not begin with all 

of these pieces in place. How the people and processes 

were assessed, understood, and guided forward is the 

real leadership success story of the Mercy effort by the 

USPHS team; this effort continues to evolve. 

THE USPHS MERCY MISSION: “GO WEST AND DO GOOD THINGS”

The overall mission order was to “go west and do 

good things.” It meant that actual operations would 

be developed and based, in no small measure, upon 

what was encountered when the USNS Mercy arrived 

on station. Mission definition depended to a large degree upon the resources already in place in the region, 

the priority needs of the local Indonesian people, and 

resources that the USNS Mercy and her crew could 

bring to bear in the relief effort. Mission clarity was 

only that which could be conjured or inferred, not what 

was provided, nor even what could be seen or verified 

until arrival in the area of operations. 

The USPHS team took the mission order as a mandate to develop its own mission contingencies and 

integrate them with the larger Navy mission as it 

developed, sometimes minute by minute. To meet its 

own developing mission demands, the USPHS team 

prepared several operational capabilities. Contingency 

planning included direct clinical services for the ship’s 

personnel and those patients who would be received 

on station; environmental health missions; biomedical 

engineering missions; and population-based behavioral health missions. The first three mission capabilities 

were immediately discernible and clearly understood. 

The last was not. Among the USPHS team there developed a desire to take services “beyond the boat,” 

meaning going to shore-based operations and moving 

beyond direct-service provision to include large-scale, 

population-based public health missions.11

While the USPHS team brought direct clinical 

service capability, it also brought unique expertise to 

help local agencies create service programs in relief 

environments, methods to work collaboratively with 

a wide range of relief operations, and the ability to 

integrate seamlessly with operating relief systems and 

structures already in place. However, these capabilities 

were seen as novel by much of the leadership, and even 

useless by some of them. Indispensable support for 

these capabilities came from Rear Admiral William C 

Vanderwagen, commander of the USPHS team and the 

Secretary of Health and Human Services representative on station, and Captain DM Llewellyn, the medical 
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

treatment facility (MTF) commander. Early on, they 

communicated their support for the population-based 

approaches12 recommended by the USPHS behavioral 

health team. Trusting the team’s expertise and advice, 

they enabled the mission to go forward despite the fact 

that such methods were outside the normal operating 

spectrum of the MTF and untested in previous deployments. Rear Admiral Vanderwagen, in particular, saw 

the approach as critical to any large-scale response, 

directed the team to develop it, and advocated for it 

across the leadership lanes from Washington, DC, to 

the MTF itself. 

Initial Assessments and Collaboration

USPHS personnel were on the first helicopter in to 

Banda Aceh from USNS Mercy and began assessment 

and collaboration efforts at that time. The operational assessment and initial collaboration efforts for 

population-based services lasted 5 days. During that 

time, individual meetings were scheduled with over 

a dozen NGO and governmental agencies engaged in 

psychosocial recovery activities, local schools were 

visited to determine the needs as expressed directly 

by local school teachers and head masters, and USPHS 

team members participated in various meetings with 

representatives of over 50 NGOs and agencies that 

provided behavioral health services in the province. 

Very quickly the assessment indicated: 

1. The needs were beyond anything any of the 

team members had ever seen before. 

2. There were over 200 agencies/forces/NGOs 

operating in the theater with widely varying 

capabilities, only limited coordination, and 

very divergent approaches to relief efforts. 

3. The USPHS team would be in this immediate 

area of operation for an unknown, but presumably very short, length of time, possibly 

only days.

4. Of 17 USPHS officers initially available for 

shore-based operations, only seven officers 

were available for population-based behavioral health services; the remaining personnel 

were needed for other healthcare missions 

and to provide direct services on the ship.

The behavioral health personnel, unlike other capabilities shipboard, faced an ambiguous situation and 

three key initial decision points, only the first two of 

which were under their direct control: 

1. What can reasonably be done in days, not 

weeks, given the enormity of need? 

2. What should be offered and to whom?

3. Will anyone want what the behavioral health 

personnel have to offer?

The behavioral health climate was sensitive, particularly for the USPHS team members from the Mercy. The 

prevailing feeling among the NGOs in Banda Aceh was 

that the USNS Mercy was late to the response, would 

be there only long enough to take part in a public relations event, and would probably look to “take over” 

as opposed to “work with” programs already in place. 

It was also expected that western psychological/psychiatric interventions would be used with little regard 

for deeply held spiritual and traditional belief systems 

that may not be congruent with them. This was not an 

open or initially welcoming operational environment, 

but one that viewed Mercy personnel and their offers 

with cool distance.

It was also a situation that began to change with 

a critical exchange that has since become known by 

international colleagues of the US team as “the diplomatic pants incident.” In this particular incident, the 

open-hand leadership approach was demonstrated, 

with particular attention paid to mission success, not 

personal success. 

The United Nations Children’s Fund (UNICEF) and 

the Australian Agency for International Development 

(AusAID) were the organizations with which the Mercy

personnel saw the most potential for collaboration and 

at-scale impact for programs. Highly professional, 

experienced, and respected throughout the relief area, 

they had resources, infrastructure, and personnel, and 

were there for the long haul. Three meetings were 

held with various personnel from those agencies over 

the course of the first few days after arrival. The first 

two meetings appeared to be very encouraging, with 

many ideas shared and possibilities for collaborations 

discussed. At the third meeting, however, there was a 

distinctly disquieting change, particularly with respect 

to UNICEF response to the USPHS personnel.

The USPHS team was confronted with an impromptu, but mission-critical, decision point. It proved to be 

a moment of leadership awareness that substantially 

changed the overall behavioral health mission outcome. In retrospect, the US team’s recognition of the 

potentially course-changing implications of subtle 

changes in vocal tone, physical posture, and interpersonal distance proved to be as important to mission 

success as the actual words exchanged between team 

members and their international partners. The following case study demonstrates the importance of followup conversations in these circumstances. 

Case Study 39-1: After the formal meeting completed, 
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Combat and Operational Behavioral Health

when just a couple of the Mercy USPHS team members 

were together, the obvious question that hung in the air 

was asked: 

Did the USPHS team do something to offend? 

The UNICEF colleagues politely replied, “Why are you 

wearing uniforms today?” 

It was explained that the team members were uniformed 

officers of the United States Public Health Service. The behavioral health team leader went on to explain that although 

the team had worn civilian attire to previous meetings, they 

were wearing uniforms on this particular day because the 

team leader’s only pair of civilian pants had been permanently 

stained with helicopter hydraulic fluid the day before and, not 

wanting to be disrespectful, he opted to wear a clean uniform 

instead of the soiled civilian pants. The rest of the team had 

followed suit. The answer to the question that followed was 

a bit more complicated, however. 

“Are you military?” 

It was explained that, although the team was assigned 

to the US Navy for this humanitarian mission, as USPHS 

officers, they were part of the US Department of Health and 

Human Services and generally prefer to fight disease, not 

people. 

The UNICEF partners responded with smiles of relief. 

“We would much prefer the dirty pants,” they commented, 

“as it is against our [UNICEF] charter to work with military 

forces unless it is absolutely necessary.” 

“Then dirty pants it shall be.” 

After this exchange, the tension evaporated. Assurances 

were made, collaborations sealed, and operations began in 

earnest. Understanding that they had become a symbol of the 

collaboration, the USPHS team leader wore the “diplomatic” 

(ie, dirty) pants ashore for the remainder of the mission. 

Good-natured humor and self-effacement were 

embodied in such behaviors and approaches, and, 

although seemingly secondary to specific program 

delivery, it was exactly these processes that created 

the interpersonal environment that allowed the programs to be delivered at all. For the US personnel to 

be seen by the international relief community, and the 

Achenese in particular with the fears they associated 

with US involvement, as approachable and capable 

of personal humility and self-effacement was critical to their accepting US content and programmatic 

support. The importance of these approaches and 

processes cannot be overstated. The United States was 

seen with human faces and supportive, helping hands 

through these approaches, which spanned the breadth 

of services provided by the entire MTF. Those friends 

with expertise, in the case of the population-based 

programs, were readily welcomed when expertise 

absent such personal connection was not. 

Program Development and Delivery

The next critical leadership decision was to integrate

the USPHS behavioral health team of seven into the 

initial UNICEF and AusAID planning team of five, 

to create a single management team. That team, in 

turn, chose to develop programs and train a cadre of 

individuals to deliver psychosocial interventions for 

school-aged children in every school in the province. 

The collective plan called for the USPHS team, 

within 1 week’s time to: 

	 •	 develop a training curriculum;

	 •	 train the UNICEF/AusAID staff in its delivery; 

	 •	 prepare and distribute associated documentation; and 

	 •	 administerto 45 governmental and NGO staff

the final training program of 40 contact hours 

covering 43 content areas. 

The Indonesian colleagues were unsure whether 

the USPHS team was capable of developing and 

delivering such a program within such a short time 

frame, especially with Indonesian interpreters. The 

team provided assurances that it could do so. The 

program would create a network of trainers to carry 

on long after the Mercy mission was completed, and it 

could be delivered in a short period of time, although 

some thought privately that it was an impossibly short 

period of time. 

The first critical step in the development of the program involved collecting, evaluating, and preparing 

the necessary materials. Using e-mail, the Internet, and 

a large international virtual team from academic and 

NGO organizations, the US team relied almost completely on the information provided to it electronically 

from these sources around the world. That information 

was received within 24 hours of the first request and 

amounted to over 500 pages of training and intervention documentation. 

The next critical decision point came during a planning meeting when the USPHS/UNICEF/AusAID/

Aceh team was evaluating training information. 

Originally, the mission concept called for USPHS 

personnel to provide the training with Indonesian 

translation. The Indonesian members of the planning 

team, however, included professors of psychology and 

other human-service subject-matter experts. Most of 

these personnel had advanced degrees, were residents 

in the province, and were highly capable trainers and 

facilitators. The conversation during the meeting suggested that the quantity of training information might 

need to be cut by half to provide adequate time for 

translation during the presentations. The specter of 

such a loss of information yielded a substantial change 

in approach: what if the collective international team 

gave the Indonesian members all the information, 
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

partnered with them as they created their own training program, and mentored them as they delivered it 

in Indonesian to Indonesians?

This was perhaps the most important and powerful shift in approach throughout the entire mission. 

The “Black Wave” devastated the people of Aceh. 

Lives, property, infrastructure, and ways of life were 

destroyed. Following the physical destruction, community confidence was also damaged as armies of 

personnel and foreign assistance descended upon the 

province and began “doing things for” the victims 

rather than “doing things with” the community. Until 

members of the US team took an important second 

look at their own approach, they were engaged in the 

very same damaging process. 

With this new strategy, the long-term power of the 

program began to grow and the US team members 

were accepted as colleagues, not outside “experts.” The 

new approach provided a vehicle for the Indonesian 

people to take charge of their own and their province’s 

psychosocial recovery, beginning with their children. 

The shift put the Indonesians on the team in charge 

of everything. The international team—meaning 

everyone else—became their support team. The US 

team members were now seen as trustworthy, and 

thus transitioned from intruders to welcome advisors 

and collaborators.

Two days were added to the preparation time to 

allow for this change in approach. Two more Indonesian facilitators were contracted by UNICEF to assist. 

This international group then began developing what 

eventually became known as the “assembly line” for 

choosing program content and having it immediately 

translated and packaged for delivery. The entire training program content was developed in this manner in 

less than 5 days. 

The most important aspect of the health diplomacy 

model that emerged from this mission was that the 

model facilitated a diverse group of people, from all 

over the world, to become an integrated team. It was 

promoted, in no small measure, as a direct result of 

this change in approach. Consensus became the standard for program development—roles were created 

and people filled them based on program needs, not 

necessarily professional credentials, and those team 

members who would soon leave stepped back and 

supported those who would remain. 

Final Preparations and One Last Hurdle

When the second Mercy precept was formulated 

(“We are not ‘the pros from Dover’”),13 it was with the 

USPHS team members in mind. It was modified to 

include “We are not the pros from Djakarta” after the 

final Indonesian members of the team arrived from the 

capital and the whole training curriculum came close 

to unraveling 2 days before it was to be delivered. One 

of the new members wanted to try a very different approach to several aspects of training. The Indonesian 

members met with the international team for advice 

about how to proceed. They then met as a team to address the concerns, educate the new members about 

why the program was as it was, and welcomed them 

into the process. It worked; consensus was achieved, 

only minor and very beneficial adjustments were made, 

and the program was finalized for delivery with everyone’s roles clearly delineated and agreed upon. Most 

importantly, the team integrated new membership, 

incorporated new ideas without losing the overall approach, and did it without altering the consensus approach that was the hallmark of the entire process. 

The trainings themselves were the culmination 

of a short but intense period of development filled 

with deep emotion and renewed spirit of hope for the 

training staff and the approximately 90 people from 

throughout Aceh Province who would themselves 

become trainers. The training brought together a wide 

range of both governmental and NGO personnel from 

across northern Sumatra, gave them detailed content 

and a network of people upon whom they could rely 

to help them, and instilled confidence that they could 

deliver this training themselves upon their return 

home. As of this writing, the programs are still operating and the Abidin University Hospital in Banda Aceh 

has dedicated space for the programs there to support 

their ongoing operation. 

SUMMARY

The program described in this chapter developed 

from a USPHS leadership approach. It was then modified into an international collaboration among several 

agencies in the middle of the chaos of the relief effort, 

and transitioned from a program given by outside 

“experts” to one ultimately formulated and delivered 

by the people of Indonesia themselves. The development team included many who were directly affected 

and suffered significant personal losses, while others 

knew only what they saw reported via news media 

prior to their arrival. Several team members had no 

previous relief experience, although others had years 

of experience in such efforts. Several of the relief agencies represented had never before worked together, nor 

worked directly with the US Navy or USPHS; the initial 

levels of suspicion about motives and capabilities in 
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the response were high. That they all ultimately came 

together in a spirit of common cause is a testament to 

the best of what is possible in times of great human 

need, and when personal interests are subsumed to 

support the greater good and provide large-scale successes for others.

The success of this program also demonstrates the 

significant benefits that can result when quiet, but 

informed leadership principles are understood and 

acted upon. Absent the open-handed leadership approach, there would have been no collaboration and 

no subsequent program. Future missions and their 

commanders will face similar chaos and unknowns, 

but some of the precepts developed in the Mercy

model may prove useful in developing the clarity 

and collaborations necessary to effect change at-scale 

in health systems following major conflagration or 

catastrophic emergencies. Attachment 2 to this chapter 

contains these precepts, exactly as they were written by 

the USPHS team during relief efforts and as reported 

in their after-action report. Emerging operational approaches such as the PsySTART rapid mental health 

triage platform can also be used as tools to further 

these aims. They are particularly effective when the 

relief and response lanes are shared among agencies 

and forces, rather than wholly “owned” by a particular 

command structure. Because these cases make up the 

vast majority of international relief efforts, the Mercy

approaches appear to maximize effectiveness via better 

collaboration where command and control would be 

either counterproductive or rejected outright by the 

other agencies involved in the response. 

REFERENCES

1. Tzu L, Wieger L, Bryce D. Tao-Te-Ching: The Classic Chinese Work in English Translation. New York, NY: Random House; 2005.

2. US Department of Health and Human Services. What is the commissioned corps? United States Public Health Service 

Web site. Available at: http://www.usphs.gov/aboutus/questions.aspx#whatis. Accessed August 18, 2010. 

3. Perez J, Coady J, DeJesus E, McGuinness K, Bondan, S. Operation Unified Assistance population-based programs: US 

Public Health Service and international team. Mil Med. 2006;1:S53–S58.

4. Magnitude 9.1–off the west coast of northern Sumatra 2004 December 26 00:58:53: UTC. US Geological Survey Web site. 

Available at: http://earthquake.usgs.gov/earthquakes/eqinthenews/2004/usslav/#summary. Accessed September 

30, 2010. 

5. McGuinness KM, Coady JA, Perez JT, Williams NC, Mcintyre DJ, Schreiber MD. Public mental health: the role 

of population-based and macrosystems interventions in the wake of Hurricane Katrina. J Prof Psychol: Res Pract. 

2008;39(1):58–65. 

6. Norris F, Murphy A, Baker C, Perilla J. Severity, timing, and duration of reactions to trauma in the population: an 

example from Mexico. Biol Psychiatry. 2003;53(9):769–778.

7. Sternberg R. A systems model of leadership: WICS. Am Psychol. 2007:62(1):34–42.

8. Reissman D, Schreiber M, Klomp R, et al. The virtual network supporting the front lines: addressing emerging behavioral health problems following the tsunami of 2004. Mil Med. 2006;1:S40–S43.

9. Thienkrua W, Cardozo BL, Chakkrab M, et al. Thailand Post-Tsunami Mental Health Study Group. Symptoms of 

posttraumatic stress disorder and depression among children in tsunami-affected areas in southern Thailand. JAMA. 

2006;296:549–559.

10. Schreiber M. Learning from 9/11: toward a national model for children and families in mass casualty terrorism. In: 

Daneli Y, Dingman R, eds. On the Ground After September 11: Mental Health Responses and Practical Knowledge Gained. 

New York, NY: Haworth Press; 2005: 605–614.

11. Coady J, Perez J, Schreiber M. The way forward: innovations in disaster mental health. Calif Psychol. 2007;40(2):41–44.

12. Schreiber M, Gurwitch R, Coady J, Perez J, Wong, M. Toward a National Model for Children and Families in Mass Casualty 

Events. New York, NY: Springer Publishing; in press.

13. Hooker R. M*A*S*H. New York, NY: Simon & Schuster; 1969.
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

ATTACHMENT 1: EARTHQUAKE DISASTER RELIEF

Major earthquakes have the potential to be one of the most catastrophic natural disasters affecting humanity, 

as evidenced by the recent earthquakes in Bam, Iran, Pakistan, and Peru. Earthquakes of significant size set off a 

chain of events that significantly affects the public health and medical infrastructures of the region. Accelerated 

urbanization in seismically active parts of the world dramatically increases the vulnerability of these regions. 

Worldwide, more than a million earthquakes occur each year, with nine countries accounting for 80% of earthquake fatalities (China, Japan, Pakistan, Chile, Russia, Turkey, Peru, Iran, and Italy1–6). In the United States, the 

state experiencing the most earthquakes is Alaska.1,2

Numerous factors influence earthquake mortality and morbidity, including natural factors, structural factors, 

and individual factors. Aftershocks are a particular concern and may occur for a prolonged period of time. For 

example, during the Northridge, California, earthquake more than 14,000 aftershocks occurred in the region over 

the next 5 years.3 Landslides and mudflows after earthquakes account for significant morbidity and mortality. 

Hazardous materials (chemical, biological, radioactive) are an increasing risk after earthquakes due to accelerated urbanization. Following the Loma Prieta earthquake in California in 1989, toxic materials were responsible 

for about 20% of after-earthquake injuries. Flooding from dams with structural damage and fires continue to be 

additional causes of mortality and morbidity after earthquakes.7–9

Structural factors affecting injury or death rates include trauma caused by building collapse. In fact, approximately 75% of earthquake fatalities are caused by collapse of buildings that were poorly constructed or 

not earthquake resistant.10–12 Individual risk factors include age, health, and emotional stability. Demographic 

factors associated with increased risk for death and injury are persons over the age of 60, children between 5 

and 9 years of age, and chronically ill persons.12 The increased vulnerability of these groups is because of lack of 

mobility, exacerbation of underlying diseases, and inability to withstand major traumatic injury. Entrapment, the 

occupants’ locations within a building, their behavior during the earthquake, and time until rescue, constitute 

the factors affecting mortality and morbidity. 

Logistical support is an essential element of disaster relief and an area in which the military excels. The mass 

casualty response to earthquakes includes four essential elements of disaster medical response: (1) search and 

rescue, (2) triage and initial stabilization, (3) definitive medical care, and (4) evacuation.13 The requirements for 

search and rescue and definitive care, and the need for outside assistance from military and civilian teams, are 

significantly increased in earthquake disasters compared to other natural disasters because of the severity of 

wide-spread damage and the complexity of injuries.

Psychological trauma and other adverse psychological sequelae are frequently the side effects of earthquake 

disasters for a number of reasons. Earthquakes occur with little or no warning compared to hurricanes (several 

days of storm tracking) or even tornadoes (often with several hours of meteorological information). This lack of 

warning deprives victims of time to take psychological and physical protective action, and exacerbates a sense 

of loss of control over the destructive event. Earthquakes expose victims to serious threats to personal safety, 

increasing their vulnerability to future psychological symptoms. One of the important lessons learned in disaster 

medical response is the necessity to configure teams based on functional capacities, not professional titles. A 

capacity for mental health interventions is critical, and mental healthcare teams are now incorporated into most 

civilian and military disaster response teams in the United States.

Earthquakes are a major cause of the full spectrum of traumatic injuries, both physical and psychological, and 

frequently require outside medical and public health disaster assistance. Ultimately, disaster mitigation will be 

the most significant factor in decreasing mortality and morbidity from earthquakes.

Acknowledgment

This attachment was prepared by Susan Miller Briggs, MD, MPH, Associate Professor of Surgery, Harvard Medical 

School; Director, International Trauma and Disaster Institute, Massachusetts General Hospital, Boston, Massachusetts.

REFERENCES

1. Noji EK, ed. The Public Health Consequences of Disasters. New York, NY: Oxford University Press; 1997.
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Combat and Operational Behavioral Health

2. Hays WW. Perspectives on the international decade for natural education. Earthquake Spectra. 1990;6:125–143.

3. Prager EJ. Furious Earth: The Science and Nature of Earthquakes, Volcanoes, and Tsunamis. New York, NY: McGraw-Hill; 

1999.

4. Perez E, Thompson P. Natural hazards: causes and effects. Lesson 2–earthquakes. Prehosp Disaster Med. 1994;9:260–

271.

5. US Geological Survey. Scenarios of Possible Earthquakes Affecting Major California Population Centers, With Estimates of 

Intensity and Ground Shaking. Menlo Park, Calif: USGS; 1981. Open-File Report 81-115.

6. Blake P. Peru Earthquake, May 31, 1970. Report of the CDC Epidemiologic Team. Atlanta, Ga: Centers for Disease Control 

and Prevention; 1970.

7. Showalter PS, Myers MF. Natural disasters in the United States as release agents of oil, chemicals, or radiological 

materials between 1980–1989: analysis and recommendations. Risk Anal. 1994;14:169–182.

8. Durkin ME, Thiel CC, Schneider JE, et al. Injuries and the emergency medical response in the Loma Prieta earthquake. 

Bull Seismological Soc Am. 1991;81:2143–2166.

9. Hayes BE, Freeman C, Rubin JL, et al. Medical response to catastrophic events: California’s planning and the Loma 

Prieta earthquake. Ann Emeg Med. 1992;21:368–474.

10. Colburn AW, Murakami HO, Ohta Y. Factors Affecting Fatalities and Injury in Earthquakes. Engineering Seismology and 

Earthquake Disaster Prevention Planning. Hokkaido, Japan: Hokkaido University; 1987. Internal Report.

11. EQE Engineering. The October 17, 1989 Loma Prieta Earthquake: A Quick Look Report. San Francisco, Calif: EQE Engineering; 1989.

12. Coburn AW, Spence RJS, Pomonis A. Factors Determining Human Casualty Levels in Earthquakes: Mortality Prediction in 

Building Collapse. Reston, Va: US Geological Survey; 1992.

13. Briggs SM, ed. Advanced Disaster Medical Response Manual for Providers. Boston, Mass: Harvard Medical International; 

2003. 
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ATTACHMENT 2: THE MERCY MODEL

The Mercy (ship and concept) was an untested capability arriving at the site of an unprecedented event. 

Extraordinary devastation, great chaos, much need, little information about overall response, and, of equal 

importance, little information on the ground and among agencies there about us, who we were, and what we 

might do. We did not know ourselves what we might be capable of doing. There was fear, particularly among 

the international mental health community, that we were going to interfere or otherwise act unilaterally without 

cooperation or coordination. The international relief community, including our own US organizations, viewed 

us with suspicion. Western psychological methods were not widely understood, or greatly accepted, and our 

reputation—real or conjured—was that we would come in for a few days, see a limited number of patients (more 

to use as props for media opportunities than genuine assistance), get our pictures taken, congratulate ourselves, 

and then leave. As a team, we assumed this going in and swore we would do nothing of the sort. The Mercy

model began with that promise. The precepts as they were formulated were: 

1. “Go West and Do Good Things...” This was essentially the mission order until the ship arrived on station: our overarching precept was to promote the greater good, not our particular role in the effort. 

2. We are not “the pros from Dover”—borrowing the line from the book M*A*S*H.1 The principle here is 

collaboration, not independent action. Egos and personal ownership of information and approaches 

are checked at the helicopter door. 

3. We are here as students of the people and culture we are here to assist, because the better we understand, the better we can serve. 

4. We work for and with agencies ashore, not the other way around. We do not work independently, unless we have capabilities that are useful, support those that are already in place, or are desired by the 

agencies with whom we work. 

5. For behavioral health, given limited time, personnel, and resources, we will focus on public health and 

population-based approaches to maximize program development, penetration, and effects. Responding to the area’s behavioral health relief systems and infrastructure needs is our primary concern, not 

direct service. We are responding to a disaster of unprecedented proportions. We could limit our overall 

impact by only delivering direct services, or we could take our limited personnel resources and seek 

to maximize potential impact by working with systems programmatically. Somewhat novel, but not 

at all unprecedented. 

6. Initial work will be assessing the mental health infrastructure, programming, agencies, and services, 

then developing relationships with agencies, not developing programs independent of them. The 

building of the relationships with other agencies is the most critical step in the entire process; without 

the relationship, there is no program. New relationships with agencies may be met with suspicion; we 

should approach this as an opportunity, not a threat. 

7. Collaborative leadership, consensus approach: coordination not control, development not ownership, 

shine spotlight on others not ourselves, and collaboration among the team and the teams with whom 

we work. Seek consensus wherever possible and defer to others when conflict arises or differences 

threaten the process. Adopt local approach when such exists. Simple concepts, though extremely difficult to execute and should neither be overlooked nor undervalued. 

8. We will not promise anything that we can’t deliver, period. 

9. Team members do what needs to be done regardless of position or professional background. 

10. Promote respect for divergent people, professions, worldviews, and spiritual beliefs. 

11. “Wisdomkeepers” must be sought and welcomed—language and cultural guidance are essential. We 

will learn as much as we teach. 

12. International team formation is critical; positive interpersonal relationships, group formation, promotion, and collaboration are primary goals. 

13. Focus on facilitation for program development, not instruction, so the process of program development 

is taught by doing. Through this process new leaders are developed and the people are empowered. 

14. Create tools for program development and show how to use them: don’t just provide the programs 

themselves. 

15. Focus on approach for paraprofessionals and nonprofessionals, not professionals...because there aren’t 

any, or at least not enough to make any substantive difference. The “paraprofessionals” are both the 
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experts of the culture and the facilitators of the programs. They bring valuable and essential skills to 

the trainings and must be empowered to implement programs.

16. We are an international team with a local presence. We are, in a very real sense, a local presence for an 

international team and knowledge trust, including many of the finest disaster recovery people around 

the world. Utilizing digital and other technologies, we are in this together and will work together as a 

worldwide virtual team. 

17. Programs will need to be formulated with great speed, will be discrete and time limited—we do not 

know how long we will be on station in any given place and we will not start something we can’t finish. Thus, we will work as quickly as possible to provide stand-alone programming. 

18. Mobilize local expertise and capability, wherever possible, then support it with programming and disseminate the overall process widely, particularly where there has not been such an approach before. 

This was particularly true in Aceh, where there was limited infrastructure, and what infrastructure was 

there developed posttsunami. This offered an opportunity to support the new network and capability 

in ways that might not otherwise have been possible. 

19. Use a program assembly line approach to maximize collaboration and speed of program production. 

It is during this process that the relationships and trust developed between organizations and people. 

We did what we said we would do and we promoted active collaboration, not passive acceptance, for 

the program’s development: 

a. Team consensus on program specifics; we began by asking the question: “If we could do anything, 

what would the program look like?” Taking that ideal, we then asked, “How can we do this?” and 

mobilized the network, both in Aceh and internationally, to try to get as close to the ideal as possible. 

This we learned from AusAID [Australian Agency for International Development] and UNICEF 

[United Nations Children’s Fund]. 

b. Content gathering: gathering as much information as possible as quickly as possible in the areas 

requested, then reduce that information to a usable set of reference materials from which to choose 

final products.

c. Logistical and resource support: where, how, who, funding, mechanisms of support, travel, security, 

local transportation and housing, etc. Completely UNICEF and AusAID managed. 

d. Editorial/programmatic: consensus collaboration on what content, from all that was received, would 

finally be used in the presentations. 

e. Media preparation: taking the selected information and putting it into the proper format, PowerPoint, reference documents, etc, for participants. 

f. Translation: taking the final training products and translating them, primarily from English into 

Indonesian, and placing them into the day’s presentation curriculum and reference documentation. 

g. Trainer preparation: review materials with trainer and promote input on feasibility of content and 

method. 

h. Presentation: as much as possible, use local trainers and program people. We will support and 

supervise as needed, but this is their show, not ours. We helped produce, but they star.

20. Evaluation: current evaluations are being completed by members of UNICEF, AusAID, Karinivasu, 

and Women’s Crisis Counseling. The evaluation will cover other international agencies’ experiences 

in working with the behavioral health team and its role in the collaboration.

21. Ongoing collaboration: while the programs might be time limited, the relationships are not and the 

potential for ongoing support and collaboration is very real, particularly with technology and digital 

capabilities to maintain and support it. Plan for and promote it. 

REFERENCE

1. Hooker R. M*A*S*H. New York, NY: Simon & Schuster; 1969.
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Behavioral Health Issues and Detained Individuals

Chapter 40

BEHAVIORAL HEALTH ISSUES AND 

DETAINED INDIVIDUALS

RICHARD TOYE, PhD,* and MARSHALL SMITH, MD†

INTRODUCTION

TRAINING THE TEAM

Predeployment Preparation

The Clinical Process in Detainee Care

Unit Transition

EFFECTIVE USE OF TRANSLATORS

DEVELOPING A TREATMENT PLAN

Behavioral Management Considerations

Medication Management and Distribution

Communicating With Other Sites

SPECIAL CLINICAL ISSUES

HUNGER STRIKES: A UNIQUE DETAINEE CLINICAL ISSUE

Assessment

Intervention

Consultation

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army Reserve; Company Commander, 883rd Medical Company (Combat Stress Control), 495 Summer 

Street, Boston, Massachusetts 02210; formerly, Brigade Behavioral Health Consultant, 804th Medical Brigade, Fort Devens, Massachusetts

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Behavioral Health, Landstuhl Regional Medical Center, CMR 402, Box 1357, APO AE 09180; 

formerly, Chief, Outpatient Behavioral Health, Landstuhl Regional Medical Center
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Combat and Operational Behavioral Health

INTRODUCTION

The US military provides appropriate healthcare 

services for enemy prisoners of war and other individuals detained during operations. Doctrine and international treaties require that detainees be provided 

“equivalent care” to prevent deterioration of their 

condition. The scope of detention healthcare operations is dictated variously by the magnitude of the 

detention activities in theater, the typical duration of an 

individual’s detention, cultural norms and situational 

factors affecting the problems presented by detainees, 

and the availability of resources in theater.

In Operation Iraqi Freedom, behavioral health 

services to detainees first emerged as a critical operation in 2003, when it was discovered that local psychiatric inpatients had been released into the streets 

by retreating enemy forces, and that Coalition troops 

had captured and detained many of them in facilities 

at Umm Qasr. The emergent need to distinguish between distressed psychotic individuals and acting-out 

enemy combatants required immediate diversion of 

combat and operational stress control assets to the 

detention mission. At that time, noncombatant detainees who were seriously mentally ill were discharged 

to community care. In 2004, as detainee operations 

stabilized, nongovernmental organization surveyors 

expressed concern that seriously mentally ill individuals retained in detention were receiving care from 

providers other than licensed behavioral healthcare 

practitioners and that the standard of equivalence 

of care was not being met. At the time of this text’s 

preparation, three separate medical task forces with 

augmented behavioral health teams have rotated 

through theater detainee healthcare operations in 

Iraq. This chapter provides a basic framework of operations in detainee behavioral healthcare, reflecting 

the lessons learned by the first two contingents, Task 

Force Medical (TF MED) 115 and TF MED 344. To 

help the units tasked with this challenging job apply 

these lessons, the chapter will discuss critical mission activities and common problems in the process 

of preparing and executing the detention behavioral 

healthcare mission.

TRAINING THE TEAM

Predeployment Preparation

Predeployment is a stressful time for all involved. 

The unit mission focus is on common training tasks; the 

command emphasis is on facilitating service members’ 

transition from the home environment to the combat 

environment. Nevertheless, every effort should be 

made for personnel to receive appropriate missionspecific training prior to deployment to a detention 

mission. Predeployment preparation should include, 

at a minimum, four essential components: (1) reviewing current Department of Defense (DoD) and federal 

and state corrections healthcare policy and procedures, 

(2) establishing communication with unit personnel 

currently on site in theater, (3) reviewing cultural information specific to the host nation, and (4) gaining 

familiarization with the detention care setting. 

Most DoD behavioral health providers have never 

worked in the corrections environment, much less the 

detention healthcare environment; a review of current 

corrections policy and procedures is a must. Detention 

healthcare is similar to healthcare given to patients 

overseen by the Federal Bureau of Prisons, an agency 

of the US Department of Justice. Bureau of Prisons 

standard operating procedures (SOPs) provide the 

model used to develop military protocols for detention 

care. These various SOPs1,2 address essential topics 

including suicide prevention, medication distribution, 

and screening procedures, all key elements in the detainee care mission. If time permits, personnel should 

consider visiting a local corrections establishment to 

talk with the medical personnel about providing care 

in a corrections environment. 

Perhaps the most important step in preparing to 

deploy is establishing communication with the personnel being replaced. This point cannot be stressed 

enough. The current active unit has implemented SOPs 

that will be suitable for most purposes, and deploying staff should obtain and review them to become 

familiar with current operations and capitalize on 

lessons learned before arriving in country. The currently deployed unit can also provide information on 

particulars of the environment such as billeting information, recreational facilities, supplies to bring, and 

available resources. Communication may be difficult 

because of time zone differences, but multiple channels exist: e-mail, telephone, or even videoconference, 

if available. Exchanging contact information benefits 

everyone; for the outgoing unit, the process of training 

the incoming unit has its own value. Most units have 

tremendous pride in their organization and appreciate 

others’ interest and willingness to accept their feedback 

and experiences. Changes in existing protocols will 

undoubtedly be needed, but current SOPs provide a 

good place to start. 

If no behavioral health unit was previously in country and the mission is to establish the first detention 

behavioral healthcare program in the area occupied, 
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Behavioral Health Issues and Detained Individuals

it is especially important to understand the standards 

by which behavioral healthcare will be evaluated, as 

well as learning what assets will be available to support the mission. Although the program is mandated to 

provide detainees with equivalent care, the perception 

of what “equivalent” means can vary widely, so it is 

important to establish as soon as possible what services 

and level of care are intended. DoD doctrine, US Bureau of Prison standards, and community standards 

within the area of operations (AO) can help inform 

this decision.1–5 

In most cases, detainees are from a different culture 

than the typical service member patient. Cultural differences can be an obstacle to establishing rapport and 

to patient care delivery. Misunderstandings between 

patient and clinician can be frustrating in an already 

tense environment, so it is important for providers to 

be familiar with common local customs and courtesies. This information can be found on the Internet, in 

textbooks, and in other historical sources. If possible, 

a briefing by someone from the particular culture 

will be very helpful. Prior to deployment in 2005, TF 

MED 344 enjoyed extensive cultural briefings from 

Iraqi expatriates, which made the transition into that 

environment much smoother than it might otherwise 

have been.

Additionally, briefing by a medical provider from 

the culture is invaluable. Names of medications and 

the social significance of different forms of treatment may differ. It is essential to know some of the 

cultural differences in the way medicine is practiced; 

for instance, the perception of mental illness can vary 

tremendously among cultures. Understanding some 

of the basic differences and perceptions increases the 

effectiveness of even basic treatments; however, it is 

important to assess the quality of source information. 

For example, TF MED 344 was repeatedly informed 

that rural Iraqis considered behavioral health issues to 

be signs of malign influence, and that the indigenous 

personnel were unsophisticated and wary of behavioral health issues. In fact, the population appeared 

to have a good knowledge of behavioral health issues 

and protocols. One illiterate farmer, detained during a 

sweep of his community, thanked providers for their 

interest in his mental state and acknowledged that he 

was depressed, but stated his preference to work with 

his local cleric about his feelings of loss over the death 

of his sons in the conflict.

Cultural issues and phenomena are limitless, and 

there is no way to be totally prepared for the situation 

in theater. For example, it is common knowledge that 

psychosis often presents differently in different cultures. When TF MED 344 staff encountered a detainee 

who reported concerns about his visions of a talking 

chicken, the question arose as to whether this was a 

psychosis or malingering. Certainly in a US population, malingering was more likely. Discussion with 

translators and other detainees provided no indication that chickens had any particular significance in 

this culture, and other psychotic individuals in camp 

tended to have auditory hallucinations without visual 

manifestations. While it was not possible to be sure, 

the subsequent presentation of several other patients 

with exactly the same hallucinations suggested to 

staff that the “talking chicken” phenomenon was 

malingering behavior. In stark contrast, the extremely 

high incidence of self-injurious behavior turned out 

to have several cultural antecedents, including both 

an acceptance of excoriation as a religious ritual and 

a history of self-mutilation among prisoners during 

the Saddam Hussein regime to avoid being brutalized 

even more by their guards.

While cultural issues are legion, it also is important 

to recognize the universal nature of mental illness. For 

example, one patient managed by TF 344 reported 

that God spoke directly to him and told him that all 

infidels would die. This presentation could certainly 

have reflected the social-political context of the conflict; 

however, other camp residents repudiated the patient’s statements and were concerned for his welfare 

and safety. The individual was truly psychotic and 

responded well to antipsychotic medications. Another 

detainee presented with a long history of self-injurious 

behavior, and swallowed any sharp object he could 

find. His behaviors increased as attention to them 

increased. He was diagnosed as a self-destructive 

borderline personality and required extremes of behavioral management.

The context of care in a detention camp differs 

significantly from deployment to any other forward 

operating base or operations center. In a detention 

camp, the enemy is not only outside the perimeter, but 

has a large presence within the perimeter as well. This 

has two main effects. First, security protocols assume 

a significant place in day-to-day operations. Second, 

coalition personnel are confronted with a uniquely 

stressful task of interacting on a daily basis with the 

enemy, creating a number of behavioral health issues 

that can affect operations.

Security issues are always legion during deployment to a hostile AO. In detention care, security is 

doubly important. Access to the patient routinely 

requires special clearance and passes, and time must 

be planned to allow for multiple security checks. 

Patients are not seen privately. “Outpatient” interactions may be through a security barrier. Armed guards 

accompany hospitalized patients or those seen in a 

clinic. Clinical schedules must be coordinated with the 

guards’ transportation schedules for these custodial 

staff. Daily operations are likely to be interrupted by 
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Combat and Operational Behavioral Health

head counts, missing person checks, or crowd control 

operations. In the Iraq AO, detainees were assigned 

numbers rather than being referred to by name, 

making it difficult to track cases, especially because 

detainees were routinely shifted from camp to camp 

as a security precaution.

Medical and custodial staffs are patently affected 

by having to interact with the enemy on a daily basis. 

They cannot treat the enemy aggressively, and must 

provide compassionate care even when threatened 

or disparaged by the detainee. They cannot establish 

friendships or trusting relationships with the individuals they see most often each day. The stress of detainee 

care causes irritability, anger, and dissatisfaction rarely 

seen in other healthcare or operations centers. Management of this distress is an important part of the 

behavioral healthcare mission.

The Clinical Process in Detainee Care

The clinical process in detention care also differs 

markedly from that in other clinic-based operations. 

Staff may or may not need a refresher in basic clinical 

assessment and brief counseling techniques, but the 

team invariably requires training in detention operations. Training should address screening, assessment, 

intervention expectations, crisis response, and coordination of care.

Every new detainee is screened for behavioral 

health risk factors as part of their initial medical 

evaluation. A brief questionnaire covering previous 

behavioral health treatment and current behavioral 

health concerns is administered through an interpreter. 

Familiarity with the screening process and with typical 

detainee reactions to the behavioral health interview is 

a must. Intake screening is a volume business: screening must proceed at the pace of internment operations. 

This can range from 50 screenings a week to 150 a day, 

with little advance notice, depending on the pace of 

operations in theater. It will be tempting to assign one 

or two individuals to the screening process, because 

it is inherently different from other clinical operations 

and can be accomplished best by personnel who are experienced with the procedure. Even when this is done, 

however, every member of the team must be able to 

complete the screening interview both to provide surge 

capacity and because this is a must-do procedure that 

if not completed delays the movement of the detainee 

into the camp.

The intake screen identifies new detainees who need 

follow-up evaluation. Detainees may also be referred 

for evaluation by military police, by the medical team, 

by other detainees, or through self-referral. At Abu 

Ghraib in 2004 and 2005, after systematic improvements in the detention facility were established, it was 

typical for providers to see a dozen individuals for 

new assessment and disposition each week. Personnel must be comfortable with conducting a functional 

assessment leading to initial diagnosis and disposition in sparse conditions, using an interpreter for the 

interview portion of the assessment. Clear criteria 

for assessment and disposition should be established 

and practiced prior to deployment. Mobilization site 

training will most likely provide “typical” cases that 

are florid in their presentation, a training model that 

is unrealistic and not useful. Instead, training should 

focus on assessment of anxiety disorders in an anxietyprovoking situation, identification of malingering, 

and differential diagnosis of adjustment disorder and 

major depression. The patient cannot be expected to 

be a reliable informant; the information received will 

be distorted by translation; and the setting will create 

ambiguities that make a typical assessment model 

untenable. The behavioral health clinician must rely 

on behavioral signs and reports of functional impairment from collateral sources at least as much as on the 

patient’s own report.

Ongoing review of the active caseload is more 

complex in detention care than in the clinic or in the 

corrections setting. Patients do not have regular appointments; they are scattered across a barbed wire 

encampment and are moved frequently for security 

reasons. A concerted effort must be made to develop 

and sustain a patient tracking system. Once continued 

care is established, clear outcome criteria should be 

established and monitored for each case. Establishing 

outcome criteria will probably be the part of this process most reminiscent of normal clinical practice.

One of the most frequent questions asked by providers outside of this setting is whether the military 

really “does therapy with those guys.” Odds are that 

most intervention will involve medication management, behavioral intervention, and education or brief 

supportive counseling rather than psychotherapy per 

se. Among the many factors mitigating against the establishment of therapeutic trust are the likely brevity of 

care, as well as cultural and privacy issues preventing 

in-depth treatment in most cases. However, as in any 

setting, treatment approaches should be adjusted to 

meet the needs of the individual.

Detention care can be volatile, and is a 24-hour 

operation. The clinical team is on call at all times. 

Although the facility includes physical safeguards to 

keep aggressive and suicidal detainees secure, custodial staff values the reassurance and direction that 

on-call behavioral health consultants provide when 

detainees have problems off-shift. Clinicians must 

respond to every call, even if the situation is under 
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Behavioral Health Issues and Detained Individuals

control. A common problem is threats of self-harm to 

obtain camp privileges. In Iraq, where many historical 

factors facilitated self-excoriation, it was not uncommon to be called to attend to a detainee who had cut 

himself shallowly across the chest and threatened 

further self-harm if his demands were not met. In the 

United States, this behavior would be an indication of 

serious underlying pathology, but in this setting the 

behavior was more often than not an extreme example 

of manipulative or coercive behavior on the part of a 

detained individual.

Finally, the behavioral health team will not operate in isolation. Detainees receiving behavioral health 

services are also under care of the medical team. Some 

primary healthcare providers will prefer to prescribe 

their own psychotropics, and some will use medicines 

from the behavioral health formulary for other purposes, such as pain management. Nongovernmental 

organizations are often involved in coordinating social 

services for the detainee. It is necessary to establish 

protocols for coordinating medication procurement 

as well as coordinating care with the healthcare team, 

including medication procurement, record keeping, 

and social service contact management. The behavioral 

health team should train on and practice these protocols before entering the operational area.

Unit Transition

Several things can be done to optimize the transition 

from one unit to its replacement at the detention center. 

The outgoing unit will probably know their replacements at least a month or two before the transition. If 

the incoming unit has not contacted the outgoing unit 

in that period, the outgoing unit should work through 

their leadership to contact and establish a working 

relationship with their replacements. In addition to 

preparing for a successful handoff, preparing the 

detainees over a period of about a month is useful in 

minimizing disruption. Replacements should arrive 

early enough that outgoing staff can demonstrate current procedures for at least a week. 

This staffing overlap is commonly referred to as 

the “left seat/right seat ride.” To set up the new unit 

for success, it is strongly recommended that staff with 

similar roles be paired with outgoing staff during duties for several days, allowing newcomers to adjust to 

the environment, see the day-to-day operation, and ask 

questions. A date should be designated for the takeover 

of duties by the new staff, accompanied the first time 

by outgoing staff. Optimally, the oncoming unit should 

have at least a day or two to function independently 

prior to the departure of the outgoing unit, although 

this schedule can run into problems. In both TF MED 

115 and TF MED 344 some medical teams were ready 

to relinquish their duties the day replacements arrived. Others, feeling pride of ownership, did not feel 

comfortable standing by while the replacement staff 

took over and learned the job.

Tours are generally for 1 year and invariably rapport will be established between staff and detainees. 

Detainees talk among themselves and with other 

medical and nonmedical staff, and often have some 

idea when units are scheduled to depart, knowing 

that units usually change somewhere around the 11- or 

12-month point. Detainees have an active interest in the 

transition and may ask detailed questions. They will 

understand the transition process and probably try 

to find out exactly when the new unit will take over. 

Some appreciate the care they received and will feel 

anxiety about the upcoming transition and termination. However, operational security should be kept in 

mind: detainees should not be given specific dates or 

any other information that may be used to threaten 

security. Personnel should be vague and ensure detainees that their care will continue; no information 

about troop movements should be divulged. 

Units preparing for departure often shift focus to 

the task of reintegration and manage ongoing tasks 

with less interest and enthusiasm. Personnel should 

maintain operational focus: the outgoing unit has the 

responsibility to prepare both the detainees and the 

gaining unit for a successful, seamless transition. A 

modified termination process and a well-planned and 

executed left seat/right seat ride will give the outgoing 

unit closure, knowing that the mission they conducted 

and improved upon will be handed over to people they 

were able to train. The gaining unit will build upon and 

modify procedures to optimize the care they deliver 

over the course of their tour.

EFFECTIVE USE OF TRANSLATORS

Communication with detainees is essential to effectively assess and treat them. Most detainees will not 

speak English, and unless the medical staff speaks the 

detainee’s language, the use of a translator is vital in 

obtaining a good history. In some settings, translators 

are intentionally rotated among sites and services as a 

security measure, making it impossible to thoroughly 

train a few select individuals. This may be a source 

of contention. Frequently, as a medical team becomes 

familiar with a translator, they feel confident in them 

and request sole access to them. This is not good practice. During TF MED 344’s tenure, no fewer than three 
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proficient and apparently friendly translators were 

removed from service: two were found to have passed 

information to hostile elements, and one was removed 

for continually asking for cast-off uniforms. Incessant 

questions about vacation plans or other personal information, which might be normal in other settings, 

are not a sign of a reliable interpreter.

It is unlikely that many translators will have expertise in behavioral health or behavioral health terminology. Some cultures may have different understanding of 

terms such as “hallucinations” or “delusions,” so questions about these symptoms may get lost in translation 

and render the assessment ineffective. Other concepts 

may be uncommon in a particular culture, and some 

questions might be seen as offensive or disrespectful. 

Translators may have their own opinions about the 

patient’s problems, and may not make the effort to 

translate the questions exactly. Furthermore, personnel 

must be aware that hired translators may be traditional 

enemies of the detained population: they may come 

from neighboring countries in conflict with that of the 

detainee, or they may have opposing politics.

Personnel should take time up front to get to know 

the translators and ascertain their understanding of 

behavioral health terminology, as well as their ability 

to convey information to a detainee. Translators should 

understand the importance of asking the patient every 

question posed, rather than providing answers themselves. Hired translators should be used when possible, 

but the unavailability of hired translators should not 

impede the successful execution of the mission. In the 

absence of a hired translator, detainees who are fluent 

in English may be required to serve as translators. 

Custodial staff may be able to recommend a detainee 

who has proven to be effective and may have assisted 

them on other occasions. Although clinicians might 

initially be reluctant to use a detainee as a translator, 

having a trusted detainee assist can be both extremely 

effective and enlightening. Detainees may feel more 

comfortable opening up to a fellow detainee who they 

respect and admire than to a hired translator they may 

not trust. Establishing a rapport with the detainees is 

important for successful treatment, and sometimes 

having a working relationship with one of their peers 

who speaks English can facilitate an effective therapeutic relationship. 

DEVELOPING A TREATMENT PLAN

It is important to bear in mind, in this setting more 

than most, that diagnosis is functional: the goal is 

not necessarily to determine the etiology and nature 

of the disorder but to develop effective treatment. 

International standards for care in this setting specify 

treatment of mental disorders that result in incapacity 

to care for oneself or in increased risk of deterioration of function or health; the emphasis on functional 

impairment must be highlighted. Functional impairment is a critical ingredient in deciding to provide 

care, especially if resources are limited. To that end, 

personnel must 

	 •	 diagnose only to the level of the available

data; 

	 •	 develop treatments using rubrics that maximize functional outcome as simply and as 

safely as possible; and 

	 •	 rely on outcome monitoring to adjust and

eventually to titrate treatment. 

Diagnosis and treatment in detention care is vulnerable to many problems not experienced in other 

settings: language and cultural barriers to establishing 

good communication, subtle cultural factors associated 

with the meaning of mental illness for the detainee, 

pressure in detention to acquire marketable drugs or 

to garner attention or respite from the compound, and 

group dynamics affecting the individual’s behavior. 

The absence of good collateral information and the 

biases of the interpreter and custodial staff toward 

mental illness and toward the detainee complicate 

matters immeasurably. Available information includes 

the self-report of the detainee, third-party reports from 

camp mates and custodial staff, records from medical 

services provided during detention, observation, and 

functional assessment. Because the translation may 

be unreliable, the clinical interview should rely more 

heavily on behavioral observation than most clinicians 

are accustomed to. 

Behavioral Management Considerations

Establishing a program for managing behavioral 

problems, or providing consultation, is an essential 

part of a successful detainee behavioral healthcare mission. Military police deal with behavioral challenges 

daily and often turn to the behavioral health team for 

advice and support. Some detainees test the limits of 

acceptable behavior, which must be handled effectively 

to prevent others from acting in similar fashion. Often, 

unacceptable behavior occurs to achieve secondary 

gain, and the behavioral health team can educate the 

corrections staff on appropriate means to address the 

behavior without rewarding the detainee (which reinforces the behavior and causes others to engage in the 

same or similar behavior). The behavioral management program can empower the corrections staff and 
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Behavioral Health Issues and Detained Individuals

significantly curtail inappropriate detainee behavior.

Detainee custodial staff members have one of the 

most challenging jobs in the military. Staff members 

may have a corrections background, and these personnel can utilize their prior experience and training to effectively manage inappropriate behavior. Others have 

no prior corrections experience and may be operating 

in a detainee environment for the first time with very 

limited training. Faced daily with hostile and belligerent detainees, most custodial staff do an exceptional 

job maintaining order and discipline. When detainees 

engage in behavior that poses a threat to themselves or 

others, custodial staff will call on the behavioral health 

team for assistance. To facilitate teamwork, behavioral 

health personnel should establish a working relationship with custodial staff early in deployment. Behavioral health personnel should introduce custodial staff 

to the most common behaviors associated with mental 

illness and encourage them to get the behavioral health 

team involved early if they have concerns or are unsure 

of how to handle a particular situation. Custodial staff 

will appreciate knowing they can call on behavioral 

health professionals if they need assistance. Often, 

the behavior can be controlled by simply removing 

the detainee from the environment or by giving the 

detainee some time alone away from other detainees. 

Furthermore, the behavioral health team is responsible 

for training the custodial staff to recognize when a 

detainee may be psychotic, experiencing another Axis 

I disorder, or having a primary Axis II problem so they 

can contact the team to make an assessment. A good 

clinical assessment will aid in determining what the 

primary problem is and help in making the appropriate decision to resolve the situation. 

Primary Axis II problems, common in any corrections population, can be expected in the detainee 

population as well. Common reasons for acting-out 

behavior involve secondary gain such as wanting more 

cigarettes, wanting to get out of the heat and into an 

air-conditioned building, and a host of other reasons 

primarily viewed by the detainee as obtaining pleasure 

and reducing suffering. Inappropriate behavior may 

include self-injurious behavior such as cutting, eating 

barbed wire, making suicidal statements, making suicidal gestures, and faking seizure-like activity or other 

medical conditions that commonly require removal 

from confinement and evaluation in the hospital setting. This behavior can be significantly reduced by 

having a medical or behavioral health team evaluate 

detainees in their living space and by transporting 

them only if medically indicated. However, contact 

with the behavioral health team on site can itself become a detainee’s goal.

Despite some similarities to corrections setting, the 

detention care setting is unique, and common clinical 

assumptions about the etiology of acting-out behavior 

must be suspect. Although some detainees cut themselves or threaten suicide for reasons such as trying 

to leverage a move to a better tent, other acting-out 

behavior may have a more malign purpose: creating 

a distraction so that another detainee may be threatened or killed, distracting custodial staff from efforts 

by detainees to build a tunnel, or signaling a plan for 

a riot. At times there may be no apparent reason for 

such behavior. On one occasion in 2005, detainees were 

received at Abu Ghraib from an Iraqi prison. All were 

screened for health and behavioral health needs, and 

most were found to be in poor condition because of 

harsh conditions at the Iraqi prison. Somewhat to the 

surprise of providers, most expressed pleasure at being returned to Abu Ghraib, where they had initially 

been triaged months earlier before being turned over 

to the Iraqis. One such individual, who was extremely 

vocal in his pleasure at returning to the relative comfort 

of American detention, nevertheless faked a seizure 

within an hour of being returned to the camp. 

Having a designated observation area located in the 

detainee compound allows medical staff to bring the 

care to the detainee and limits the need for transport 

outside of the compound. In addition to observation, 

basic first aid, including suturing, bandaging, checking vital signs, administering medications, and other 

necessary interventions that do not require transport 

to the hospital can be done in the detainee compound. 

The designated area should be near the corrections 

staff command post or another area where detainees 

can be watched constantly but within their compound 

and as close to their living area as possible, so even 

direct contact with the behavioral health team can be 

limited if malingering to obtain such contact is suspected. TF MED 115 dealt with the increasingly selfinjurious behavior of one detainee by strictly limiting 

the patient’s access to the hospital, a treatment plan 

that required constant reassurance to the emergency 

medical teams that were called on to dress moderately 

severe self-inflicted injuries in the camp’s field setting. 

This strict restriction on access to the hospital eventually reduced the frequency of self-injurious behavior 

by the detainee, proving its value.

Medication Management and Distribution

Although some detainees with mental illness will 

not require medications, others will, and should be 

offered the appropriate medication to effectively 

treat their respective illness. Mental illnesses among 

detainees reflect those in the general population and 

include mood disorders, anxiety disorders, psychotic 

disorders, substance use disorders, personality disorders, and others listed in the Diagnostic and Statistical 
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Combat and Operational Behavioral Health

Manual of Psychiatric Disorders. Many medications commonly used and available in the United States are not 

available throughout the world, so cultural awareness 

can play an important role in prescribing appropriate 

medications. A given detainee may have been effectively treated on a psychotropic medication prior to 

being detained and should remain on that medication. 

Additionally, if the treatment is going to be necessary 

and continued after the detainee is released, selection 

of a medication that is available in the local economy 

should be strongly considered to facilitate accessibility 

and ongoing treatment. Otherwise, the indications, 

contraindications, side effects, and prescribing guidelines for a particular class of medications remain the 

same as in other settings.

Depending on the size of the detainee population 

and the number of detainees on medication, distribution can be a complicated and time-consuming process. 

Care must be given to prevent hoarding; consideration 

should be given to potential lethality or medical complications; and if possible selection of medications 

that can be taken daily, rather than more often, will 

increase compliance and decrease the demand on the 

staff distributing each medication. 

Each staff member responsible for distributing 

medication should be trained on the proper distribution technique. The technique is essentially the same 

as what is practiced in many US prisons: distributing 

each dose separately and watching closely to prevent 

deception and hoarding. A sequence of actions needs to 

take place to ensure that the right patient receives the 

medication, and actually swallows it (Exhibit 40-1).

This is required for each medication, and each 

detainee must be required to follow the procedure. 

Hoarding medications can be a serious problem, and 

abuse of psychotropics is endemic in this population. 

Medical staff, including behavioral health personnel, must be trained in this process, and leadership 

should make spot checks to ensure the process is being 

adhered to. Mental health personnel should take the 

lead in this process. Detainees may protest initially, 

but with continued practice most comply without 

hesitation. Furthermore, the process of interacting with 

detainees twice a day improves the therapeutic alliance: some detainees view the interaction as extremely 

supportive and benefit clinically from the interaction, 

although this process can be time consuming and 

very demanding on the medical staff member. Staff 

members can rotate administering medications. This 

also helps prevent burnout and helps the staff get to 

know the detainees.

Some detainees may be on other medications prescribed by different providers. It should be routine 

to review the medical record or to check with the 

pharmacy to get a list of all prescribed medications for 

each detainee to ensure there are no contraindications 

or overlaps in medication. Medical providers should 

discuss potential side effects for each medication with 

detainees and ensure each detainee has given informed 

consent prior to starting a medication. A medication 

education program is useful to prepare detainees for 

eventual release, when they will probably be provided 

a several-day supply of medication.

Communicating With Other Sites

Interacting with behavioral health staff at other 

detention sites should be facilitated early in the deployment. Detainees often are transferred from one site 

to another depending on the legal issues associated 

with their case. Communication between detention 

camps allows the effective transfer of detainees with 

behavioral health problems and enhances the continuation of treatment without interruption. The gaining 

facility should prepare by reviewing pertinent medical records, obtaining appropriate medications, and 

discussing any concerns with the staff members who 

have been treating the detainee. Without a working relationship between staff, detainees will be transferred 

EXHIBIT 40-1

MEDICATION DISTRIBUTION PROCESS 

FOR DETAINEES 

•	 Confirm the patient’s identity by comparing

the detainee’s identity card or armband to 

the person presenting for treatment (trading 

armbands for favors is not unknown); do not 

administer the medication if identification is 

not positive. 

	 •	 Administer each medication as a single dose;

do not give a detainee requiring medication 

twice a day both doses in the morning. 

	 •	 Ask the detainees to hold out their hand, and

then place the medication in their hand. 

	 •	 Ensure they have water to help with swallowing the medication. 

	 •	 Watch them carefully as they put the medication into their mouth and swallow. 

	 •	 After they swallow, have them open their

mouth and stick out their tongue to check for 

“cheeking” the medication. Have them open 

their hands with their fingers spread apart to 

ensure they don’t have the medication still 

in their hands. 

	 •	 After making sure they have actually swallowed the medication, the detainees can be 

excused from the area. 
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Behavioral Health Issues and Detained Individuals

and the gaining team can potentially be caught off 

guard and this may impact patient care. Communication between staff at different sites should occur on 

a regular basis, because moves often are sudden and 

unanticipated. The frequency can be determined based 

on patient acuity and need. Sometimes the gaining 

team receives information about transfers before the 

losing staff. Problems arise when detainees arrive at 

the new location and say they were taking psychiatric 

medications or receiving psychiatric treatment, and 

there is no record of the treatment. Often the detainee 

does not know what medications are being administered. Without the knowledge of current diagnosis 

and treatment, an effective treatment plan may be 

interrupted and the detainee will have to start the assessment and treatment process from the beginning, 

a frustration for both the detainee and the behavioral 

healthcare staff.

SPECIAL CLINICAL ISSUES

Common syndromes in detention care include 

situational reactions to capture and adjudication, fear 

of other detainees, distress related to being separated 

from family, and reactions to the inevitable inactivity 

associated with detention. Detainees often present 

with acute anxiety immediately after transfer to the 

facility or before trial. They often complain of insomnia, fatigue, or depressed mood, symptoms that on 

inquiry are related to poor sleep habits and inactivity. Awareness of these situational factors can reduce 

overdiagnosis and overuse of medication with this 

population.

Individuals in detention often attempt to assert control, gain special privileges, or reduce boredom in ways 

that bring them to the attention of the behavioral health 

team. Aggression toward others, unusual behavior 

such as bathing in sewage, and suicidal statements or 

parasuicidal behavior may be typical signs of mental 

illness, but in this context often are manipulative or 

testing behaviors. Hunger strikes, another behavior 

of significance seen in the detention population, are 

discussed in detail below because of their unusual 

political nature. Differential functional diagnosis and 

training of custodial staff in behavioral management 

are important tools in managing these potentially 

disruptive concerns. 

Cognitive disorders present a special challenge in 

military detainee care. Primary disorders that may 

present include the entire gamut of these illnesses: 

developmental disorders including mental retardation; acquired traumatic brain injury, acute or chronic; 

metabolic, vascular, or other invasive lesions from a 

medical cause; or age-related dementia. All represent 

special circumstances affecting the detainee’s ability to 

function and therefore trigger a special obligation on 

the part of the military caretaker. Unfortunately, most 

instruments designed to detect cognitive impairment 

are insensitive to cultural factors and to educational 

deprivation, making them unsuitable in this setting, 

even when effective, nonbiased translation services 

are available.

Privacy and confidentiality are recurring issues 

in behavioral health service systems. Although it is 

benevolent to argue that the detained individual has 

a right to confidentiality, in this setting even the right 

to refuse treatment may be arguable if detainees’ behavior causes substantial risk to themselves or others. 

Command has a legitimate interest in the mental state 

of detainees with serious emotional or cognitive issues, 

as do custodial staff responsible for the compound. It 

is likely that other residents of the compound will be 

aware of the patient’s behavioral health issues, especially if the behavior is disturbed. Interviews must be 

conducted in the public view, or at least with a guard 

present. Reasonable respect for human dignity and 

privacy is always indicated, but in this setting confidentiality in its strictest interpretation is unlikely and 

should not be promised.

Medical record management is another special 

clinical issue in the military detention setting. International standards require a single portable medical 

record that follows the patient and that can be accessed 

by the patient, his or her representative, or oversight 

agencies such as the International Red Cross. This 

apparently simple requirement is complicated by the 

typically dispersed nature of forward base detention 

settings: the record-keeping facility is likely to be in 

the hospital, not the camp, necessitating maintenance 

of a local working record in many instances. In the 

current conflict, detainees are identified by number, 

rather than by name, because of ambiguities in establishing identities and also to protect the individual. 

This makes matching the patient to the record difficult 

as well. Frequent movement of detainees for security 

or legal reasons further complicates compliance with 

medical record standards.

HUNGER STRIKES: A UNIQUE CLINICAL ISSUE

Behavioral health consultation to hunger strikes 

constitutes a special or command-directed assessment 

and as such requires the involvement of a doctorallevel behavioral health provider to meet the criterion of 
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Combat and Operational Behavioral Health

equivalent care to detainees. The military psychologist, 

psychiatrist, or doctoral social worker involved must 

be aware of international standards for the treatment 

of hunger strikers and the theater policy on hunger 

strikes; must be cognizant of cultural factors impinging 

on the detainee’s decision to fast; and if at all possible 

must consult with the facility commander, with Judge 

Advocate General staff, and with the detainee’s primary care provider to determine relevant contextual and 

situational issues before engaging with the detainee or 

making recommendations to command.

There is strong international sentiment in favor 

of hunger strikers, based on a history of their use to 

protest repressive political regimes. The international 

medical community supports self-determination by 

the detainee and proscribes forced feeding.6,7 Nevertheless, not all hunger strikes have the same degree 

of legitimacy.8 Reactive food refusers, much more 

common than political hunger strikers, are much more 

likely to rapidly terminate their fast without adverse 

consequences.

A typical hunger strike protocol9 requires the behavioral health provider to assess the competence of 

the fasting detainee at the outset of the hunger strike 

and daily thereafter. In addition to the complications 

created by the adversarial nature of a detention setting, 

the crosscultural aspects of assessment in a military 

context make this a challenging task. Because assessment will be ongoing throughout the hunger strike, 

the provider must be aware of the typical course of 

a hunger strike and of the impact of starvation on an 

individual’s emotional and cognitive status.

Assessment

The detainee engaging in a hunger strike is not allowed to refuse reasonable evaluations. The situation 

is analogous to evaluating a reluctant person suspected 

of dementia: the assessment is in the patient’s best 

interest. However, it is important to attempt to obtain 

informed consent for this and subsequent assessments, 

if only to establish a reasonable working relationship 

with the patient. The purpose, extent and limitations 

of evaluation, boundaries of the relationship with the 

provider, role conflicts that may develop, and issues 

of medical record confidentiality should be described. 

If the detainee refuses to be interviewed, observation 

and information from collateral sources become critical 

in establishing the person’s competence. In one such 

instance in theater, the attending physician was given a 

fixed interview protocol to follow that allowed assessment of immediate, delayed, and procedural memory, 

and was primed with specific questions to ask. The 

psychologist observed the interaction on closed-circuit 

television to allow clinical assessment of the patient’s 

cognitive status.

Relevant factors in determining initial competence 

to fast include the presence of a mental disorder affecting judgment and decision making; problems 

with impulse control leading to importune behavior; a 

cognitive disorder including mental retardation, brain 

injury, or dementia; coercion by or influence of others; 

and inaccurate situational information. Personal history, facility records, and clinical observation during 

the interview are essential tools in the assessment. 

Standard cognitive instruments are unlikely to be 

available, making psychometric evaluation of dementia or cognitive disorder difficult. The last two factors 

listed, coercion or influence by others and inaccurate 

situational information, are less accessible to historical 

review or direct assessment, but are important areas 

of concern. One incipient hunger strike during the TF 

MED 344 experience was avoided by clarifying the 

process of judicial review for the detainee.

The initial interview should clarify that the detainee 

does intend to engage in a hunger strike. Language 

problems and confusion on the battlefield can create 

inaccurate perceptions: one detainee transferred from 

a division internment facility to the tertiary internment 

facility or theater internment facility for a hunger strike 

protocol in early 2006 immediately denied intent to fast 

when interviewed in the emergency room and ate as 

soon as his gastrointestinal distress and nausea were 

treated. As part of clarifying intent, the behavioral 

health provider discusses with each detainee whether 

he plans to fast to death, or if he will accept medical 

advice and limit his hunger strike when his health is 

imperiled. 

The behavioral health provider is mandated to 

clarify the detainee’s reason for entering into a hunger strike. The provider does not, however, become 

engaged in negotiating with the detainee concerning 

demands, for a variety of reasons: maintaining a useful neutrality with the detainee separates the issue of 

refusal to eat from the issue that the detainee wishes to 

bring to public attention, an important strategy in managing the hunger strike situation. In one typical hunger 

strike situation, the detainee began every conversation 

with a request to see the combatant commander; each 

request was met with a response that the commander 

was aware of the request and the psychologist could 

do nothing to facilitate this matter.

Daily reassessment of the detainee’s emotional 

and cognitive status is required. A routine should be 

established with the primary care provider that allows 

the behavioral health provider to review any medical factors that may be affecting the detainee and to 

interview the primary care provider about his or her 
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Behavioral Health Issues and Detained Individuals

interactions with the detainee. Initial reassessments are 

usually not fruitful except to help establish a pattern 

and a relationship, as cognitive and emotional changes 

are unlikely in the first week of the hunger strike.

Follow-up assessments include evaluation of subtle 

cognitive changes caused by altered nutritional status, 

such as a tendency to make more risky decisions, 

become irritable, and be increasingly oppositional, 

especially in situations involving confrontation.10

Minor memory or concentration problems that may 

signal the onset of delirium resulting from reduced 

metabolism, medications, altered nutrition, or organ 

dysfunction must be recognized early to avoid rapid 

cognitive deterioration. Hunger strikers with suicidal 

or morbid ideation, alteration in future orientation, 

or reduced interest in pleasurable activity, may be 

depressed—a condition for which they may allow 

treatment. The assessment also evaluates the detainee’s 

confidence in his physician, his understanding of the 

medical information he is provided, and his intent to 

persist in the hunger strike.

Cognitive measures are sensitive to educational and 

cultural factors (few instruments have been normed for 

use in different cultures) and are vulnerable to practice 

effects; repeated administration on a daily basis will 

invalidate their use just as the information they can 

provide becomes more critical. The behavioral health 

provider should design an observational protocol using routine interactions in the detention setting to assess memory, concentration, verbal fluency, and motor 

coordination rather than relying on tests.

Documentation of findings is critical. There are three 

possible outcomes of a hunger strike: the detainee 

ends the hunger strike voluntarily, the detainee is 

fed forcibly, or the detainee dies from complications 

related to not eating. Especially in the event of forced 

feeding or death, the basis for medical and subsequent 

administrative decisions about care must be clearly 

documented and communicated.

Intervention

The behavioral health provider cannot collaborate 

with coercive or deceptive strategies, nor agree to strategies that might be perceived as maltreatment of the detainee. Although it is reasonable to withdraw privileges 

or hold the detainee in isolation to prevent contagion 

or coercion, for example, it is not reasonable to restrict 

access to hygiene facilities or exercise. Exposing the 

patient to pleasant aromas and pleasing presentations 

of meals may be useful; deliberate exposure to others 

eating, taunting with food, or excessive exposure to food 

may constitute abuse and is likely to be counterproductive. Threats of forced feeding are counterproductive, 

create an adversarial atmosphere, and are considered 

coercive by the international community.

Psychological management of the hunger strike 

should focus on limiting unwarranted attention to the 

detainee during the hunger strike to reduce unintended reinforcement of the unwanted behavior. Medical 

management and administrative negotiations should 

be matter-of-fact and without emotional overlay. Effort 

should be made to separate treatment of the hunger 

strike and treatment of the concerns raised by the detainee: the decision-maker for the demands should be 

distinct from the medical and custodial personnel who 

work with the detainee. These two issues should never 

be linked during discussions with the detainee. 

Consultation 

The military behavioral health provider consults to 

the attending physician and to command regarding 

various aspects of the hunger strike situation, often 

in ways not anticipated by the command authority. 

It was the senior author’s experience that command 

expectations may exceed the role of the consultant: 

there may be an expectation that the behavioral health 

provider has greater insight into the hunger striker’s 

motivations than is possible, or that the provider may 

in some way be able to intervene and somehow induce 

the hunger striker to end the fast. Clear delineation of 

roles and capabilities is essential.

Healthcare providers do have a valuable role in 

protecting both the patient and the military command 

from the adverse consequences of the hunger strike. 

The careful balance between consulting to the care of 

the hunger striker, balancing competing ethical issues 

often associated with this situation, acknowledging 

international standards of care, and advising command regarding effective actions requires a thoughtful 

approach to this type of situation. 

The behavioral health provider discusses with the 

treating physician the available literature on hunger 

strikes, the ethics associated with managing both 

hunger strikers with a terminal goal and those willing 

to accede to medical advice, and the importance of 

avoiding an adversarial relationship with the patient. 

The physician should be encouraged to establish 

benchmarks for various decisions, including informing the patient of critical medical milestones and 

what findings to use to signal command that medical 

incapacity may be imminent.

Command is likely to consider forced feeding very 

early in the hunger strike, in part because the consequences of allowing the detainee to die in custody are 

extreme and in part because of limited knowledge 

about the likely time frame of the hunger strike. Keep-
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Combat and Operational Behavioral Health

ing the detainee alive through forced feeding, however, 

may simply prolong the hunger strike, carries its own 

medical risks, and is not likely to be necessary for 

health reasons in the first weeks of the strike. Good 

medical advice is critical to limiting the commander’s 

reactive responses, and effective consultation on approaches to the hunger striker will give command 

options other than coercive methods.

SUMMARY

Providing psychiatric care in a battle zone to an enemy combatant poses unique professional and personal 

challenges. There is no true civilian analogue to this 

situation. Because the mission is unique, it is important 

to develop a clear understanding of the clinical mission and its inherent systemic issues before entering 

the area of operations. It is vital to understand the full 

political and humanitarian impact of the behavioral 

healthcare provider’s role in this setting to appreciate 

the importance of the mission and to reconcile the 

accompanying complex and often contradictory emotions and reactions. 

REFERENCES

1. US Department of Justice, Federal Bureau of Prisons. Program statements for medical, dental, and health policies (6000 

series). Available at: http://www.bop.gov/DataSource/execute/dsPolicyLoc. Accessed July 8, 2010.

2. American Public Health Association. Standards for Mental Health Services in Correctional Institutions. 3rd ed. Washington 

DC: APHA; 2003.

3. US Department of the Army. Enemy Prisoners of War, Retained Personnel, Civilian Internees and Other Detainees. Washington, DC: DA; 1997. Army Regulation 190-8.

4. US Department of the Army. Medical Support to Detainee Operations. Washington, DC: DA; 2006. Field Manual 

4-02.46.

5. US Department of the Army. The Law of Land Warfare. Washington, DC: DA; 1956. Field Manual 27-10.

6. World Medical Association. WMA Declaration of Malta on Hunger Strikers. Available at: http://www.wma.net/

en/30publications/10policies/h31/index.html. Accessed July 8, 2010.

7. English V, Gardner J, Romano-Critchley G, Sommerville A. Management of prisoners on hunger strikes. J Med Ethics. 

2001;27:203–204.

8. Reyes H. Medical and ethical aspects of hunger strikes in custody and the issue of torture. International Committee 

of the Red Cross Web site. 1998. Available at: http://www.icrc.org/web/eng/siteeng0.nsf/htmlall/health-article010198?opendocument. Accessed July 8, 2010.

9. Oklahoma Department of Corrections. Hunger strikes. Operations Memorandum 140122. Available at: www.doc.state.

ok.us/Offtech/op140122.pdf. Accessed July 8, 2010.

10. Fessler DMT. The implications of starvation induced psychological changes for the ethical treatment of hunger strikers. J Med Ethics. 2003;23:243–247.
657

Mental Healthcare in the United Kingdom Armed Forces

Chapter 41

MENTAL HEALTHCARE IN THE UNITED 

KINGDOM ARMED FORCES

NEIL GREENBERG, MD*; JAMIE HACKER HUGHES, PsychD†; MARK EARNSHAW, BA(Hons), MSc‡; and

SIMON WESSELY, MD§

INTRODUCTION

HISTORY

CONTEMPORARY DEFENSE MENTAL HEALTH SERVICES

Operational Organization

Ministry of Defence Posttraumatic Stress Disorder Legal Case

Trauma Risk Management

CURRENT RESEARCH AND FUTURE DIRECTIONS

SUMMARY

*Commander, Medical Corps, United Kingdom Armed Forces; Defence Professor of Mental Health, King’s College, London, Weston Education Centre, Cutcombe Road, London SE5 9RJ; formerly, Senior Lecturer in Military Psychiatry, Academic Center for Defence Mental Health, King’s College, London

†

Head of Defence Clinical Psychology, Ministry of Defence, Joint Medical Command, Coltman House, Whittington Barracks, Lichfield, United Kingdom 

WS14 9PY; formerly, Senior Lecturer in Military Psychology, Academic Center for Defence Mental Health, London, United Kingdom 

‡

Lieutenant Colonel QARANC, Ministry of Defence, St Georges Court, Bloomsbury Way, London, WC1A 2SH, United Kingdom; formerly, Research 

Fellow, Academic Centre for Defence Mental Health, London, United Kingdom

§

Department Head, Department of Psychological Medicine, King’s Centre for Military Health Research, King’s College, Weston Education Centre, 

10 Cutcombe Road, London SE5 9RJ United Kingdom; formerly, Honorary Lecturer in Forensic Psychiatry, Institute of Psychiatry, London, United 

Kingdom
658

Combat and Operational Behavioral Health

INTRODUCTION

Defense mental health services (DMHS) in the 

United Kingdom (UK) are primarily community based 

and provide both operational and homeland services 

to all 200,000 of the personnel in the UK armed forces. 

This chapter will examine the history of military mental health in the UK and bring readers up to date on 

important procedural and operational aspects of the 

DMHS today. 

HISTORY

In keeping with its tradition as the senior military 

service in the UK, the Royal Navy first established 

formal services to manage and treat service personnel 

who suffered from psychological problems. In August, 

1818, a lunatic asylum was opened at the Royal Naval 

Hospital Haslar1

; today a Royal Navy Department of 

Community Mental Health (DCMH) remains at Haslar 

Hospital. With the outbreak of World War I, British 

Army psychologists and neurologists deployed to 

France in 1914 in support of British troops. Operating 

from field hospitals, casualty clearing stations, and, 

later, “NYDN” (not yet diagnosed neurological) hospitals, these practitioners saw large numbers of personnel suffering from “shell shock,” “disordered action of 

the heart,” and related syndromes. Personnel deemed 

unfit for further combat, at least in the immediate 

future, were evacuated to rear areas or to the UK.2

 A 

large number of hospitals were established in Britain, 

including Craiglockhart3; Seale Hayne, a converted 

agricultural college; and Sir Edward Mapother’s No. 

2 General Hospital in Stockport.4 These institutions 

provided treatment for shell shock and other disorders, aiming, if possible, to return individuals to the 

front to continue fighting. Specialist training courses 

in military psychiatry were also established at the 

Maudsley Hospital in London and, by Gordon Mott, 

at Maghull Hospital in Liverpool. Specialist centers for 

the treatment of disordered action of the heart were 

also established at Mount Vernon in Hampstead and 

Sobraon House in Colchester. 

Although the British Psychological Society had 

been founded at University College London in the 

1890s, psychology was a largely experimental science 

in World War I; it was some years before psychotherapy and clinical psychology became disciplines 

in their own right. The first military psychological 

practitioners, such as Charles S Myers and William 

H Rivers, were mostly medical doctors. Myers later 

became consultant psychologist to the British Expeditionary Force, and Gordon Holmes was consultant 

neurologist. Myers established four forward NYDN 

centers modeled on the French system,5

 and, later, 

five forward “disordered action of the heart” centers 

in France, in addition to the hospitals in Britain. These 

facilities were established well before Thomas Salmon, 

the American psychiatrist, visited France in 1917 and 

influenced what has since become known as “forward 

psychiatry.”6

Following World War I, the UK built up a network of 

special civilian treatment centers and hospitals to treat 

the ongoing casualties generated by the war, peaking 

in 1921. (At that time nearly 15,000 inpatients and 

3,000 outpatients were still suffering with war-related 

psychological disorders.) Although the vast majority 

of those who worked throughout the war for the British military mental health services returned to civilian 

employment, some remained in the services, forming a 

core of psychological practitioners during the build up 

to World War II. For the additional practitioners necessary for the Royal Navy, Army, and new Royal Air 

Force (RAF), formed between the wars from the Royal 

Flying Corps (originally part of the Army), neurologists and psychiatrists were recruited from four main 

sources (all in London): the Tavistock Clinic (Army), 

the Maudsley Hospital (Royal Navy), Saint George’s 

Hospital (Royal Navy), and Guy’s Hospital (RAF).7

For the first time psychologists were also recruited 

to work in personnel selection. Otherwise, the pattern of British Army military mental health service 

provision in World War II nearly mirrored that in 

the earlier war. In addition to a number of forward 

hospitals, treatment facilities also operated in the UK, 

including No. 41 Neuropathic Hospital in Bishop’s 

Lydeard (where the Tavistock Clinic psychoanalyst JA 

Hadfield, one of the first to use collective hypnosis and 

abreaction, was based) and the better-known centers 

at Northfield (where Wilfred Bion, John Rickman, and 

Michael Foulkes, the founders of group psychotherapy, 

worked). In addition, forward psychiatry began to 

be practiced, often by accident or through necessity, 

but increasingly by design, in North Africa, Italy, and 

northwest Europe. 

Support for the psychiatrists was far from unanimous, however; many saw them as fifth columnists (a 

clandestine group seeking to undermine the government), and Winston Churchill referred to psychiatrists 

as “gentlemen asking odd questions.”8

 Stigma was 

still attached to patients with mental illness. The RAF 

Neurological Hospital at Matlock was established as 

the final treatment center for the growing number of 

“lack of moral fiber” (LMF) cases, an administrative 

category rather than a diagnosis. This category was 
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Mental Healthcare in the United Kingdom Armed Forces

begun after 250 “breakdown” cases occurred after the 

Battle of Britain in 1940; by the end of the war the LMF 

category included nearly 3,000 cases of breakdown 

per year.9 It is believed that fear of being labelled as 

LMF was essential to keeping RAF pilots motivated to 

fly despite the high risk of being shot down (mission 

attrition rates of 50% were common, especially during the early days of the war).10 Sergeants labeled as 

LMF were reduced to the lowest rank and put to work 

shovelling coal, peeling potatoes, or even mining coal. 

LMF officers were asked to resign or transferred to 

desk jobs in administration. Many of those categorized 

as LMF had already completed a dozen or more 

operational raids, but the designation was deemed 

useful for encouraging continuous operational flying 

in the face of extreme risk.

By the end of 1943, the number of psychiatrists 

totalled 227 in the British Army, 43 in the RAF, and 35 

in the Royal Navy.11–13 The majority of the 35 military 

psychologists14 worked with selection panels and designed aptitude tests to ensure that officers were up to 

standard. These World War II selection tests included 

the “leaderless group,” a method by which a group of 

potential officer candidates are encouraged to come 

up with a plan to deal with a mock incident without a 

leader being assigned in order to see what transpires 

(ie, does a “natural” leader emerge?). It remains the 

basis for selecting the officers’ cadre today. Unlike in 

the United States during World War II, mental health 

professionals were rarely used in screening for vulnerability to future breakdown. This aptitude testing 

policy represented a major “democratization” of officer 

selection, in keeping with the social transformations 

the war brought about across society. At the end of the 

war, however, all the psychologists were demobilized, 

leaving only the psychiatrists in the service.

In the late 1960s, the UK began deploying large 

numbers of forces to contain the increasingly unstable 

situation in Northern Ireland. The particular demands 

of this counterinsurgency operation—effectively 

asymmetric warfare with an unknown and unseen 

enemy—began to take its toll on the mental health of 

troops. The Northern Ireland “troubles” continued 

until the late 1990s. Although no concrete evidence 

suggests that the conflict was more traumatogenic than 

other military operations, many of its veterans suffered 

from posttraumatic stress disorder (PTSD) and other 

psychological injuries.

In 1982, Britain again went to war, this time thousands of miles away across the Atlantic,15 to recapture 

the Falkland Islands invaded by Argentina weeks 

before. Although the Royal Navy deployed psychiatrists to the conflict, the overall mental health burden 

was thought to be small. However, some current 

anecdotal evidence indicates that marines who sailed 

back to the UK after the war fared better in mental 

health outcomes than their airborne colleagues and 

other infantry units that were air-trooped home. These 

stories suggest that the marines settled back into their 

day-to-day lives after talking through their experiences during the sea voyage, as there was no formal 

mental health support made available for the troops 

during the voyage home. The airborne paratroopers, 

in contrast, displayed violent and aggressive behavior 

at home because they missed the necessary time to 

“decompress.”16 However, no research has been carried out to support or refute these claims.

At the end of the 20th century, UK forces were 

deployed on a number of fronts. Operation Banner, 

the name given to the Northern Ireland deployment, 

continued, with troops rotated at regular intervals for 

3-month “emergency” tours, 6-month tours, and 2-year 

“permanent” tours. In addition, British troops were 

deployed on United Nations and North Atlantic Treaty 

Organization peace and stabilization missions to 

Bosnia-Herzegovina, Kosovo, and Macedonia. Army 

field mental health teams (FMHTs) deployed in the 

majority of these operations, often led by psychiatrists 

in the initial “surge” phases, but increasingly relying 

on a pool of well-trained, highly skilled, and relatively 

autonomous mental health nurses drawn from the hospitals and community clinics to operational roles.17 At 

the same time, however, defense cuts and downsizing 

led to the closure of all but three military hospitals; 

these have since shut. Today, there is no dedicated 

military hospital in the UK, and military medical care is 

provided in military wings of civilian hospitals called 

“military district hospital units.”

In addition to these and other peacekeeping operations (eg, in Lebanon, Rwanda, and Sierra Leone),18 the 

UK was involved in two major, if short-lived, wars, 

followed by ongoing and increasingly intense operations in the hostile theaters of Iraq and Afghanistan. 

Saddam Hussein’s invasion of Kuwait in 1991 led 

to a rapid British military deployment—Operation 

Granby—as part of a multinational coalition led by 

the United States to reclaim the country from the Iraqi 

forces. British Army psychiatrists and mental health 

nurses deployed with the Army field hospitals as field 

psychiatric teams but, where possible, adopted a freestanding roving role providing mental health briefings, 

psychological debriefings, and mental health assessments as required throughout theater. A Royal Navy 

mental health team deployed with a hospital ship, 

offshore in the Mediterranean Sea, and RAF mental 

health teams supervised the aeromedical evacuation 

and repatriation of mental health casualties. This role 

continues outside times of major conflict, with RAF 

mental health nurses on standby to escort service personnel with mental health and other problems back to 
660

Combat and Operational Behavioral Health

the UK from anywhere in the world.

When British and American forces invaded Iraq 

in 2003 (the British component of the invasion and 

occupation is known as Operation Telic), FMHTs 

composed of psychiatrists and Army mental health 

nurses again deployed with the UK’s air assault and 

armored brigades, and were part of two military field 

hospitals. Again, the Royal Navy supplied a mental 

health capability on the primary casualty-receiving 

facility—Royal Fleet Auxiliary Argus—and the RAF 

continued to operate as before. All mental health aeromedical evacuations and repatriations went to Duchess 

of Kent’s Psychiatric Hospital (since closed) for assessment, treatment, and, if necessary, admission. Those 

requiring outpatient treatment, including mobilized 

reservists (who made up a large percentage of some 

Operation Telic units, especially medical units), were 

referred to the network of DCMH.

Contemporary Defense mental health services

The goal of DMHS is to provide military personnel with speedy access to skilled, effective, flexible 

treatment based on individual needs.19 The DMHS 

approach aims to foster recovery and rehabilitation, 

ensuring that personnel are rapidly returned to duty 

whenever possible, or supported and enabled to make 

a smooth, seamless, and effective transition back into 

civilian life. Treatment, care, and rehabilitation are 

provided in close proximity to the person’s work 

environment to maximize occupational recovery and 

in close partnership with primary and secondary care 

facilities. A clear understanding of the unique nature 

of military ethos, composition, and task underpins 

the effective delivery of mental healthcare to service 

populations. Delivery of this care is multidisciplinary, 

provided by a variety of skilled professionals, depending on individual needs.

The UK armed forces emphasize that stress management and day-to-day mental health hygiene are 

functions of the chain of command rather than medical or support services. The same principles apply for 

physical and psychological disorders; for instance, the 

management of hydration is directed by unit leaders in 

the same way as stress management. Both may need a 

subject matter expert to provide appropriate information and training; however, the subject matter expert 

does not assume responsibility for the process.19,20

When the chain of command is unable to continue 

to support personnel, three levels of mental healthcare provision exist: (1) primary care, (2) community 

mental healthcare, and (3) inpatient care. Provision of 

mental healthcare has moved from a hospital-based 

to a community-based service, mirroring changes in 

the UK’s civilian National Health Service. Care in the 

community, as the process is termed in the National 

Health Service, has been a key element of UK government health planning over the last 2 decades and is 

considered well-suited to both military and civilian 

mental healthcare delivery. A report by an independent 

team of experts led to the closure of the last military 

inpatient facility in early 2004. Currently all inpatient 

care is provided by an independent service provider 

(a private psychiatric hospital) on a pay-per-patient 

basis. Military protocols advocate using inpatient care 

for the minimum amount of time possible because 

community management is seen as the key to effective 

occupational rehabilitation. 

The “workhorse” of the system is the DCMH, 

which carries out all specialist mental health functions within the DMHS. There are 15 DCMHs in the 

UK, with additional units in Germany, Cyprus, and 

Gibraltar. The departments are tasked with treating 

service personnel, providing a range of mental health 

educational programs, liaising with the independent 

service provider, and facilitating medical discharges 

when appropriate. The current cadre of some 200 

military mental health professionals across the services 

are primarily uniformed members of the Royal Navy, 

Army, or Air Force. However, social work and psychology services are provided by civil servants. Most of the 

service members (75%) are nurses, with the remainder 

composed of psychiatrists, clinical psychologists, and 

social workers. Presently occupational psychologists 

and occupational therapists do not form part of the 

uniformed cadre. 

Policy and strategy for the DMHS comes from the 

surgeon general’s department through executive and 

professional advisory committees. In the UK, the military surgeon general, who may be a member of any 

service, is the head medical officer of all three services. 

The head of DMHS is the defense consultant advisor, 

and each service has a consultant advisor and a senior 

nursing officer. Although DMHS care is delivered 

on a triservice basis (ie, mental health professionals 

from each service routinely provide care to personnel 

of all three services), each service is responsible for 

career development and personnel management of 

its members.

Operational Organization

The deployable uniformed mental health assets 

are composed of registered mental health nurses (also 

called community psychiatric nurses), and consultant 

psychiatrists. The consultant psychiatrists traditionally 

have deployed only during the initial surge phase 
661

Mental Healthcare in the United Kingdom Armed Forces

of operational deployments; at later stages, community psychiatric nurses form FMHTs with telephone 

supervision and a visiting service from a consultant 

psychiatrist. Experience has shown that the most effective FMHTs comprise one officer at captain-to-major 

level (or equivalent) and one senior noncommissioned 

officer. This structure helps remove barriers across 

the military rank structure and destigmatize military 

mental health.

Operational planning includes a casualty estimate, 

which, in conjunction with the size of the deploying 

force, dictates which mental health assets are deployed. 

In the majority of traditional war fighting scenarios, 

an FMHT consisting of a psychiatrist and two or three 

community psychiatric nurses is deployed at role 2 

(role 2 is usually collocated with the dressing station 

in the region of 1-hour travel by road from the fighting 

troops). Traditionally based at role 3 (3–4 hours traveling time by road from the front line) and collocated 

with the field hospital is a further complement of mental health personnel including a consultant psychiatrist 

and community psychiatric nurses. 

Predeployment

Before deployments, the DCMH and FMHT assess 

medically downgraded personnel or those undergoing 

mental health treatment to give a clear indication to 

commanders about whether these personnel might be 

fit to deploy, and if so, whether there are employability 

restrictions. Ideally, the deploying FMHT also assists 

with preoperational stress management presentations5

 and meets the commanders of units they will 

support in the operational theater to clarify arrangements (mental health personnel are often logistically 

prevented from deploying with units they supported 

in peacetime locations). The provision of formal briefings to all deploying personnel is mandated by policy. 

Such briefings are intended not only to provide factual 

information on stress reactions but also to detail the 

mental health provision (and how to access it) during 

the forthcoming operation. Specific briefings on subjects such as body handling or dealing with prisoners 

of war may be given, depending on the nature of the 

forthcoming deployment.

During Deployment

Teams aim to travel to all units in theater seeing 

patients as required (usually referred from medical 

services) and undertake a command liaison role within 

the unit lines. Operational travel restrictions sometimes prevent this mode of operations, and mental 

health professionals can then find themselves stuck 

in one location, unable to respond to other needs. In 

these instances patients may travel to the FMHT, but 

they will consequentially lose proximity support from 

their units. 

Assessment of potential patients in theater loosely 

follows the flowchart in Figure 41-1, which explains 

the referral pathway according to the seminal work 

undertaken by Goldberg and Huxley concerning the 

pathways to care followed by psychiatric patients in 

the community.21 Mental health nurses work with unit 

commanders and medical staffs to provide occupationally relevant advice aiming to maintain the fighting 

force whenever possible. However, unit commanders 

hold the ultimate responsibility in assigning operational duties. These decisions are based on a number 

of factors including the operational situation, the unit 

support available, and the location of medical and 

psychiatric assets.

Postdeployment

In line with postdeployment operational stress management policy,20 DMHS professionals assist with any 

decompression process. The level of decompression 

package is left to the brigade commander to decide 

in consultation with medical or psychiatric advisors. 

The surgeon general’s policy dictates that some form 

of homecoming brief will be delivered to returning 

troops, which should be tailored to suit the intensity 

of the operation once the unit has returned to the decompression area (a low-threat location in theater or 

another base such as Cyprus) or peacetime location.

Ministry of Defence Posttraumatic Stress Disorder 

Legal Case

In 2002, a number of former military personnel 

sued the Ministry of Defence (MOD) over claims of 

psychological injury related to their operational service.22 The claimants did not dispute their assignment 

of operational duties but claimed that the MOD was 

negligent in failing to provide appropriate predeployment screening and training as well as appropriate 

postoperational care that might have prevented, or 

at least detected and treated, their disorders prior to 

discharge from the services. Judgment in the PTSD 

group action was handed down by Lord Justice Owen 

on May 21, 2003. The judge found for the MOD on 

almost all of the generic issues, despite criticizing the 

ministry in several areas. The judge found against the 

MOD in 4 of the 16 lead cases, but these cases turned 

on their individual facts and did not represent institutional failure. 

During subsequent examination of the case, the 

judge made clear that the MOD has a duty to provide a 

safe system of work for its personnel where reasonable 
662

Combat and Operational Behavioral Health

and practical. It does not, however, have a duty to do 

so in the course of combat, where the interests of personnel are subordinate to the military objective; this is 

known as “combat immunity.” The judge defined combat so that the immunity was not restricted to troops 

in the presence of the enemy but also all active operations against the enemy when personnel are exposed 

to the threat of attack, including attack and resistance, 

advance and retreat, pursuit and avoidance, and reconnaissance and engagement. Immunity extends to the 

planning of and preparation for operations in which 

there is the possibility of attack or resistance, including 

peacekeeping or policing operations in which personnel are exposed to the threat of attack.

The case was heated, and 16 subject matter experts 

from the UK, United States, Israel, and Australia gave 

evidence at the trial. Subjects discussed included 

screening before recruitment and before and after deployment, the potential use of critical incident psychoLevel 5

Level 4 (UK/BFG)

Level 3 (RTU)

Level 2

Level 1

Discharged at UK/BFG 

airhead for medical 

officer follow-up

Discharged at UK/BFG 

airhead for DCMH 

follow-up

Admitted to UK 

inpatient unit 

(ISP)

Returned to 

UK/BFG via unit 

welfare system

Returned to UK/BFG 

via aeromedical 

evacuation route 

RTU: maintained 

with FMHT 

support

RTU: recommend unit 

repatriation

Evacuation to 

role 3 (field 

hospital

Full mental health assesment 

undertaken by FMHT

Chain-ofcommand referral

Assessed by 

military medic

Self-referral

Assessed by 

medical officer

Chain-ofcommand referral

Personnel in theater

Self-referral

Figure 41-1. Operational mental health referral flowchart.

BFG: British Forces Germany

DCMH: Department of Community Mental Health

FMHT: Field Mental Health Team

ISP: inpatient service provider

logical debriefings, preventative stress inoculation, and 

decompression or postdeployment briefings. None of 

these measures were found to be robustly effective in 

the prevention or treatment of psychological injury.22

An MOD internal report,23 providing guidance for 

the future management of operational mental health 

issues, called for initiating a robust research program, 

training the chain of command to identify the signs of 

stress and assist anyone likely to “break down,” and 

instituting a stress awareness strategy to destigmatize 

mental health problems and encourage those who 

need help to request it.6

Trauma Risk Management

In the late 1990s, the brigadier in charge of the 

Royal Marines Commandos, an elite group of military 

maritime personnel who often form the UK’s rapid 

reaction force, tasked a staff officer to investigate ways 

RTU: return to unit

UK: United Kingdom
663

Mental Healthcare in the United Kingdom Armed Forces

to improve his troops’ mental health in response to operational stress. An initial critical incident psychological debriefing program was rejected within the robust 

culture of the marines. Staff subsequently developed 

a more successful peer support/psychological risk 

assessment program called Trauma Risk Management 

(TRiM), which has since been adopted by a number of 

UK organizations, including some of the emergency 

services and the diplomatic service.

The program, now fully integrated into the Royal 

Marines and many parts of the Royal Navy and Army, 

aims to equip nonmedical personnel with the skills 

to detect service members who might be suffering 

from traumatic stress problems. TRiM practitioners 

are trained to provide relevant mentoring and support in the aftermath of potentially traumatic events 

and deployments and, when necessary, to encourage 

persistently distressed personnel to seek referral from 

professional sources of mental health support.24,25

The program has been embedded within the existing 

personnel management systems. For example, during initial training young marines are instructed in 

field craft, shooting skills, and using TRiM support. 

Potential TRiM practitioners are selected for their 

interpersonal skills, experience, and common sense. 

Once trained, they provide basic psychoeducational 

packages to their units. Furthermore, all promotion 

courses within the Royal Marines Command provide 

some detail on TRiM, ensuring that all marines, and 

especially those in leadership positions, are aware of 

TRiM and able to use the system. The training program 

has gained external certification and has also been 

considered by the US military26 (preliminary training 

courses for US personnel were held in Washington, 

DC, in 2003, and San Diego, California, in 2005). The 

TRiM system is also to form part of the new US Army 

Psychological First Aid package designed for use by 

Army medical staff. 

Among the TRiM program’s strategic aims is to 

be a vehicle for organizational culture change. The 

course aims to destigmatize mental health issues and 

provide a pool of informed peers or mentors who are 

likely to be more acceptable than mental health professionals as sources of support. Research on UK military 

peacekeepers showed that more than 90% of personnel 

talked to peers about their deployments, whereas only 

8% talked to medical or welfare staff.27

A cluster randomized controlled trial is underway 

in the Royal Navy to ensure that TRiM does not suffer 

the same fate as the critical incident psychological debriefing program. The trial will attempt to identify any 

potential for TRiM to do harm, as well as any positive 

or negative cultural changes that occur on warships 

that have received TRiM training. A possible positive 

result of the trial would be an increase in referrals with 

no increase in mental health problems.

Current Research and future Directions

The King’s Centre for Military Health Research 

(KCMHR) is the primary UK military mental health research institution. Although numerous other academic 

centers conduct relevant research into both serving and 

retired UK military service personnel, none has a solely 

military orientation. The center boasts close links with 

an internationally acclaimed war studies department at 

King’s College London and offers a master of science 

degree in war and psychiatry. 

KCMHR has just completed a 3-year study on the 

health of about 12,000 randomly sampled UK military 

personnel, examining the recurrence of “Gulf War syndrome” problems and the rates of psychiatric injury 

following Operation Telic. Results so far show no rise 

in multisymptom conditions.28,29 Furthermore, regular 

military personnel have not been especially affected 

by service in Iraq in terms of posttraumatic stress or 

general psychological or physical symptoms. Veterans 

of Iraq deployments drink more alcohol and display 

more risky behaviors than those who did not deploy, 

but the absolute risk increase has been small. This result does not appear to be true for reservists, who are 

displaying significant changes in both psychological 

and physical health. The absolute risk increase is still 

small (a doubling of PTSD symptoms from about 3% 

to 6%); however, the research has prompted MOD 

attempts to mitigate the problem (made more acute 

because veteran and reservist mental healthcare is not 

provided by the military). 

With predeployment data on a subset of those deployed in Operation Telic, KCMHR was able to model 

the effects of predeployment mental health screening 

(when it had been conducted). The results showed that 

predeployment screening would not have reduced 

postoperational psychiatric illness, but would have 

had a significant deleterious effect on the numbers of 

personnel deployed.30

Other work underway is investigating the impact 

of military service on family life, the usefulness of 

medical countermeasures to mental illness, and the 

effects of potential exposure to depleted uranium. 

KCMHR intends to follow the cohort for many years 

to gain relevant insights into the health of the UK service member in the 21st century. Preliminary results 

that have influenced strategic MOD policy include 

the finding that providing too much informed choice 

can adversely influence vaccine compliance31 and 

that predeployment mental health screening is likely 
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Combat and Operational Behavioral Health

1. Jones E, Greenberg N. Royal Naval psychiatry: organisation, methods and outcomes 1900–1945. Mariner’s Mirror. 

2006;92:190–203.

2. Johnson W, Rows RG. Neurasthenia and the war neuroses. In: McPherson WG, Herrringham WP, Elliott TR, eds. History of the Great War, Diseases of the War. Vol 2. London, England: HMSO; 1923.

3. Salmon TW. The care and treatment of mental diseases and war neuroses (‘shell shock’) in the British Army. Ment Hyg. 

1917;1:509–547.

4. Jones E, Wessely S. Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War. Hove, UK: Psychology Press; 

2005.

5. Myers CS. Shell Shock in France, Based on a War Diary. Cambridge, England: Cambridge University Press; 1940.

6. Salmon TW. Care and treatment of mental diseases and war neurosis (“shell shock”) in the British army. In: Salmon 

TW, Fenton N, eds. Neuropsychiatry. Vol X. The Medical Department of the United States Army in the World War. 

Washington, DC: GPO; 1929: 497–547.

7. Shepard B. A War of Nerves: Soldiers and Psychiatrists 1914–1994. London, England: Jonathan Cape; 2000.

8. Churchill WS. War cabinet minutes (TNA PREM4/15/2. December 1942). In: Jones E, Wessely S. Shell Shock to PTSD: 

Military Psychiatry from 1900 to the Gulf War. Hove, UK: Psychology Press; 2005.

9. McCarthy J. Aircrew and “lack of moral fibre” in the Second World War. War Soc. 1995;18:87–101. 

10. Jones E. “LMF”: The use of psychiatric stigma in the Royal Air Force during the Second World War. J Milit Hist. 

2006;70:439–458.

11. O’Connor R. Work of Psychologists and Psychiatrists in the Services. TNA/WO32/11974, 5 December 1946. UK National Archives (Kew, Richmond, Surrey). 

12. Rees JR. The Shaping of Psychiatry by War. London, England: Chapman and Hall; 1945.

13. Sandiford HA. Army Psychiatry Advisory Committee Minutes (TNA, WO32/13462, 5 July 1945). In: Jones E, Wessely 

S. Shell Shock to PTSD: Military Psychiatry From 1900 to the Gulf War. Hove, UK: Psychology Press; 2005.

ineffective.30

The recently established Academic Centre for Defence Mental Health is a small cadre of MOD mental 

health staff attempting to stimulate DMHS research. 

The center also provides the defense consultant advisor in psychiatry, an advisor to the surgeon general, 

with regular reports on emergent research findings into 

potentially useful MOD policy actions. The MOD is 

increasingly realizing the need to use relevant research 

findings to inform future policy making.

SUMMARY

UK military psychiatry has a rich historical basis. 

Modern mental health provision is heavily community based, with operational provision being 

delivered by rendering appropriate support to the 

chain of command, which, in UK military doctrine, 

is primarily responsible for the psychological welfare of troops. The DMHS cadre of single-service 

uniformed and civilian staff provide triservice care, 

with a recently increased emphasis on research that is 

already providing a plethora of useful data informing 

and influencing MOD policy. Having weathered a 

protracted legal case and the shrinkage of the armed 

forces, the DMHS will continue to focus on supporting the sailors, soldiers, and airmen of the UK 

armed forces, as well as personnel and operational 

commanders in their missions, while ensuring the 

use of the ever-increasing body of research evidence 

to inform future practice.

References
665

Mental Healthcare in the United Kingdom Armed Forces

14. Hacker Hughes JGH. Unpublished MSc Dissertation. British Naval Psychology 1937–1947: Round Pegs Into Square Holes?: 

University of London. 2007.

15. Freedman L. The Official History of the Falklands Campaign. Vol II. War and Diplomacy. London, England: Frank Cass; 

2005.

16. Hughes JG, Earnshaw NM, Greenberg N, et al. Use of psychological decompression in military operational environments. Mil Med. 2008;173(6):534–538.

17. Deahl MP, Gilham AB, Thomas J, Searle NM, Srinivasan M. Psychological sequelae following the Gulf War: factors 

associated with subsequent morbidity and the effectiveness of psychological debriefing. Br J Psychiatry. 1994;165:60–

65.

18. Hacker Hughes JGH, Campion BC, Cameron F, Devon M. Results of a survey on psychological health of British 

peacekeepers deployed during 2002. European Psychother[special edition]. 2003: 204.

19. Greenberg N, Temple M, Neal L, Palmer I. Military psychiatry: a unique national resource. Psychiatr Bull. 2002;26:227–

229.

20. Surgeon General’s Policy Letter 03/06. The Prevention and Management of Traumatic Stress Related Disorders in AFs 

Personnel on Operations. Ministry of Defence: London, England; 2006

21. Goldberg D, Huxley P. Mental Illness in the Community. London, England: Tavistock Publications; 1980.

22. McGeorge T, Hacker Hughes J, Wessely S. The MOD PTSD class action—a psychiatric perspective. Occup Health Rev.

2006;122:21–28.

23. Applegate D. Lessons learnt from the PTSD group actions. Service Personnel Board: a paper by the stress project 

leader. Ministry of Defence: London, England; 2003.

24. Jones N, Roberts P, Greenberg N. Peer-group risk assessment: a post-traumatic management strategy for hierarchical 

organizations. Occup Med (Lond). 2003;53:469–475.

25. Greenberg N, Cawkill P, Sharpley J. How to TRiM away at posttraumatic stress reactions: traumatic risk management—

now and the future. J R Nav Med Serv. 2005;91:26–31.

26. Keller RT, Greenberg N, Bobo WV, Roberts P, Jones N, Orman DT. Soldier peer mentoring care and support: bringing 

psychological awareness to the front. Mil Med. 2005;170:355–361.

27. Greenberg N, Thomas S, Iversen A, Unwin C, Hull L, Wessely S. Do military peacekeepers want to talk about their 

experiences? Perceived psychological support of UK military peacekeepers on return from deployment. J Ment Health. 

2003;12:6:561–569.

28. Hotopf M, Hull L, Fear NT, et al. The health of UK military personnel who deployed to the 2003 Iraq war: a cohort 

study. Lancet. 2006;367:1731–1741.

29. Horn O, Hull L, Jones M, et al. Is there an Iraq war syndrome? Comparison of the health of UK service personnel after 

the Gulf and Iraq wars. Lancet. 2006;367:1742–1746.

30. Rona R, Jones M, Hull L, et al. Would mental health screening of the UK armed forces before the Iraq War have prevented subsequent psychological morbidity? BMJ. 2006;333:983–984.

31. Murphy D, Hooper R, French C, Jones M, Rona R, Wessely S. Is increased reporting of symptomatic ill health in Gulf 

War veterans related to how one asks the question? J Psychosom Res. 2006;61:181–186.
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669

Military Psychiatry Graduate Medical Education

Chapter 42

MILITARY PSYCHIATRY GRADUATE 

MEDICAL EDUCATION

CARROLL J. DIEBOLD, MD*; WENDI M. WAITS, MD†; MILLARD D. BROWN, MD‡; and DAVID M. 

BENEDEK, MD§

INTRODUCTION

HISTORY

PROGRAM LEADERSHIP 

Role of the Program Director 

Faculty Development

CURRICULUM

Core Competencies

Medical Students and Core Competencies 

Psychotherapy Competencies

General Psychiatry Residency Curriculum

Research and Scholarly Activity

Military Psychiatry Curriculum

Postresidency Fellowship Training 

RELEVANCE IN MISSION PERFORMANCE

Knowledge

Skills

Attitudes

FUTURE OF GRADUATE MEDICAL EDUCATION

SUMMARY

*Colonel, Medical Corps, US Army; Chief, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-

5001

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Inpatient Psychiatry Service, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett 

White Road, Honolulu, Hawaii 96859-5001; formerly, Child and Adolescent Psychiatry Fellow, Tripler Army Medical Center, Honolulu, Hawaii

‡

Major, Medical Corps, US Army; Psychiatry Residency Director, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-5001 

§

Colonel, Medical Corps, US Army; Professor and Deputy Chair, Department of Psychiatry, Uniformed Services University of the Health Sciences, 4301 

Jones Bridge Road, Bethesda, Maryland 20814
670

Combat and Operational Behavioral Health

INTRODUCTION

Graduate medical education (GME) is an essential aspect of military medicine. To maintain a 

healthy and productive operational force primed 

for success in varied environments and scenarios, 

medical personnel must possess adequate training 

and experience to provide appropriate and timely 

healthcare to service members. The unique skills 

required for a military healthcare provider to thrive 

in both operational and garrison environments 

necessitate comprehensive training and education. 

General lessons learned from past conflicts revealed 

that healthcare providers acquired knowledge and 

experience treating casualties on the battlefield rather 

than relying on training received from civilian medical institutions. From the advent of military GME in 

the early 20th century, the primary mission has been 

to prepare medical personnel to function in all types 

of operations. 

As military graduate medical education evolved, 

military-specific proficiencies were introduced early 

in the training process. Before beginning the first 

year of GME, most trainees complete the Basic Officer 

Leadership Course, in which rudimentary knowledge 

such as extending military courtesies, proper wear of 

the uniform, elementary leadership skills, and basic 

soldier proficiencies are taught.1

 Students who do not 

have the opportunity to complete the basic course prior 

to entering GME will complete this training shortly 

after graduation. Consistent with training given to all 

assigned soldiers, a military treatment facility (MTF) 

with a GME program may require trainees to participate in annual common task training to maintain 

proficiency in basic military skills such as nuclear, 

biological, chemical response; weapons familiarization and maintenance; and military communication 

procedures. 

Psychiatry is the medical specialty with the greatest number of military-unique tasks. Like a civilian 

psychiatrist practicing in a public institutional setting 

such as a prison or forensic healthcare facility, the 

military psychiatrist is consistently confronted with 

dual-agency issues, necessitating consideration of the 

needs of the organization versus those of the patient.2

However, unlike civilian behavioral healthcare providers, who can decide their degree of involvement in 

forensic and administrative psychiatric issues, military 

psychiatrists do not have a choice in participating 

in such cases, thereby requiring extensive training 

in military-unique behavioral health topics such as 

command-directed mental health evaluations, Rule 

for Courts-Martial 706 evaluations, security clearance 

assessments, and medical evaluation boards.3–6 Each 

of these military-unique administrative evaluations 

requires specific training and experience to perform 

competently. In addition to unique administrative 

tasks, the military psychiatrist must develop diverse 

skills such as consulting with commands, briefing 

nonmedical military leaders, providing psychoeducation to soldiers and leaders, and constructing realistic 

treatment plans while taking into account a service 

member’s duties.

This chapter will present the evolution of psychiatry GME in the military healthcare system from its 

origins in the early 20th century to the current process of training military psychiatrists. The US Army, 

Navy, and Air Force all participate in psychiatry GME, 

maintaining a pipeline of well-trained graduates who 

are frequently deployed to combat zones shortly after 

completion of training. Training programs vary in size 

and structure, including service-specific programs, 

programs sponsored by one service that accept trainees from other services, partnerships with civilian 

and Veterans Administration programs, and a joint 

service program in Washington, DC. All programs 

are accredited by the American Council of Graduate 

Medical Education (ACGME), fulfilling the same academic requirements observed by civilian programs, 

in addition to providing education in unique military 

psychiatric skills.7

 In addition to residency training in 

adult psychiatry, military psychiatry GME programs 

can offer subspecialty fellowship training in child 

and adolescent, forensic, addiction, and geriatric 

psychiatry. 

Areas addressed in the chapter will include leadership of a GME program, role of the program director, 

faculty development and recruitment, curriculum, 

contribution of undergraduate medical education to 

psychiatry GME, and research opportunities within 

training programs. The relevance of military psychiatric training will be presented, in addition to recommendations on how this unique specialty education 

can be enhanced in the future. 

History

Formal psychiatric GME in the US military is a 

relatively new entity, the development of which has 

mirrored civilian psychiatric training in the United 

States in many ways. In other ways, however, it has 

developed independently, establishing a unique 

legacy and creating for its alumni a broader clinical 

skill set than that acquired by most graduates of civilian training programs. Colonel (Retired) Michael 
671

Military Psychiatry Graduate Medical Education

G Wise authored an excellent summary of military 

GME through the mid 1980s, the highlights of which 

are summarized below.8

The first psychiatric “residents” in the Department of 

Defense (DoD) appear to have been four servicemen—

two from the Navy and two from the Army—assigned 

to work at Saint Elizabeths Hospital in Washington, 

DC, for a period of 2 years beginning in 19099 (the same 

year that Sigmund Freud first lectured at an American 

university, introducing the psychoanalytic movement 

to the United States and increasing American interest 

in psychiatry10). At the beginning of World War I, psychiatrists in the Army numbered only 50,11 an amount 

drastically insufficient to treat the 4 million US soldiers 

who would eventually serve in the war.12 In an effort 

to address this issue, the Army commissioned many 

psychiatrists from state hospitals, and nonpsychiatric 

Army physicians were enrolled in civilian neuropsychiatric training programs that lasted an average of 6 

weeks.11 By the time of the 1918 armistice, nearly 700 

psychiatrists were serving in the Army.11

Following World War I, psychiatrists gradually left 

the military, to such an extent that by 1940 uniformed 

psychiatrists on active duty numbered less than 

100.13,14 One year after the attack on Pearl Harbor, an 

improved and standardized neuropsychiatry course 

for nonpsychiatric military physicians was established 

and offered at a handful of civilian institutions.14

During the remainder of World War II, this 12-week 

course produced 1,300 graduates, referred to as “90-

day wonders.”15

In 1946, Congress passed the National Mental 

Health Act, which provided federal funds for a number of mental health initiatives, including training 

for mental health professionals.10 Over the course of 

the next decade, eight military psychiatry residency 

programs opened and received accreditation from 

ACGME (Table 42-1).8 The “90-day wonder” program 

remained active at Fort Sam Houston, Texas, from 

1946 to 1950, while physicians in the new psychiatric 

residencies completed their training.16

The field of psychiatry was also gaining a foothold 

in the civilian sector. During this same decade, the first 

Institute on Psychiatric Services meeting was held, the 

Psychiatric Services journal was established, the American Psychiatric Association authorized the creation 

of district branches, the first meeting of the American 

Psychiatric Association Assembly was held, the first 

Diagnostic and Statistical Manual of Mental Disorders was 

published, and psychoactive drugs were introduced 

in the United States.9

Perhaps as a result of psychotropic medications being introduced and the subsequent decreased number 

of psychiatric hospital admissions, three of the US military’s first psychiatric residencies closed shortly after 

opening: the Navy’s Great Lakes, Illinois, program in 

1948; the Navy’s San Diego, California, program in 

1954; and the Army’s Fitzsimons, Colorado, program 

in 1958.8

 However, the remainder of the programs 

stayed open for many years (Figure 42-1).

During the 1980s, as memories of the Vietnam 

War were fading and a Cold War conflict seemed 

increasingly less likely to materialize, pressure from 

the federal government to consolidate US military 

installations increased.17 After a preliminary round of 

DoD-initiated closures in 1988, Congress passed the US 

Department of Defense Base Realignment and Closure 

Act of 1990 (also known as the “BRAC law” or Public 

Law 101-510),18 which established a non-DoD committee and a schedule for the evaluation of military bases 

for closure. As a result of this legislation, additional 

BRAC rounds occurred in 1991, 1993, and 1995. 

Closure of military psychiatry residency programs 

took varied paths. The Presidio in San Francisco, 

California, home of Letterman Army Medical Center, 

table 42-1

american council of graduate medical education accreditation history

of US Military psychiatry residencies

Year Programs Accredited or Discontinued

1946 Bethesda (Md), Great Lakes (Ill), and Philadelphia 

(Penn) Navy programs accredited

1948 Walter Reed (Washington, DC) and Letterman 

(Calif) Army programs accredited; Great Lakes 

program discontinued

1950 Fitzsimons (Colo) Army program accredited

1951 San Diego (Calif) and Oakland (Calif) Navy programs accredited

1954 San Diego program discontinued

1958 Fitzsimons program discontinued

1965 Wilford Hall (Tex) Air Force program accredited

1976 Dwight D Eisenhower (Ga) Army program accredited; Philadelphia program moved to Portsmouth 

(Va) and accreditation continued

1977 Wright-Patterson (Ohio) Air Force program accredited

1978 Tripler (Hawaii) Army program accredited

1981 San Diego program reaccredited

1983 Oakland program discontinued

1993 Letterman program discontinued

1999 Dwight D Eisenhower program discontinued

Data source (through 1987): Wise MG. The past, present, and 

future of psychiatric training in the US armed services. Mil 

Med.1987;152:550–553.
672

Combat and Operational Behavioral Health

was identified for closure in 1988.19 Its final cohort 

of psychiatry residents graduated in 1993, and the 

hospital closed 1 year later.20 The training program at 

Eisenhower Army Medical Center in Augusta, Georgia, 

although not an official casualty of the BRAC, was 

closed preemptively by the Army in 1999 because of a 

dwindling pool of applicants.21 Similarly, although Oak 

Knoll Naval Hospital in Oakland, California, was not 

identified for closure until the 1993 BRAC, the Navy 

had already relocated the psychiatry training program 

from Oakland to San Diego in the mid-1980s.

In 1995, in an effort to fortify their programs against 

the threat of closure, the three DoD hospitals in the 

national capital area—Walter Reed Army Medical 

Center in Washington, DC; the National Naval Medical 

Center in Bethesda, Maryland; and Malcolm Grow Air 

Force Hospital in Prince George’s County, Maryland—

combined forces, creating the National Capital Area 

Consortium. Affiliated with the Uniformed Services 

University of the Health Sciences (USUHS), in Bethesda, Maryland, the consortium program is currently the 

largest active military psychiatry training program. 

A new BRAC initiative in 2005 has called for the 

= Navy

= Army

= Air Force

= Joint Svc

NCA Consortium

Tripler

Wright-Patterson

Portsmouth

Eisenhower

Wilford Hall

Oakland

San Diego II

San Diego I

Fitzsimons

Letterman

Walter Reed

Philadelphia

Great Lakes

Bethesda

1946 1956 1966 1976 1986 1996 2006

Figure 42-1. A graphic timeline of accredited US military psychiatry programs. The dotted lines represent when programs 

were either transferred to another location or merged.

NCA: National Capital Area; Svc: Service

closure of Walter Reed by 2011,22 but the consortium 

psychiatry residency program is expected to remain 

intact and headquartered at what is currently the National Naval Medical Center. The 2005 BRAC initiative 

also called for the consolidation of Wilford Hall Air 

Force Medical Center with Brooke Army Medical Center in San Antonio, Texas. By 2011, only a San Antonio 

Military Medical Center is expected to exist, with the 

north campus (Brooke) being primarily an inpatient 

facility and the south campus (Wilford Hall) having 

only outpatient services.23 As in Washington, DC, the 

Air Force psychiatry residency program in San Antonio 

is expected to remain intact.

The global war on terror (GWOT) has contributed 

to an increase in behavioral health problems among 

active duty personnel and their families, as well as 

among veterans and civilians in the United States. 

Interest in psychiatry as a career field also appears to 

be on the rise, perhaps as a direct result of this GWOTinfluenced increased demand.24 The future of military 

psychiatry GME will likely continue to parallel the 

need for services during times of war, as has been the 

case for the past century.

program Leadership

The military stresses competent leadership as an essential factor in successful completion of the mission. 

Much of an officer’s military education is composed 

of development and utilization of proper leadership 

techniques.25 Although the majority of military medical officers will never serve in command positions, 
673

Military Psychiatry Graduate Medical Education

many will become service, section, or department 

chiefs, directly responsible for delivering high-quality 

medical care in addition to promoting the professional 

development of subordinates. A fortunate few will 

be appointed to lead GME programs, taking on the 

responsibility of training future military clinicians to 

excel in varied environments.

The department chairperson performs diverse roles 

in a military psychiatry GME program. Besides the 

requirements established by ACGME, the chairperson 

must also meet the standards expected of a military 

leader.7 Essential attributes include articulating a clear 

vision, prioritizing the mission, managing personnel, and overseeing the budget, all while supporting 

the goals of the MTF commander. As the military 

healthcare system evolves into a managed care model 

emphasizing clinical productivity as a measurement 

of fiscal success, GME leaders are challenged with 

demonstrating financial success while maintaining a 

quality training program. GME-related activities such 

as clinical supervision, didactics, trainee performance 

assessments, medical education committees, psychiatric clinical report reviews, and research-related 

activities do not produce workload credit, resulting 

in a lower productivity standing compared with other 

MTFs that do not have GME programs.

Success of a military psychiatry program is predicated on the department leadership being able to 

incorporate GME into four essential tasks: (1) direct 

patient care delivery, (2) deployment cycle support, (3) 

operational readiness of personnel, and (4) research 

activities. Until the mid-1990s, military psychiatry 

GME programs were relatively insulated from external influences such as managed care and operational 

taskings. Programs readily focused on psychiatric 

education, utilizing direct patient care, clinical supervision, didactics, and research, augmented by a 

military psychiatry curriculum, to prepare trainees 

for success as clinicians in an MTF practice or as a 

garrison-based division psychiatrist. GME leaders 

were not pressured by the requirement to formulate 

intricate business plans to predict and subsequently 

demonstrate clinical productivity. Specific military 

psychiatric curriculum consisted of several didactic 

courses and focused on familiarization with basic 

military organization structure and function, dualagency issues, performing military-unique administrative mental health evaluations, interacting with 

operational leadership, and operational military 

mental health doctrine, much of which was from the 

Vietnam era and in the process of being updated. The 

operational experience for trainees was limited to a 

rotation during the final year of residency to a post 

with a large troop population, and in many instances 

such rotations lacked formal structure or stated goals 

and objectives. 

As the evolution of managed care within the military healthcare system of the late 1990s coincided with 

the changes in defense strategy after September 11, 

2001, conducting military GME became much more 

complex and challenging. Leaders of GME programs 

wer no longer able to dedicate resources exclusively 

to the training mission but were forced to balance 

multiple requirements while devising methods to 

maximize the learning experience of trainees. GME 

programs became directly affected by the GWOT 

through deployment of faculty and taskings to participate in deployment cycle support at locations serving 

as deployment platforms. Advantageously, trainees 

were given the opportunity to participate directly in 

many deployment cycle support activities, as well as 

to provide treatment for casualties evacuated from 

the theater of operations. A challenge for the GME 

leadership was to ensure that adequate supervision 

and training occurred during the provision of such 

services.26

With the extended GWOT-related campaigns of 

Operation Iraqi Freedom and Operation Enduring 

Freedom in the first decade of the 21st century, most 

graduates from Army psychiatry GME programs 

deployed to a combat zone within 2 years of completing training, requiring the programs to provide 

comprehensive instruction and practical experience in 

operational psychiatry. Faculty at the two Army GME 

programs became part of the psychiatry deployment 

pool and served in diverse assignments throughout 

both theaters of operations, directly enhancing the 

quality of the operational psychiatry curriculum. 

Prior deployment experience became a determining 

factor for prospective faculty, and by the end of 2006, 

over 75% of the active duty staff psychiatrists at the 

two Army psychiatry programs had deployed to a 

combat theater.27

Role of the Program Director 

A residency program’s existence and viability 

critically depends on a program director who is fully 

engaged and active in the program’s daily activities. 

In the field of psychiatry, such active participation is 

even more paramount in running a successful residency program. The field of psychiatry requires that 

residency graduates not only be skilled in diagnostic 

assessments and treatment modalities, but that they 

also be capable of engaging patients and systems to 

construct realistic individualized treatment plans. 

Such capabilities can be utilized effectively only if the 

psychiatrists are fully aware and in control of their own 

personal mental health. Therefore, a quality psychiatry 

residency program encourages trainees to develop an 
674

Combat and Operational Behavioral Health

awareness of how their own histories can potentially 

affect their ability to engage patients in clinical service 

delivery and program faculty in their educational 

pursuits. The psychiatry residency program director 

must therefore possess skills as an effective parent, 

colleague, arbitrator, visionary, and leader when interacting with residents and faculty. 

When groups are formed in which some have power 

and control over other members, acting out behaviors 

will inevitably follow. In a residency program, the 

program director must anticipate these behaviors and 

develop methods of preventing them when possible, 

in addition to maintaining proper boundaries when 

challenged. The faculty and program director are 

expected to avoid leveraging their power differential 

while guiding the trainees through a process of personal growth and learning. The program director must 

learn to respond appropriately to acting out behaviors 

with the requisite amount of action, while redirecting 

residents with such behaviors toward more constructive use of their energies. 

Psychiatry residency training evolves along a developmental continuum. The beginning section usually 

involves encouraging residents to apply newly learned 

knowledge in patient care and to develop clinical instincts in evaluation and treatment procedures. During 

the middle phase, the program director helps residents 

consolidate basic skills and begin developing more 

advanced skills in therapeutics through treatment 

of challenging and treatment-resistant cases. Finally, 

during the end stage of training, the program director 

develops situations for the resident to become a leader 

of junior colleagues and begin taking on independent 

responsibilities as a credentialed provider. 

The visionary program director must be aware 

of the future of psychiatry as an evolving medical 

specialty while remaining cognizant of how the 

military plans to address its future behavioral health 

challenges. The latter requires the program director 

to maintain connections with military behavioral 

health leaders so the needs of the military system can 

quickly be built into the training of future military 

psychiatrists. These changing needs force the program 

director to continually refine the vision and mission 

of the program, articulating these refinements clearly 

and concisely to the faculty and residents. Program 

directors must also stay current with the latest developments and research in psychiatry, which is rapidly 

developing from a field of general syndromes to a 

complex specialty containing significant advances in 

neuroscience and therapeutics. 

Leaders of organizations are tasked with many responsibilities that can quickly become overwhelming 

and burdensome, and those whom they lead look to 

them for mentorship and guidance. Leaders’ behaviors 

set the tone for the entire organization and are naturally scrutinized by subordinates. Program directors 

must therefore be aware of the significance an action 

can have across the residency training program. The 

fundamental operating principles of a residency must 

be repeatedly articulated so that residents and faculty 

can understand the rationale and potential outcomes of 

certain decisions. Faculty and trainees may not agree 

with a decision, but they need to be made aware of how 

decisions are consistent with the stated principles of 

the program. With so many ongoing issues to incorporate into a residency program, the program director 

must balance being open to feedback at all levels with 

making decisive and timely decisions to keep the program current with psychiatry as a specialty and also 

with the needs of the military.

Faculty Development

In addition to capable GME leadership, recruitment 

and selection of appropriate faculty is a critical element 

to program success. Besides uniformed clinicians, the 

teaching staff is composed of civilian faculty employed 

by the federal government, clinicians on personal 

service contracts, and possibly faculty members from 

local civilian psychiatry GME programs. 

As with any enterprise, the recruitment and retention of bright, experienced, and energetic supervisors 

directly affects program success. A psychiatry GME 

faculty member should possess the inner drive for personal growth, passion to promote learning in trainees, 

and professional experience to provide capable supervision and guidance.7

 The composition of a military 

psychiatry GME faculty should be a mix of established 

clinicians with significant experience in academic settings and midcareer psychiatrists with an interest in 

further development of teaching and mentoring skills. 

In many instances, the more professionally mature 

members of the faculty are retired military clinicians 

who possess a wealth of practical military psychiatric 

experience. 

Retention of military physicians beyond completion 

of initial active duty service obligation has been a challenge since the conclusion of Operation Desert Storm. 

The potential of prolonged operational deployments 

combined with dwindling resources and the evolution of managed care within the military healthcare 

system has produced a less attractive environment for 

prolonged service. However, one extremely favorable 

aspect of military medicine is the wide scope of career 

tracks available.28 Within several tours of duty posttraining, active duty psychiatrists are in a position to 

mold their careers in a single area, such as a clinical, 
675

Military Psychiatry Graduate Medical Education

operational, command, academic, or research-based 

concentration, with the flexibility to shift between 

these tracks. For the academically oriented military 

psychiatrist, the potential to become faculty at one of 

the military GME programs is a tremendous incentive 

to continue practicing medicine on active duty.

Potential faculty members are identified throughout 

the entire career path of the military psychiatrist. Occasionally, an outstanding trainee demonstrating a talent 

for academic psychiatry may be recruited to remain on 

staff as a junior faculty member while further refining 

teaching and mentoring skills under the guidance of 

senior faculty. More likely, promising graduates with 

an interest in teaching and academics will serve at least 

one tour as an MTF or operationally based psychiatrist 

to gain practical clinical and administrative experience 

as an independent healthcare provider. Another group 

consists of clinicians who initially were not recognized 

as future faculty members, but through a combination 

of experience, reassessment of career aspirations, and 

possibly attaining specialized skills such as forensic or 

addictions psychiatry training, may be deemed faculty 

material at midcareer or later. 

No codified requisite criteria exists for consideration 

for faculty appointment to a military psychiatry GME 

program, but the candidate should demonstrate superior clinical, leadership, management, scholarship, and 

military skills with an underlying passion to develop 

future military psychiatrists. A search committee composed of current faculty members should be formed 

to identify and interview candidates. One method to 

screen potential faculty is using ACGME competencies 

to predict a resident’s level of performance as an independent practitioner.7

 The potential faculty member 

should markedly exceed the baseline standard for each 

of the competency areas, with focus on the ability to 

provide mentorship and guidance (Exhibit 42-1). Additional data to be assessed are performance during 

GME training, scope of assignments post-GME, input 

from supervisors and colleagues, and unique skills to 

enhance the training program.

Recruitment of a dedicated and multitalented 

faculty is essential for the success of a military psychiatry training program. The increased frequency of 

exhibit 42-1

american council of graduate

medical education competencies

1. Patient care that is compassionate, appropriate, and effective for the treatment of health 

problems and the promotion of health.

2. Medical knowledge about established and 

evolving biomedical, clinical, and cognate 

sciences, as well as the application of this 

knowledge to patient care.

3. Practice-based learning and improvement 

that involves the investigation and evaluation of care for their patients, the appraisal 

and assimilation of scientific evidence, and 

improvements in patient care.

4. Interpersonal and communication skills that 

result in the effective exchange of information and collaboration with patients, their 

families, and other health professionals.

5. Professionalism, as manifested through a 

commitment to carrying out professional 

responsibilities, adherence to ethical principles, and sensitivity to patients of diverse 

backgrounds.

6. Systems-based practice, as manifested by 

actions that demonstrate an awareness of 

and responsiveness to the larger context and 

system of healthcare, as well as the ability 

to call effectively on other resources in the 

system to provide optimal healthcare. 

Data source: Accreditation Counsel for Graduate Medical 

Education. Psychiatry program requirements. ACGME 

Web site. Available at: http://www.acgme.org/acWebsite/

RRC_400/400_prIndex.asp. Accessed October 28, 2009.

 Curriculum

operational deployments since September 11, 2001, 

has necessitated frequent shifting and restructuring of 

faculty duties. To provide future military psychiatrists 

with the necessary skills to thrive in multiple complex 

environments, the GME faculty must be dedicated 

to the mission of being teachers, mentors, and role 

models. 

During the last 2 decades, the establishment of 

the core competencies and the psychotherapy competencies as the basic evaluation tools has brought 

significant changes to psychiatry GME. Training 

requirements are gradually shifting to an outpatientcentered treatment model as the inpatient rotation 

standard has been steadily reduced. Specific didactic 

requirements have also been expanded with the evolution of psychiatric subspecialties such as forensic, 

geriatric, and psychosomatic medicine, as well as 

with advancements in psychopharmacology. Training 

programs must also provide residents with adequate 

exposure to the challenges of managed care, because 

most psychiatrists-in-training will not have a practice 
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Combat and Operational Behavioral Health

composed exclusively of direct-payment patients. In 

addition to the elements unique to psychiatry training, military programs have unique training requirements pertinent to the diverse role of the uniformed 

psychiatrist.

Core Competencies

The core competency movement within ACGME 

began with the “outcomes movement” by the US 

Department of Education in the 1980s and accelerated in Canada in 1996 through the publishing of the 

Canadian Medical Education Directions for Specialists 

(CanMEDS) 2000 Project report.29 This movement 

grew out of a recognition that the role of the physician has changed from a paternalistic medical expert 

model to a model in which the medical expert is part 

of a medical decision-making team that includes the 

patient. Also, the rapid pace of advancement of medical knowledge has repeatedly emphasized the need 

for physicians to be avid life-long learners and for 

residency training programs to teach new physicians 

how to develop life-long learning skills. In response 

to the change in the mechanism of healthcare delivery, 

ACGME and the American Board of Medical Specialties launched the core competencies program for all 

American residencies in 1999.30 In 2001, the psychiatry 

residency review committee (RRC) became the first 

RRC to change its official program requirements. 

The following year, site reviewers began assessing 

whether or not programs had begun to implement the 

core competencies. Similar to the overall emphasis in 

healthcare on the ability to assess quality in medicine 

by such certifying organizations as the Joint Commission, ACGME mandated outcome measures to assess 

competency in the core areas.31

The core competencies consist of six main elements: 

(1) medical knowledge, (2) patient care, (3) interpersonal and communication skills, (4) practice-based 

learning and improvement, (5) professionalism, and 

(6) systems-based practice.7 Medical knowledge and 

patient care emphasize the traditional elements of 

physician medical education over the past century. 

Medical school and clinical experiences in residency 

form the foundation of medical knowledge that 

physicians use to perform competent, safe patient 

care. The patient care competency focuses on interactions with patients, including the psychiatry-specific 

psychotherapy core competencies. Interpersonal and 

communication skills have become increasingly more 

important as fully informed consent and a focus on 

patient choice have steadily increased throughout 

the past 60 years, since the passage of the Nuremburg 

Code in 1947.32 Practice-based learning and improvement emphasizes the ability to understand and grow 

from clinical experiences in addition to keeping current on recent advances. The goal is to instill such abilities during training so that practitioners continue the 

process throughout their entire medical careers.

Professionalism is an essential aspect of any occupation, encompassing the requisite skills and sense 

of commitment needed to function in a competent 

and safe manner. No amount of medical expertise 

can overcome the requirement for strict standards of 

behavior that define professionalism and serve as the 

backbone for a strong physician-patient relationship. 

In addition to acting professionally with patients and 

healthcare colleagues, the military clinician has an additional obligation to maintain the high standards of a 

military officer.33 Finally, advances in medical practice 

have resulted in effective management and control of 

many chronic illnesses in the outpatient setting, which 

in turn has created a need for increasing collaboration 

with many different organizations to maximize the 

well-being of patients. The systems-based training 

competency emphasizes this ability to operate within 

systems of care, in coordination with many types of 

healthcare professionals, thereby maximizing quality 

of life for patients. By training within a systems-based 

environment, the military psychiatry resident gains an 

appreciation for the importance of utilizing primary, 

secondary, and tertiary prevention.34

Implied in the competency model is the idea that 

length of time in training alone is insufficient to establish competence. Rather, a consistent ability to use 

a specific set of knowledge, skills, and attitudes must 

be demonstrated by the trainee prior to clearance for 

graduation. Further development will produce a longitudinal assessment tool for competence as opposed 

to completion of a set of timed requirements. However, 

little evidence exists on what outcome measures can 

reliably assess the psychiatric core competencies. Currently, many programs use some form of standardized 

assessment tool in conjunction with subjective input 

from multiple sources such as supervisors, instructors, and mentors to assess overall competency of 

trainees.35

Medical Students and Core Competencies 

The core competencies of interpersonal and communication skills, professionalism, and systems-based 

practice in particular require trainees to demonstrate 

the ability to interact effectively with persons other 

than patients. Because they are so crucial to successful 

medical practice, development of these competencies 

begins very early in the medical education process. At 

the heart of these competencies is the theme of working 
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Military Psychiatry Graduate Medical Education

cooperatively within multidisciplinary teams of other 

medical professionals in a manner that synergizes efforts to provide the best care for patients. With nurses, 

occupational therapists, medical technicians, and administrative staff, medical students are often members 

of these multidisciplinary teams. 

At USUHS, the only US federal medical school and 

the principle source of future military physicians, military medical students are introduced to the concepts 

of team learning, practice, and interpersonal communication through a variety of small-group laboratory 

exercises based on clinical vignettes. Students also 

participate in Introduction to Clinical Medicine smallgroup courses, where they learn and practice medical 

interviewing and physical examination skills with 

patients from the treatment facilities in the national 

capital area. 

Psychiatry residents from the National Capital 

Consortium’s psychiatry GME training program are 

actively recruited and encouraged to participate as coinstructors with full-time university faculty members 

in these exercises and courses. In this manner, residents 

are afforded opportunities to demonstrate their medical knowledge, to discuss principles of systems-based 

medicine, and to role model professional relationships 

with junior medical officer students and senior cofaculty. 

Third-year USUHS medical students currently 

participate in clinical clerkship rotations on psychiatry wards and clinics at the three medical centers 

within the National Capital Consortium; at Tripler 

Army Medical Center, Hawaii; and at Wilford Hall 

Air Force Medical Center (soon to be known as the 

San Antonio Military Medical Center–South). Additionally, 3rd- and 4th-year students from USUHS 

and other medical schools may also rotate at civilian 

treatment facilities and other military medical centers. 

At these sites, residents (under the appropriate guidance of military GME faculty) also hone their skills 

as mentors, teachers, supervisors, role models, and 

team leaders. 

GME program faculty members appointed by 

the USUHS Department of Psychiatry as clinical site 

directors at each of these sites assure that residents 

contribute to the core knowledge and competency 

requirements of the Liaison Committee on Medical 

Education for psychiatry clerkship students. Students are responsible for learning the fundamentals 

of psychiatric assessment, differential diagnosis and 

treatment, mental status examination, safety assessment, treatment planning, and case presentation to 

multidisciplinary teams during these rotations. In 

providing both didactic and “hands-on” training for 

medical students, GME residents also develop and 

demonstrate the RRC-required core competencies, as 

well as honing the professional and leadership skills 

necessary for the practice of psychiatry in military 

medical settings.

Psychotherapy Competencies

Psychiatry residency programs have had to restructure their training strategy to meet the competency 

requirements for various psychotherapies, including 

supportive therapy, psychodynamic therapy, brief 

therapies, cognitive-behavioral therapy, and combined medication and psychotherapy. The evolution 

of managed healthcare converging with marked 

advancement in psychopharmacology shifted the 

emphasis of psychiatry GME away from long-term 

psychotherapeutic treatment and toward a crisis intervention model. In response, many psychiatry residency programs experienced a shift in culture away 

from emphasis on psychotherapy skills toward a more 

neurobiology-based approach that led to increased 

reliance on safer, less burdensome medications for 

treating mental illnesses. By the end of the 1990s, numerous programs around the country were struggling 

to find the financial resources necessary for robust psychotherapy training.36 In contrast, military residency 

programs faced less financial pressure to demonstrate 

productivity and thus were able to maintain a strong 

emphasis on psychotherapy skills development. 

In 2001, the psychiatry RRC mandated not only 

that residencies must start implementing the six core 

competencies, but additionally that they must develop 

assessment tools to certify that their graduates are 

trained and competent in all five psychotherapies.37

No directives have been written on how to teach, 

develop, or assess each of these psychotherapies, and 

development of competencies was left to individual 

programs to design and implement.

General Psychiatry Residency Curriculum

An accredited psychiatry residency program must 

be 48 months in length, including the postgraduate 

year 1, also known as internship. Graduation from 

medical or osteopathic school is a prerequisite to enter 

such a program. The psychiatry internship usually 

consists of approximately 6 months of basic medical 

training in primary medicine areas, such as internal 

medicine, family medicine, or pediatrics, and about 

6 months of neurology and psychiatry training. Postgraduate year 2 typically involves mostly inpatient 

psychiatry rotations, as well as rotations in addictions, 

consultation-liaison, geriatric psychiatry, and other 

clinical experiences. The majority of outpatient psycho-
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Combat and Operational Behavioral Health

therapy and medication management training occurs 

during postgraduate year 3. Finally, postgraduate year 

4 involves consolidating medication management and 

psychotherapy skills, mentoring junior trainees, and 

learning administrative skills necessary for interacting 

in the larger system of medical care.7

Requirements for completion of GME training in 

psychiatry have evolved over time. During the past 

2 decades, focus has shifted from inpatient psychiatric experience to outpatient rotations, mirroring the 

medical industry’s evolution of an outpatient-based 

treatment model. For example, the required time for 

inpatient psychiatry rotations in 1984 was 12 months, 

compared to a minimum of 6 months in 2007.7,38

ACGME mandates specific time requirements for 

certain rotations, and others are left to the discretion 

of the training program (Exhibit 42-2). 

Three other aspects to psychiatry residency training 

are unique and increase the complexity and cost of executing a training program. First, much of psychiatric 

care occurs in one-on-one sessions with a patient. The 

duration of a typical appointment can be from 30 to 

90 minutes, with a low reimbursement rate compared 

exhibit 42-2

SUMMARY OF AMERICAN COUNCIL 

OF GRADUATE MEDICAL EDUCATION 

RESIDENCY REVIEW COMMITTEE 

REQUIREMENTS FOR PSYCHIATRY 

RESIDENTS, AS OF 2007

Timed Experiences

	 •	 Primary Care Medicine: 4 months in

internship year

	 •	 Inpatient Psychiatry: minimum of 6

months

	 •	 Outpatient Psychiatry: 12 consecutive

months

	 •	 Neurology: 2 months

	 •	 Consult-Liaison Psychiatry: 2 months

	 •	 Child and Adolescent Psychiatry: 2

months

	 •	 Addiction Psychiatry: 1 month

	 •	 Geriatric Psychiatry: 1 month

Untimed Experiences

	 •	 Forensic Psychiatry

	 •	 Community Psychiatry

	 •	 Family/Couples Therapy

	 •	 Group Therapy

	 •	 Electroconvulsive Treatment

	 •	 Psychological Testing

to other medical specialties. Because of the very sensitive nature of topics discussed and the structure of 

psychotherapy sessions, there are significant barriers to 

having a supervisor directly observe a trainee’s interactions with patients. Some programs in the military are 

beginning direct observations via video links to offices 

with consent by the patient as a means to observe but 

not intrude on the patient-physician interaction. 

Secondly, as mandated by ACGME, psychiatry 

trainees must meet with supervisors individually at 

designated times to review clinical encounters that 

have already occurred.7 Each trainee must have 2 

hours a week of individual time with faculty supervisors to discuss recent evaluations and therapy cases. 

Therefore, if a program has 25 residents, faculty must 

spend 50 hours a week of nonclinical time reviewing 

cases with the trainees, leading to a large amount of 

fiscally nonproductive time for both residents and 

supervisors. 

Third, much of psychiatry training involves trying 

to understand the enormously complex field of human behavior. Residents need to understand human 

development across the lifespan and how it manifests 

differently at various points in development. For example, a 5-year-old girl might be displaying normal 

developmental behavior when she states that she sees 

an invisible friend standing next to her, whereas such 

behavior would be abnormal for a 13-year-old child. In 

addition to learning through clinical experiences and 

case supervision, psychiatry GME training requires 

a greater amount of didactic learning than any other 

medical specialty. The total time spent participating 

in didactics does not include advanced preparation 

or individual reading and research pertinent to the 

resident’s cases. Learning how to distinguish normal 

behaviors from mental disorders, understanding 

various medication and therapy treatment modalities, 

and learning how to develop realistic treatment plans 

necessitate a large reading and didactic program.7 To 

satisfy all of the academic requirements, most psychiatry GME programs have developed didactics schedules 

of about 3 to 5 hours per week per year level, resulting in an overall didactic schedule of approximately 

13 to 15 hours per week for the entire program, all 

of which is nonbillable time for faculty and resident 

participants.

Research and Scholarly Activity 

Although not specifically mentioned as a GME core 

competency, the ACGME RRC requires that involvement in scholarly activity or research be incorporated 

into residency training.7

 All military psychiatry GME 

programs require participation in a research project or 

scholarly endeavor as a requirement for graduation. 
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Military Psychiatry Graduate Medical Education

Historically, such scholarly endeavors have included 

literature reviews presented at department-wide or 

hospital grand rounds. Increasingly, however, general 

psychiatry residents have been paired with research 

mentors—GME faculty members with specific skills 

and interest in research. As a result, many GME residents graduate with a sophisticated understanding of 

study design, institutional review board procedures, 

and research report writing skills. In addition to 

numerous book chapters, military residents have 

authored or coauthored publications accepted in the

American Journal of Psychiatry, Journal of the American 

Academy of Psychiatry and the Law, Jefferson Journal of 

Psychiatry, Psychosomatic Medicine, Military Medicine, 

and American Journal of Disaster Medicine, among others. These efforts have not only advanced the practice 

of psychiatry within the military, but have also expanded the knowledge and understanding of specific 

military psychiatric issues within the larger civilian 

community. 

Military Psychiatry Curriculum

In addition to satisfying all of the standard ACGME 

requirements for a psychiatry residency program, 

military GME programs must prepare trainees to function as capable leaders immediately upon completion 

of training. New graduates can be placed into various leadership positions, such as chief of a division 

mental health clinic or officer-in-charge of a brigade 

combat team mental health section.39 The staff of a 

mental health clinic or section may include other officers, several enlisted personnel, and possibly civilian 

employees. New graduates can also be assigned to 

combat stress control units or to other medical units 

in a deployment setting, where they will be expected 

to serve in leadership roles.

A well-executed military psychiatry curriculum 

spans the entire 4-year training cycle. Issues emphasized in the military psychiatry curriculum include 

dual-agency issues, utilizing the military structure to 

support soldiers in need, and ways to reduce stigma 

and perform primary prevention efforts. Dual-agency 

issues arise more often in military psychiatry because 

Army psychiatrists serve simultaneously as physicians and Army officers.40 Most of the time these two 

roles do not conflict, but in some situations duty to the 

mission may be of higher priority than the immediate 

best interest of the soldier. Especially during combat 

operations, the needs of the group and the mission 

may sometimes trump the needs of the individual, 

potentially creating a dilemma for physicians trained 

and sworn to act in the best interests of the patient.41

This dual-agency issue is addressed frequently in the 

training of military psychiatrists.

One benefit of the military structure is the ability to 

develop and execute a comprehensive biopsychosocial 

formulation and treatment plan for a service member. 

Military psychiatry GME programs provide trainees 

with practical experience in performing clinical psychiatry while addressing pertinent military issues. 

Applying an occupational health model by working 

closely with the service member’s chain of command, 

the military psychiatrist has influence in structuring 

a soldier’s work environment via the scope of work, 

physical setting of work, and even duty hours.6

 An indepth understanding of the challenges and constraints 

faced by military units is essential for the military 

psychiatrist when consulting with service members’ 

chains of command to develop realistic treatment 

plans. To promote familiarity with the practice of 

psychiatry in a military environment, trainees participate in rotations at posts and bases with large cohorts 

of operational units. Through such interactions, the 

psychiatrist-in-training gains practical experience in 

military group dynamics and learns to develop realistic treatment plans within the constraints posed by 

the unit’s mission.

Many military psychiatry GME graduates deploy to 

an operational environment shortly after completion 

of training, so familiarity with unit structure and dynamics is tremendously important to the psychiatrist 

aspiring to be of optimal service to both active duty 

patients and unit leaders. Learning about the critical 

role of mental health in the entire deployment cycle 

support process prior to completion of residency 

training will greatly aid the military psychiatrist in 

the initial assignment.42

Unlike most civilian occupations, military service 

does not impact solely upon the service member, but 

affects the entire family unit. The high percentage of 

married service members makes adequate knowledge 

and experience in managing family dynamics, particularly in the face of deployment, necessary for military 

psychiatry trainees. The mental health needs of military children have been recognized through research

and practical experience.43 Military psychiatry trainees 

should have experience with programs that address 

such needs outside of the traditional office setting, such 

as in school-based mental health programs.44

Over the last 5 to 10 years, increasing emphasis has 

been placed on early identification of mental health 

problems through education and primary prevention 

efforts. After the September 11, 2001, terrorist attacks, 

the Army instituted Operation Solace to offer assistance to Pentagon employees. Military psychiatry 

trainees played a prominent role as members of the 

assistance team.45 Boundaries of traditional methods 

of patient care had to be crossed to allow survivors 

easy access to mental healthcare providers while si-
680

Combat and Operational Behavioral Health

multaneously decreasing the stigma to seeking help. 

For example, mental health teams of various types of 

providers were assembled to bring outreach efforts 

directly to employees in work areas, creating the term 

“therapy by walking around.” Outcome data suggest 

that such efforts may have resulted in a smaller-thanexpected incidence of mental illness at the Pentagon 

following the attack.46

Combat operations since then have provided multiple opportunities for mental healthcare providers 

to further improve educational activities, to refine 

screening of service members during the entire deployment cycle, and to minimize the traumatic effects of 

the combat experience. Further advances in military 

psychiatry curricula will result in graduates being 

better prepared for the complex military mental health 

treatment mission. 

Postresidency Fellowship Training 

Postresidency psychiatric subspecialty education 

and training (fellowship programs) are currently 

offered at several military medical centers.47 These 

programs provide the Army and Navy Medical 

Corps with the majority of their military psychiatric 

subspecialists. Historically, the Air Force has opted to 

permit relatively few of their psychiatrists to complete 

fellowship training (and these primarily through 

civilian channels), but Air Force physicians have 

also participated in the training programs described 

below. The opportunity to apply for and, if selected, 

receive subspecialty training in child and adolescent 

psychiatry, forensic psychiatry, geriatric psychiatry, 

and addictions psychiatry serves as a retention incentive for physicians who might otherwise terminate 

their active duty service. Military psychiatrists with 

subspecialty training continue to primarily practice 

adult general psychiatry in most operational billets. 

However, those assigned to tertiary care facilities and 

teaching hospitals are often assigned duties specifically related to their subspecialty skills (eg, working 

several days a week at the child psychiatry service, 

or as a medical review officer for the base substance 

abuse program). Those assigned to smaller clinics or 

medical detachments are given duties that utilize their 

expertise. For example, although military regulations 

do not require a forensic psychiatrist for the evaluation 

of competency and criminal responsibility,4

 forensically 

trained psychiatrists are called upon to conduct these 

assessments by commanders or medical service chiefs 

whenever possible. Thus, the opportunity to practice 

specialized psychiatric skills also serves as a retention 

incentive for specialty-trained psychiatrists. 

Fellowship programs in child and adolescent psychiatry accredited by the ACGME RRC are presently 

offered at Tripler Army Medical Center and Walter 

Reed Army Medical Center (as part of the National 

Capital Consortium). Walter Reed also offers RRCaccredited fellowship training in forensic and geriatric 

psychiatry, and Tripler offers addictions psychiatry 

fellowship training. Army GME plans currently permit two Army psychiatrists to enter forensic training 

each year, five psychiatrists to enter child and adolescent training, and one to enter geriatric or addictions 

training in alternate years. The programs also offer 

training to Navy and Air Force psychiatrists on a spaceavailable basis, provided their parent service agrees 

to permit their matriculation. In this way, the training 

programs generate a pool of psychiatric subspecialists sufficient to fulfill forecasted needs and to justify 

continued program accreditation. 

The US Army, Navy, and Air Force have also 

recently established annual training billets for the 

National Capital Consortium’s Disaster Psychiatry 

Fellowship at USUHS. This military-unique training 

opportunity combines a competitive master’s in public 

health program with research and clinical mentorship 

in military operational response to disasters, war, and 

terrorism, as well as rotating internships at various 

federal agencies involved in disaster response. Disaster 

psychiatry subspecialty training, though not formally 

recognized by the ACGME through an accreditation 

process, has emerged to fill a need within the military 

for psychiatrists specifically trained in public health 

interventions, health surveillance, and principles of 

disaster mental health research and practice. Because 

the military is uniquely positioned and often tasked 

to provide medical and mental healthcare in natural 

and human-caused disasters, military psychiatrists 

with subspecialty training in this arena can augment 

the response of general psychiatrists and behavioral 

health specialists. 

The opportunity to apply subspecialty skill sets in 

military operational environments—whether addressing the mental health needs of child victims of the 

southeast Asian tsunami or the medico-legal issues 

surrounding the mental health of service members 

accused of war crimes—often encourages specialtytrained psychiatrists to remain on active duty beyond 

their contractual obligations. 

Relevance in Mission Performance

The delivery of mental health services in a military 

environment differs in multiple ways from civilian 

mental healthcare. Just as an attorney who relocates to 

a new state must learn the laws and culture of that state 
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Military Psychiatry Graduate Medical Education

before establishing a practice, military mental health 

providers must thoroughly understand their service 

branch’s laws and culture to be effective caregivers. 

Military GME provides trainees with necessary exposure to the knowledge, skills, and attitudes required 

of military mental healthcare providers. Additionally, 

trainees in military programs receive guidance and 

supervision from experienced military supervisors 

while providing healthcare directly to service members and their dependents. Instruction and training in 

military-unique mental health issues is not available 

in civilian training, and being comfortable practicing 

in a military environment may be a major determinant of the length of time a military psychiatrist will 

ultimately remain in the service.8 As the Society of 

Medical Consultants to the Armed Forces emphasized 

in a 1987 white paper, “[Military] graduate medical 

education is the chief guarantor of quality medical 

care and an unmatched incentive for the recruitment 

and retention of active duty medical officers. It is the 

essential prop supporting the entire voluntary military 

medical structure.”48

The material presented in this section focuses on 

Army psychiatry GME training. Although the other 

mental health disciplines such as psychology, social 

work, psychiatric nursing, and occupational therapy 

may also offer graduate training programs in military 

healthcare facilities, psychiatry training is the longest 

and the most comprehensive. The authors of this 

chapter, all Army psychiatrists, are most familiar 

with Army standards and procedures. However, all 

branches of the US armed forces currently endorse 

a similar approach to evaluating, treating, and managing service members with psychiatric conditions. 

Additionally, each service recognizes the importance 

of addressing the issues of the entire military family 

when developing a mental healthcare delivery strategy. 

Each service also follows the same regulatory guidance, albeit with different nomenclature. Most of the 

information presented in this section is applicable to all 

mental health disciplines and all branches of the armed 

forces. Regardless of specialty or uniform, exposure 

to military systems as a trainee greatly contributes 

to the development of confidence and competence in 

caring for service members and their families during 

peacetime and war.

The military mental health field is unique, with 

many inherent challenges that are not addressed in civilian residency training programs. Besides simply offering cultural immersion, military residencies include 

both didactic and experiential training opportunities 

that appropriately prepare trainees for the jobs they 

will enter following graduation. These programs are 

a crucial component of military medicine and have 

been identified as the largest guarantor of provider 

longevity in the military. Additionally, appropriate 

implementation of the aforementioned knowledge, 

skills, and attitudes by well-trained military mental 

health providers will enhance overall unit readiness 

and improve mission performance by the units they 

support.

Military psychiatry is distinguishable from civilian adult psychiatry by two major constructs, both 

requiring years of experience to master. The first is the 

aforementioned dual-agency role, referring to the psychiatrist’s constant but necessary struggle to balance 

the best interest of the patient with the best interest of 

the patient’s unit, which includes overall unit health 

and successful completion of the military mission.45

The second construct is the extensive amount of technical, military-specific knowledge required to practice 

successfully within the military culture (Table 42-2). 

As mentioned above, all US military psychiatry 

programs are accredited by ACGME. Like psychiatrists 

trained in civilian programs, military psychiatrists are 

expected to demonstrate competence through successful development of specific knowledge, skills, and attitudes.7 Thriving as a military mental health provider 

requires the nurturing of career-specific knowledge, 

skills, and attitudes that can be gained only by repeated 

clinical encounters within military systems under the 

direction of an experienced supervisor. This section 

will introduce and explain these elements of competence as they relate to military psychiatry, accompanied 

by case examples pertinent to each. 

Knowledge

Knowledge begins with a basic understanding 

of the military culture, such as appropriate wear of 

the uniform, rank recognition, salutations, customs, 

and courtesies.49 It also involves an appreciation of 

the mindset of military leaders, who are responsible 

for the safety of hundreds of service members and 

millions of dollars worth of equipment, and whose 

success depends on their ability to motivate their 

troops to accomplish potentially life-threatening tasks 

under adverse conditions for minimal pay. Leaders 

often have neither the time nor the incentive to make 

special accommodations for service members who 

are not mentally fit for the mission at hand. Additionally, knowledge consists of understanding military 

occupations in terms of education, content, scope, 

typical duty environment, and inherent stressors. For 

example, the military psychiatrist should know that 

cooks and infantry soldiers require one of the lowest 

entrance examination scores,50 that recruiters have 

one of the most stressful jobs,51 and that aviation crew 

members are prohibited from taking certain types of 

medications.6
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Combat and Operational Behavioral Health

table 42-2

OFFICIAL DOCUMENTS WITH WHICH US ARMY PSYCHIATRISTS SHOULD BE FAMILIAR

Number Title

Army Regulations and Pamphlets

AR 40-1 Composition, Mission, and Functions of the Army Medical Department

AR 40-66 Medical Record Administration and Documentation 

AR 40-400 Patient Administration 

AR 40-501 Standards of Medical Fitness 

AR 380-67 Personnel Security Program 

AR 600-8-4 Line of Duty Investigations 

AR 600-8-22 Military Awards

AR 600-8-24 Officer Transfers and Discharges

AR 600-85 Army Substance Abuse Program 

AR 608-18 The Army Family Advocacy Program 

AR 623-3 Evaluation Reporting System 

AR 635-40 Physical Evaluation for Retention, Retirement, or Separation 

AR 635-200 Active Duty Enlisted Administrative Separations

AR 670-1 Wear and Appearance of Army Uniforms and Insignia 

DA Pamphlet 600-24 Suicide Prevention and Psychological Autopsy 

Department of Defense Directives and Instructions

DoD Directive 1332.14 Enlisted Administrative Separations 

DoD Directive 1332.30 Separation of Regular and Reserve Commissioned Officers

DoD Directive 6490.1 Mental Health Evaluations of Members of the Armed Forces

DoD Instruction 6490.4 Requirements for Mental Health Evaluations of Members of the Armed Forces 

Army Field Manuals

FM 4-02.51 (formerly FM 8-51) Combat and Operational Stress Control 

FM 6-22.5 Combat Stress 

Other Documents

DoDSER Department of Defense Suicide Event Report 

Air Force Instruction 41-307 Aeromedical Evacuation Patient Considerations and Standards of Care

Furthermore, knowledge includes familiarity with 

community resources and programs available to assist 

troubled service members and their families. Each 

branch of the armed forces has its own service-specific 

support agencies, several of which psychiatrists are 

required by regulation to contact under specific circumstances, and others that are simply available for 

anyone who needs them. The first category includes 

substance abuse education and treatment programs,52

child and family welfare programs,53 patient administration offices,54 physical evaluation board liaison 

offices,55 other mental health treatment programs in the 

community, and law enforcement agencies. The second 

category includes organizations such as the command 

chaplain group, local community service agencies (eg, 

Army Community Service, Fleet and Family Services, 

Airman and Family Readiness Centers), the staff judge 

advocate (legal), the inspector general, Military OneSource, and the Veterans Administration.56,57

Another aspect of knowledge is the military 

psychiatrist’s ability to predict the effect of clinical 

decisions and administrative recommendations on 

service members, their command, and the military 

as a whole. For example, military psychiatrists must 

have an idea of realistic alternative duties available 

to a service member who is given a mental health 
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Military Psychiatry Graduate Medical Education

profile or is prescribed sedating medications. They 

must proactively liaison with unit leaders to minimize 

stress on the service member, to help the unit accommodate the service member’s duty limitations, and to 

limit adverse effect upon the unit’s mission. Military 

psychiatrists must have an appreciation for how long it 

takes an individual to be administratively or medically 

separated from the service and how peers are likely 

to treat that individual during the separation process. 

An additional concern for commanders is that a recommendation for an administrative separation may 

trigger a flurry of requests for separation from other 

service members. This is especially concerning during 

times of high operational tempo, when a unit’s attrition 

rate is a critical factor that can degrade the unit’s ability 

to accomplish its mission. Additionally, the psychiatrist 

should know something about financial compensation 

and other benefits available to veterans upon leaving 

active duty service.

Finally, and perhaps most importantly, knowledge 

refers to being intimately familiar with a host of military regulations and instructional manuals.2 Because 

of their obligation to protect units as well as individual 

service members, military psychiatrists must know 

the medical conditions that disqualify recruits from 

entering military service, as well as those conditions 

that require a recommendation for medical discharge.6

They must be familiar with the regulation that addresses the medical disability program and know 

how to conduct a separation history and physical 

examination.55 In addition to knowing which mental 

health conditions warrant medical separation, military 

psychiatrists must be familiar with regulations pertaining to administrative (nonmedical) separations, 

which differ for officer and enlisted personnel, and 

some of which require an evaluation and recommendation for discharge by a doctoral-level mental health 

professional. During these separations, knowledge of 

the psychiatrist’s role as either a patient advocate or a 

neutral evaluator is essential.58,59

As part of a safeguard to prevent coerced mental 

health referral of service members, military psychiatrists must be very familiar with the tenets of 

the DoD policy on command-directed mental health 

evaluations, including service members’ rights in such 

proceedings, the limits of confidentiality, the psychiatrists’ obligations, the personnel involved, specific time 

limits, and required documentation.3 This policy was 

implemented in 1993 in response to congressional-level 

concern that service members were being inappropriately referred for mental evaluations after blowing 

the whistle on suspicious activities within their commands.60 Deviation from the prescribed process could 

result in significant administrative sanctions against 

the military psychiatrist. 

Additional administrative duties that do not have a 

correlate in civilian mental healthcare include security 

clearance evaluations,5

 participation in suicide investigations and appropriate documentation of suicide 

attempts,61–64 and transportation of patients via the 

military aeromedical evacuation system.65 Regulations 

pertaining to basic charting standards, maintenance 

of military medical and mental health records, and 

dispositioning of retired records are other duties required of a military psychiatrist.54,66 Since September 

11, 2001, having an understanding of service-specific 

medical and mental health units, their placement on 

the battlefield, and the behavioral health officer’s specific roles and obligations during wartime has become 

even more critical for the military psychiatrist.67–69 Such 

knowledge could conceivably be acquired through a 

concentrated training period shortly after entering 

active duty,8

 but the depth and scope of such training 

would not remotely approach the training and experience gained from a 4-year military training program. 

The following case studies, as well as the others in 

the chapter (all from the clinical experience of one of 

the authors [WW]), demonstrate the benefits of such 

a program.

Case Study 42-1: A deployed Army psychiatrist identifies 

a number of immature and maladaptive coping skills in many 

of the soldiers she evaluated. Concerned about their ability 

to successfully complete the deployment, she recommends 

most of them for personality disorder separations under 

Chapter 5-13, Army Regulation 635-200.59 Even though 

some of these soldiers are aggressive and unpredictable, 

the majority of them are not separated. The frequency with 

which the psychiatrist recommended separation reduced her 

credibility with the unit’s commander, who ultimately stops 

following through on any of the psychiatrist’s recommendations whatsoever.

Case Study 42-2: A 25-year-old deployed Army aviation 

soldier comes to the mental health clinic requesting treatment for insomnia. The soldier describes initial insomnia 

related to worries about upcoming missions that involved 

flying into hostile territory. In addition to clarifying the soldier’s 

psychiatric symptoms, the psychiatrist asks him about his 

job and work schedule. Knowing that aviation personnel are 

grounded while using psychotropic medications, as well as 

realizing that the soldier’s job could require him to wake up 

in the middle of the night and quickly perform an equipment 

check prior to flying, the psychiatrist does not feel comfortable prescribing a sleep medication for the soldier. Instead, 

she provides him with instructions in deep breathing and 

progressive muscle relaxation and schedules him to attend 

a sleep hygiene class offered by the clinic.

Case Study 42-3: A soldier walks into the mental health 

clinic with a memorandum stating that he needs a psychological evaluation to get his security clearance renewed. 

Having just graduated from a civilian residency program, the 
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Combat and Operational Behavioral Health

psychiatrist is unaware that he should have received additional documents pertaining to the soldier’s background prior 

to the appointment and that the memorandum’s questions 

must be answered in a very specific fashion. He conducts a 

one-on-one assessment of the soldier and types up a letter 

stating that he thinks the soldier should be granted a security 

clearance. His letter is rejected by the requesting security 

agency because it does not address a key question raised 

during the background check and was not submitted in the 

proper format. 

Skills

Many of the skills required of military psychiatrists, 

including assessment, formulation, crisis management, 

consultation, and various psychotherapies, are taught 

in civilian training programs. Other skills, however, 

are required uniquely by military psychiatrists, and 

can only be learned by working within a military environment. Such skills are mastered through successful 

completion of a military psychiatry GME program 

followed by experience at the initial duty assignment. 

Military-related skills include the specific interpersonal 

skills required for interacting with individual patients 

as well as their patients’ commanders and military 

support personnel. Additionally, numerous technical and administrative skills related to both patient 

care and career management are required of military 

exhibit 42-3

UNIQUE SKILLS REQUIRED OF MILITARY 

PSYCHIATRISTS

Military psychiatrists must possess the ability to

	 •	 connect with service members who are

patients;

	 •	 connect with service members who are

not patients;

	 •	 connect with unit leaders;

	 •	 be a “salesperson” and an ambassador for

the field of mental health;

	 •	 provide appropriate interventions following traumatic events;

	 •	 interact within and among various military agencies;

	 •	 access pertinent regulations;

	 •	 format and write military memoranda;

	 •	 prepare official reports;

	 •	 provide quality care in austere environments;

	 •	 counsel subordinates; and

	 •	 prepare counseling statements, award recommendations, and performance reviews.

psychiatrists. Even unique clinical skills are required, 

particularly during times of overseas deployment 

(Exhibit 42-3).

Military psychiatry is not unique in requiring good 

interpersonal skills. However, the specific interpersonal skills required of a military psychiatrist are unique 

and vary depending upon the setting. For example, 

because some service members feel uncomfortable 

interacting with providers who do not maintain the 

decorum they expect of a military officer, the psychiatrist must maintain appropriate military bearing, yet 

not be so formal and rigid as to negatively influence 

the formation of a therapeutic alliance. Like patients 

in the civilian sector, service members will open up 

in a supportive, somewhat relaxed environment. A 

military psychiatrist who is too authoritative may 

have difficulty connecting with a service member 

who is having trouble with one or more supervisors, 

and thus may inadvertently create a barrier to care. 

Conversely, a style that is too casual may give service 

member patients permission to behave unprofessionally or spend excessive amounts of time at the mental 

health clinic—behaviors that will inevitably lead to or 

worsen preexisting occupational difficulties. 

Working with unit commanders requires an entirely different interpersonal skill set, consisting of a 

business-like attitude, a focus on data and regulations, 

emphasis on mission success, and a willingness to 

accept that the commander will not always seem appreciative of the psychiatrist’s efforts to help the unit 

or the soldier. Commanders often have preconceived 

negative opinions of mental health providers secondary to prior personal or family contacts with mental 

healthcare professionals, a perceived adversarial role, 

and a skewed opinion of the ability of mental health 

to enhance mission readiness.

As clinicians, psychiatrists are expected to maintain 

their clinical skills and to keep up with current medical literature. As military officers, they are expected 

to maintain their physical fitness and be familiar 

with current military tactics, procedures, and regulations. Often, the most challenging interpersonal skill 

required of a military psychiatrist is expert marketing 

to a population that may be resistant to receiving psychiatric assistance. Unlike their civilian counterparts, 

military mental health professionals must actively 

participate in primary prevention activities through 

education and outreach efforts for the units they support. By proactively getting to know their post’s units 

and commanders, they can reduce stigma associated 

with mental health interventions, an identified barrier to care.70 The ability of military psychiatrists to 

establish themselves as viable members of a unit’s 

healthcare team will enhance access to mental health-
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Military Psychiatry Graduate Medical Education

care for soldiers. Enhanced access to care is vital in 

an era of repeated combat operations when a large 

percentage of service members self-report operational 

mental health issues.71

Military psychiatry also requires a number of 

unique technical skills, many of which include researching and writing official correspondence and 

reports of various types (Exhibit 42-4).2 Failure to take 

the appropriate course of action or failure to document 

recommendations or actions in the correct manner 

could reduce the psychiatrist’s credibility, negatively 

impact the effectiveness of the unit, and potentially 

have lifelong consequences for uniformed patients. 

The military psychiatrist must be familiar with pertinent regulations, how to access the regulations, and 

how to apply them while providing high-quality 

mental healthcare for service members and commands. 

In the US Army, regulations dictate how a medical 

chart is prepared,54 what elements of the physical 

examination are required for a disability evaluation,55

how to schedule a command-directed mental health 

evaluation,3 what information must be provided to 

commanders after a command-directed evaluation,72

how to communicate recommended duty limitations 

to soldiers and their commanders,6 how to dispose 

exhibit 42-4

DOCUMENTS AND REPORTS PREPARED 

BY MILITARY PSYCHIATRISTS

	 •	 Clinical notes

	 •	 “Sick slips”

	 •	 Extended sick slips (eg, physical profile,

limited duty board)

	 •	 Safety precaution recommendations to

commanders 

	 •	 Security clearance evaluations

	 •	 Medical review officer findings

	 •	 Medical board narrative summaries

	 •	 Suicide line-of-duty statements

	 •	 Sanity boards

	 •	 Psychological autopsies*

	 •	 Military memoranda

	 •	 Standard operating procedures

	 •	 Counseling statements

	 •	 Officer evaluation report support forms

	 •	 Officer evaluation reports

	 •	 Award recommendations

	 •	 Line-of-duty investigations

*In the US Army, as of 2001, these are completed only by 

forensically trained psychiatrists.

of closed behavioral health charts,54 and even how to 

write in the “military style.”73 Significant failure to 

practice in accordance with these regulations could 

adversely affect a provider’s reputation, credentials, 

and medical license.

Technical skills required of military psychiatrists 

also include those relevant to their career progression 

and to that of their subordinates. If conducted appropriately, the military’s performance evaluation system 

ensures that service members are provided with timely 

feedback and ample opportunities to improve upon 

their deficits.74 Similarly, the military’s award system 

recognizes exceptional performance, providing incentives for exceeding the standard.75 Both mechanisms 

to recognize performance are complex and can be 

quite confusing, even to individuals with years of 

experience. Promotions and accompanying pay raises 

depend upon the ability to successfully navigate these 

two systems. All military leaders, including most 

military psychiatrists, are responsible for counseling 

and rating their subordinates, as well as for submitting 

award requests months before they will be presented. 

The psychiatrist must be familiar with subordinates’ 

accomplishments, know what level of award such accomplishments warrant, and what language to use to 

ensure the requested award is approved. Procedure 

and language is of equal, if not greater, importance 

when preparing performance reports, and information 

on these elements is not available in any official document. It is available primarily through mentoring and 

guidance by senior officers and supervisors. 

Military psychiatry GME programs provide 

trainees the opportunity to learn about the military 

performance rating system because trainees, like all 

military officers, require an annual evaluation report. 

Through formal instruction and individual guidance 

by a supervisor, trainees learn how to document personal goals and accomplishments.74 They also become 

familiar with the process of mentoring and evaluating subordinates, which they will most likely have 

to perform at their initial postresidency duty station. 

Trainees in civilian psychiatry GME programs do not 

have the same opportunity to experience the military 

rating system and thus are at a great disadvantage 

when evaluating other mental health professionals 

upon completion of residency training. 

Military psychiatry also requires unique clinical 

skills during deployment or other duty in austere 

environments. The practice of “combat psychiatry” 

requires the ability to conduct problem-focused 

interviews in suboptimal clinical settings with little 

privacy, loud ambient noise, extremes of temperature, 

and unreliable computer and telephonic support. 

Interventions must be brief (two to four sessions) and 
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Combat and Operational Behavioral Health

solution-focused. Long-term psychotherapy is not an 

option. The military psychiatrist must learn to trust 

the clinical capabilities of staff members, which often 

include enlisted mental health specialists with less 

than a year of training. Laboratory services are often 

very limited, commonly consisting of basic serology 

and urine screens only. The results of liver and thyroid 

function tests, drug levels, and advanced drug screens 

may take weeks to return, if they are available at all. 

Stocked medications are sometimes limited to one or 

two selective serotonin reuptake inhibitors (SSRIs), 

bupropion, one sleep agent, one benzodiazepine, and 

a first-generation antipsychotic such as haloperidol. 

Mood stabilizers, atypical antipsychotics, non-SSRI 

antidepressants, and stimulants may not be available at 

all. Subspecialty consultants are also difficult to access, 

and at times a military psychiatrist may be the only 

actual physician at the location. Such topics are integrated into the curriculum of military residencies to 

prepare trainees for successful practice in diverse and 

challenging environments. The following vignettes, 

as well as those elsewhere in the chapter, are illustrative of materials prepared for military physicians in 

training.

Vignette 42-1: A psychiatrist is treating a soldier who is 

extremely angry with his chain of command. He claims that 

his commander “plays favorites” and fails to take care of his 

subordinates’ basic needs. The soldier mentions several 

unsafe practices allegedly occurring in the unit and gives 

the psychiatrist permission to investigate. The psychiatrist 

discovers that an unusually high number of individuals within 

the soldier’s company are being seen at the mental health 

clinic, their charts all documenting similar complaints. He 

requests a meeting with the company commander to discuss 

the allegations. At the scheduled appointment time, the psychiatrist arrives in a pressed uniform, prepared with a briefing 

that includes specific data about recent behavioral trends in 

the unit, evidence-based information about how unsafe and 

unfair practices could contribute to reduced unit readiness, 

and very specific recommendations on how to improve the 

situation. The company commander states that he’s interested in trying to implement the recommendations.

Vignette 42-2: A new military psychiatrist was active in 

his residency’s psychotherapy interest group and authored 

several publications on dialectical behavioral therapy. One of 

his first patients as a division psychiatrist is a young woman 

with a very troubled past whom he diagnoses with borderline 

personality disorder. Intrigued by the case, the psychiatrist 

begins to see the patient for 50 minutes twice a week. 

Enlisted mental health specialists in the clinic complain to 

their noncommissioned officer in charge that the psychiatrist 

is always in session and is never able to staff cases. The 

patient herself seems to be getting worse and insists that 

she needs a sick slip excusing her from her upcoming field 

training exercise. At the end of the 4th week, the patient’s 

first sergeant accompanies her to the appointment and 

angrily asks the psychiatrist whether or not he understands 

the impact that her absence from the training exercise will 

have on the rest of the unit, and whom he expects to look 

after her while the unit is in the field.

Vignette 42-3: A deployed Army psychiatrist is working 

at a small base at a hostile location in Iraq. Late one night, 

he is sleeping in his cot at the back of his clinic tent when he 

is awakened by a weary-appearing soldier requesting help. 

The soldier is dirty, malodorous, and exhausted. Earlier in 

the day, he returned from a long convoy during which his platoon was attacked with small-arms fire and rocket-propelled 

grenades. He claims to be tense and worried about his wife, 

whom he has been unable to call in 2 weeks. He tearfully tells 

the psychiatrist that he is scheduled to go out again the next 

morning, but that he doesn’t feel like his “head is in the game,” 

and that he questions his ability to defend his comrades. The 

psychiatrist conducts a brief assessment and contacts the 

soldier’s commander to recommend he be removed from 

convoy duty for a couple of days and be allowed to participate 

in a “restoration” program offered by the clinic. 

Attitudes

The development of appropriate attitudes may 

seem less essential than the acquisition of sufficient 

knowledge and skills in the field of military psychiatry. However, psychiatrists who approach clinical and 

administrative tasks in the military with the wrong 

attitudes may inadvertently make their lives more 

stressful and find it difficult to achieve job satisfaction. 

They must adopt an attitude of selflessness and advocacy for patients while maintaining a skeptical eye for 

malingering. They may have to treat a patient while simultaneously providing support for the patient’s unit. 

They must adopt an attitude of flexibility and humility, 

including a willingness to take on challenging tasks for 

minimal recognition. Finally, they must excel in their 

role as a leader to ensure their subordinates receive the 

recognition and promotions they deserve.

The dual-agency role discussed earlier perfectly 

demonstrates the importance of having the right attitude for the job. Military psychiatrists must be willing 

to adopt a utilitarian viewpoint.76 They must regard the 

entire population of service members as their “patient” 

and endeavor to protect that “patient” from harm, even 

at the cost of violating the confidentiality of individual 

service members. Unforeseen violations of doctorpatient confidentiality are rare, but are necessary and 

appropriate if the identified patient is experiencing 

symptoms that could compromise the safety of the 

unit. Depending on the patient’s job, such symptoms 

might include poor concentration, sleep deprivation, 

errors in judgment, severe anxiety, profound depression, delusions, hallucinations, cognitive deficits, 

impaired impulse control, and of course, suicidal and 

homicidal fantasies.
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Military Psychiatry Graduate Medical Education

Military psychiatrists must be flexible and creative, 

satisfied with limited available resources and treatment capabilities, and moderately comfortable as the 

sole psychiatrist serving troop populations as large 

as 15,000.77,78 They must accept the inability to help 

everyone, a difficult concept to acknowledge for many 

psychiatrists, who presumably entered the field to help 

their patients live happier, more productive lives. Because of the high service-member-to-psychiatrist ratio, 

military psychiatrists must also believe in the power 

of primary prevention and commit themselves to the 

concept that psychiatric care begins in the foxhole, 

where troops help one another overcome adversity. 

Psychiatrists in the military should maintain an 

air of humility and understand that a caring friend, a 

chaplain, or a commander may be more effective and 

therapeutic than a mental health professional in certain 

situations. They must also accept that the title of “captain” or “major” is sometimes preferable to “doctor” in 

military units, because the former more clearly identifies them as a part of the military team. Additionally, 

they will come to realize that most of the troops they 

serve have no idea what the difference is between a 

psychiatrist, a psychologist, and a social worker. 

The military psychiatrist must be willing to work 

under and alongside other mental health professionals, such as psychiatric nurses, social workers, and 

occupational therapists. They must also be willing to 

place a great deal of trust in the clinical abilities of their 

enlisted mental health specialists, who are often the 

first providers to make contact with service members 

seeking treatment. These personnel serve a crucial 

role in triaging patients, performing and documenting 

initial assessments, conducting educational groups, 

providing supportive counseling, and managing acute 

crises, often with fewer than 12 months of mental 

health training.79 Mental health specialists in the Reserves and the National Guard may have completely 

unrelated civilian jobs, requiring an extensive amount 

of training prior to providing patient care. Military 

psychiatry training programs incorporate into the curriculum specific experience working with other mental 

health professionals and paraprofessionals. 

Operating in a military environment under close 

scrutiny also creates a number of unique challenges. 

Military psychiatrists must always remember they are 

representatives of the US armed forces. Many military 

bases are relatively small, and psychiatrists commonly 

encounter patients and their families at various locations on post and in the surrounding communities. 

Many military psychiatrists have had the experience 

of sharing a lunch table, a medical waiting room, and 

even a shower area with their patients. Such situations, 

while essentially unheard of in a civilian setting, are 

commonplace in today’s military environment, and 

uniformed psychiatrists must be capable of maintaining good military bearing and a professional demeanor 

at all times.

Case Study 42-4: A military psychiatrist is seeing an intelligence analyst who has had difficulty sleeping since she was 

switched to the night shift 4 weeks ago, and has had a limited 

response to sleep medications. Her energy and concentration 

have reached dangerously low levels and she has already 

made a couple of mistakes on the job. While recognizing the 

soldier’s right to seek treatment confidentially, the psychiatrist has valid concerns that his patient’s ability to accurately 

report important intelligence data may be compromised. He 

contacts the soldier’s commander to recommend that she 

be given a day shift job because of her compromised ability 

to perform her duties, knowing that her security clearance 

may be suspended as a result. 

Vignette 42-4: A military psychiatrist graduated with honors from an esteemed medical school on the East Coast and 

completed a civilian residency before joining the Army. She 

was used to wearing a white coat to work and having a large 

administrative staff to assist her. She was also accustomed 

to calling her staff by their first names and to joining them 

regularly at educational dinners sponsored by pharmaceutical companies. She has a very difficult time adjusting to the 

Army and feels disrespected by the other members of her 

department, whom she regards with an air of contempt. Her 

department chief, a psychologist, counsels her multiple times 

on the importance of being a team player and interacting 

regularly with the local commands. She ultimately deploys 

to Iraq, and as soon as possible following her miserable 15 

months in the desert, elects to resign from the Army. 

Vignette 42-5: A young soldier in Afghanistan walks into 

the combat stress control clinic in the middle of a chaotic 

afternoon. The psychiatrist, who is finishing up with one 

patient and has two more waiting to see him, just learned 

that a patrol from the base was attacked and that a unit is 

requesting a critical event debriefing. He missed lunch and 

has three phone calls to return, plus a tobacco cessation 

class to teach in 30 minutes. Noticing the new soldier standing in the entryway, he snarls at her and tells her she’ll have 

to come back unless it’s an emergency. The next morning 

the psychiatrist goes to the motor pool to catch a convoy to 

a neighboring base, and discovers that this soldier will be 

his driver. 

Future of Graduate Medical Education

Military psychiatry GME faces numerous pressures 

on different fronts. As emphasis on efficiency in the 

direct care side of the military healthcare system increases, a decision on whether GME should be financed 

within the system or contracted out to the civilian side 

may become necessary. Because the field of military 
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Combat and Operational Behavioral Health

psychiatry is distinctly different than its civilian counterpart, the training of psychiatrists outside the Army 

is less tenable than in other medical specialties. The 

large shift into the core competency movement will 

directly affect the structure and content of all training 

programs. The current conflicts in the Middle East 

and the GWOT will have direct effects on the future 

of GME in psychiatry as issues involving behavioral 

health gain even more national attention. 

The viability of GME within the military, because 

of its high costs, has always been debated. As medical services inside and outside the military strive for 

optimal efficiency, medical education is placed under 

increasing pressure because of the costly general 

apprenticeship model of medical education, which 

emphasizes personal experiences with teachers, mentors, and patients. Only through personal relationships 

with teachers and mentors and plentiful patient care 

experiences can a clinician develop sophisticated 

synthesizing capabilities. Traditionally, military GME 

was not affected as much as civilian training programs 

by the managed care model, but MTF commanders 

are now assessed by workload productivity via the 

relative value unit. GME-related tasks do not produce 

relative value units and therefore have no workload 

credit, a critical factor in whether the military decides 

to continue supporting GME with military and civil 

service faculty or contract the mission to nongovernment organizations. 

The competency movement carries some promise 

for transition from time-based experiences toward a 

competency standard independent of time. Although 

more applicable to procedure-dominant medical 

specialties, the development of treatment portfolios 

of medication and psychotherapy cases will benefit 

psychiatry, allowing more longitudinal, rather than 

cross-sectional, evaluations. The competency movement will also leverage psychiatry to develop more 

relevant clinical outcome measurements, enabling 

programs to start objectively measuring their trainees’ 

patient care skills.

The current conflicts in the Middle East and the ongoing GWOT will necessitate an elevated operational 

tempo for years to come and require that the mental 

wellness of all service members receive attention from 

the military. Added emphasis on treatment of posttraumatic stress disorder and traumatic brain injury 

must be incorporated into training programs. As proximity, immediacy, expectancy, and simplicity (PIES) 

principles and force sustainment and resetting efforts 

take on increasing importance in behavioral health 

force-shaping in all environments, further emphasis 

on military psychiatry doctrine in GME programs will 

become paramount. Because the overall number of 

matriculates from USUHS and the Health Professions 

Scholarship Program has decreased in recent years, increased recruitment efforts will be necessary to ensure 

adequate numbers of future psychiatrists. 

Summary

GME is an essential aspect of ensuring safe, highquality healthcare in the United States. Training 

programs for each medical specialty must abide 

by a specific set of requirements and guidelines 

and maintain available faculty to provide adequate 

physician-in-training supervision and mentoring. 

Psychiatry GME has very extensive didactic, clinical, and supervision requirements, resulting in the 

development of a comprehensive skill set over the 

course of the training period. Military psychiatry 

GME programs observe all of these requirements, in 

addition to providing education in military-specific 

behavioral health skills, which are essential for psychiatrists to function adequately in both garrison and 

operational environments. 

Lessons learned from military conflicts over the last 

40 years indicate that psychiatric trauma from war 

is a significant medical issue; this issue has become 

a prominent concern for American society. Service 

members returning from combat deployments can 

carry psychological scars that make reintegration 

into society challenging and stressful, affecting both 

veterans and their families. Military psychiatry GME 

programs have enhanced training in all aspects of the 

deployment cycle support process to ensure that military psychiatrists are prepared to address the varied 

needs of the military family during the deployment 

cycle. With behavioral health issues secondary to military service receiving extensive scrutiny in the media 

and by government agencies, military psychiatrists 

must be comfortable practicing in potentially highprofile environments, necessitating a comprehensive 

training experience.

With the anticipated long-term duration of the 

GWOT, military psychiatry GME will continue to be 

an essential aspect of military readiness. Ongoing 

refinement of behavioral health screening throughout 

the deployment cycle, treatment of psychiatric conditions related to combat stress, and deployment-related 

interventions for military families will require military 

psychiatry GME programs to be flexible in modifying military-specific training while complying with 

the standard requirements mandated by ACGME. 

Retention of qualified military GME program faculty 
689

Military Psychiatry Graduate Medical Education

as mentors, role models, and subject matter experts 

will ensure the continued development of competent 

military psychiatrists prepared to support US service 

members and their families. 

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600-24.

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index.html. Accessed November 25, 2007.

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Chapter 43

MILITARY FORENSIC Mental health

ELSPETH CAMERON RITCHIE, MD, MPH*

INTRODUCTION

THE PSYCHIATRIST AND THE CRIMINAL JUSTICE SYSTEM

Military Law 

Forensic Evaluations or “Sanity Boards”

Sanity Boards on Detainees

Courts-Martial Expert Consultants and Expert Witnesses

MALINGERING

PSYCHOLOGICAL AUTOPSIES

behavioral science consultation teams

SUMMARY

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

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

Avenue NE, 4th Floor, Washington, DC 20002

A portion of this chapter appeared as: Ritchie EC, Benedek D, Malone R, Carr-Malone R. Psychiatry and the military: an update. Psychiatr 

Clin North Am. 2006;29(3):695–707.
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INTRODUCTION

As the wars in Iraq and Afghanistan continue, the 

US military medical system is required to address 

many issues at the interface of psychiatry and the law. 

Service members with mental health consequences 

from war impact not just the healthcare system, but 

also the military justice and disability systems. This 

chapter highlights some of the most topical forensic 

issues facing military providers, attorneys, and the 

courts. 

The extent to which violent and aggressive behavior in the aftermath of deployment can be attributed 

to combat experience remains an area of debate and 

ongoing investigation.1–3 However, of the hundreds of 

thousands of veterans deployed in these wars, only a 

small subgroup has been involved in violent crimes. 

For this group, military forensic psychiatrists will be 

called upon to make determinations of competency 

and criminal responsibility and to inform the courts 

about the potential contributions of war-related distress or disorder to criminal behavior. 

Complicating the widespread occurrence of warrelated psychological disorders is the “signature 

wound” of these wars: traumatic brain injury (TBI). 

The numerous causes of head trauma include blast 

exposure, gunshot wounds, motor vehicle injuries, 

and other accidents. The severely wounded are 

routinely screened for head trauma; however, some 

soldiers who experience periods of unconsciousness may not present for treatment. They may later 

develop difficulty concentrating or irritability but 

be misdiagnosed or receive no medical treatment. 

More recently, updates in screening for TBI have been 

widely implemented. Now all deployed soldiers receive screening for TBI, as well as posttraumatic stress 

disorder (PTSD), upon their return from an overseas 

deployment. PTSD, although a well-recognized and 

validated psychiatric disorder, has also long been associated with malingering, allegedly for the purposes 

of both avoiding prosecution or punishment, and/or 

obtaining disability compensation.

Forensic psychiatry, psychology, and social work 

focus on the intersection of mental health issues and 

the law. Core topics include competency, criminal responsibility, sexual trauma, and disability. This chapter 

focuses on forensic psychiatry, rather than the other 

disciplines, as that is the best-developed discipline in 

the military; however, the concepts will apply across 

the disciplines. 

Military forensic psychiatrists currently serve in the 

US Army, Navy, and Air Force. Forensic psychiatry 

in the military has many similarities to forensic psychiatry as practiced in the civilian world, but some 

key differences exist. This chapter will accentuate 

some of the differences. It opens with a description of 

military law, determination of competency and criminal responsibility, and the role of expert witnesses in 

the courts-martial system. The next sections discuss 

malingering and psychological autopsies. Numerous forensic issues also relate to detainees. Although 

the care of detainees is presented in another chapter 

in this volume, this chapter will briefly discuss sanity boards on detainees and the behavioral science 

consultation team policies. A full discussion of the 

military forensic psychiatry issues and the military 

legal system is beyond the chapter’s scope but may 

be found in other sources.4–8 Several case examples, 

which are composites, are presented and are meant 

to illustrate principles.

Case Study 43-1: A soldier was returned from Afghanistan in the early years of the global war on terror (GWOT). 

After serving a hard 6 months there, he received an e-mail 

from a neighbor, saying: “I have seen a red pick-up truck in 

your driveway overnight the last few nights. What’s up?” The 

soldier applied for emergency leave, saying his mother was 

dying. The day after he returned home, he and his wife had 

a fight over his perceptions that she had a lover. He pulled 

his personal gun out of the nightstand and shot and killed 

her. He then turned the gun on himself. 

The Psychiatrist and the Criminal Justice system

Military Law 

The birth of American military law can be traced 

to the first American Articles of War, which consisted 

of 69 separate articles enacted by the Continental 

Congress on June 30, 1775, governing the conduct of 

the Continental Army.5,6 Congress enacted today’s 

Uniform Code of Military Justice (UCMJ) in 1950.8–10

The UCMJ combined the laws formerly governing 

the US Army, Navy, and Air Force into one uniform 

code. As a result, the US military has its own system of 

criminal justice with hierarchical sources of rights. In 

addition to the UCMJ, military law is based on the US 

Constitution, federal statutes, executive orders containing the Military Rules of Evidence (MRE), Department 

of Defense (DoD) directives, service directives, and 

federal common law. The US Constitution applies to 

service members unless superseded by military or 

operational necessity.9,10

The UCMJ established several levels of courtsmartial. General courts-martial are analogous to felony 

trials, and special courts-martial are analogous to mis-
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demeanor trials. The summary courts-martial, comparable to a justice-of-the-peace court, is a single-officer 

court with significantly limited authority.9 The Fifth 

Amendment of the Constitution specifically denies the 

right to grand jury indictment to service members.9 In 

place of the grand jury, the military states that no case 

may be referred to a general court-martial unless there 

has been a UCMJ Article 32 investigation.9

An Article 32 investigation is an open hearing designed to inquire into the facts of the case surrounding 

the charges. Although similar to both civilian preliminary and grand jury hearings, an Article 32 investigation is a more protective procedure because it affords 

the opportunity for discovery, to confront adverse 

witnesses, and to present evidence. Additionally, the 

recommendation of the Article 32 investigating officer 

is advisory only and not a final decision.9

Forensic Evaluations or “Sanity Boards”

The issue of criminal responsibility is addressed 

in many military settings, typically during Article 32 

hearings and special and general courts-martial. In accordance with Rule for Courts-Martial 706, if it appears 

to any commander who considers the disposition of 

charges, or to any investigating officer, trial or defense 

counsel, military judge, or court member, that there 

is reason to believe that the accused (or defendant in 

civilian legal proceedings) lacked mental responsibility for any offense, the fact and basis of the belief is 

transmitted ultimately to the officer authorized to 

order such an inquiry.10

Determinations of mental or criminal responsibility 

are referred to a board, commonly referred to as a “706 

board” or “sanity board.” Sanity boards determine 

the capacity of the accused to stand trial and address 

any other questions requested by the convening authorities, usually related to the clinical diagnosis and 

criminal responsibility. The board officially consists 

of one or more persons who must be either a physician or a clinical psychologist. Normally, at least one 

board member is either a psychiatrist or a clinical 

psychologist.10

Although not specifically required by the rule, a 

military forensic psychiatrist or psychologist is in 

many cases best qualified to serve as a member of 

the board.7,10 This is especially true for cases with 

complicated mental health issues or those involving 

very serious crimes, when the potential for appellate 

scrutiny of the sanity board findings is high. Military 

lawyers usually acknowledge the specialized training 

and experience that a military forensic psychiatrist or 

psychologist brings to sanity boards, frequently asking 

convening authorities and military judges to request 

such specialists to participate during assessments of 

criminal responsibility.7

According to Article 50a of the UCMJ, 

[i]t is an affirmative defense in a trial by court-martial 

that, at the time of the commission of the acts constituting the offense, the accused, as a result of a severe 

mental disease or defect, was unable to appreciate the 

nature and quality or wrongfulness of the acts.11

The above is often called the cognitive prong of the 

insanity defense (ie, that the accused knows the difference between right and wrong). This military standard, 

like the federal standard since the Insanity Defense 

Reform Act of 1984, does not include a volitional prong 

(eg, the capacity of the accused to conform his conduct 

to the requirements of the law). The burden of proving lack of mental responsibility falls on the accused, 

who must prove the defense by clear and convincing 

evidence. The court can then find the accused guilty, 

not guilty, or not guilty by reason of lack of mental 

responsibility.11

Because the accused is obligated to participate in 

the sanity board process, protections afforded to the 

defense limit discovery of the findings. Two reports 

are prepared: (1) a full report that includes all of the 

board’s findings and the basis for its opinions, and 

(2) an abbreviated report containing only the board’s 

ultimate conclusions on all questions specified in the 

order. The full report is furnished only to the defense 

counsel and, upon request, to the commanding officer of the accused. The full report may be released by 

the board (or other medical personnel) only to other 

medical personnel for medical purposes. Release of 

the full report to any person not authorized to receive 

it is allowed only pursuant to an order by the military 

judge. The abbreviated report is provided to the officer 

ordering the examination, the commanding officer of 

the accused, the investigating officer (if any) appointed 

pursuant to Article 32, and to all counsel in the case.8

 If 

the accused chooses to raise a mental health defense, 

the full report (redacted to exclude direct statements 

made by the accused) may become discoverable.

Case Study 43-1 (continued): The gunshots were 

heard by the neighbor who had previously sent the soldier 

the e-mail about his wife. The soldier survived, although 

with severe brain damage and hearing loss. The defense 

requested a sanity board, on the basis that the soldier had 

PTSD and traumatic brain injury, and therefore was neither 

competent to stand trial nor criminally responsible because 

of his PTSD.

Sanity Boards on Detainees

In July 2008, requests for “706 Boards” or sanity 

boards began to be made for the detainees at Guan-
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tanamo Bay. This author did four sanity boards that 

fall, until the trials ceased. While no individual issues 

are discussed here, a few thorny questions will be reviewed. Issues of culture and coercion are central. If a 

detainee discusses “djin” or spirits, is that psychosis 

or cultural belief? If he says that Allah made him do it, 

is that religiosity or terrorism? If he goes on a hunger 

strike, is that depression or coercion from other detainees? If it seems he cannot understand the questions, is 

that poor education, language difficulties, or deliberate 

refusal to cooperate with the examiners?

Courts-Martial Expert Consultants and Expert 

Witnesses

In accordance with MRE 706, “[t]he trial counsel, 

the defense counsel, and the court-martial have equal 

opportunity to obtain expert witnesses under Article 

46 [of the UCMJ].”10(p275) MRE 706 also allows for accused individuals to select expert witnesses at their 

own expense. MRE 702 states that 

[i]f scientific, technical, or other specialized knowledge 

will assist the trier of fact to understand the evidence 

or to determine a fact in issue, a witness qualified as 

an expert by knowledge, skill, experience, training, or 

education, may testify thereto in the form of an opinion 

or otherwise . . .10(p275)

MRE 703 addresses the bases of opinion testimony 

by experts. It states that 

[t]he facts or data in the particular case upon which 

an expert bases an opinion or inference may be those 

perceived by or made known to the expert, at or before 

the hearing. If of a type reasonably relied upon by 

experts in the particular field in forming opinions or 

inferences upon the subject, the facts or data need not 

be admissible in evidence in order for the opinion or 

inference to be admitted.10(p275)

Sources for these facts and data include stipulations of fact, investigative and police reports, medical 

and service records, testimony heard during a courtmartial, and personal and professional knowledge.10

However, MRE 403 states that an expert’s reliable and 

relevant testimony 

may be excluded if its probative value is substantially 

outweighed by the danger of unfair prejudice, confusion of the issues, or misleading the members, or by 

considerations of undue delay, waste of time, or needless presentation of cumulative evidence.10(p255)

MRE 704 allows experts to testify on the ultimate 

issue, stating that the expert’s “opinion or inference 

otherwise admissible is not objectionable because it 

embraces an ultimate issue to be decided by the trier 

of fact.”10(p275) MRE 705 allows the expert to testify 

in terms of opinion or inference and give the expert’s 

reasons therefore without prior disclosure of the 

underlying facts or data, unless the military judge 

requires otherwise. The expert may in any event be 

required to disclose the underlying facts or data on 

cross-examination.10(p275)

The defense may request an expert consultant if a 

sanity board’s opinions are deemed favorable to the 

prosecution, if mitigating factors might affect sentencing, or in both cases.6

 The expert may be either civilian 

or military. In accordance with a seminal military case, 

United States v Toledo, the defense must specifically request appointment of a confidential expert consultant 

for the consultant to be protected by the attorney–client 

privilege. Such requests are often subject to intense 

scrutiny during pretrial motions.7

 If the appointment 

is not granted, the military forensic psychiatrist may 

still function as an expert within the limitations of 

rules of discovery. 

The defense may request a military forensic psychiatrist or psychologist to testify during the merits 

phase (or “guilt phase”) or after conviction during 

the sentencing phase. For example, the expert witness 

may be asked to provide expert testimony during 

the merits or sentencing phases about the impact of 

combat-related PTSD, “Gulf War syndrome,” or the 

“Vietnam syndrome” on the mental state or behavior 

of the accused.12 In addition, the expert witness may 

be specifically asked to provide testimony on mitigating factors during the sentencing phase. For example, 

issues addressed by military forensic psychiatrists 

include the cumulative effects of sleep deprivation 

(secondary to combat stress or combat-related PTSD) 

and operational tempo on judgment and decisionmaking capacity. 

Either defense or trial counsel may request expert 

consultation if a sanity board reaches a conclusion that 

is not favorable to its side. In addition, sanity boards 

have been successfully challenged on the basis of thoroughness, accuracy, and misapplication of the proper 

military standard for criminal responsibility. 

 The military forensic psychiatrist may also be asked 

to provide expert testimony for the prosecution during 

the merits phase on counterintuitive behaviors of an 

alleged victim, such as “rape trauma syndrome” or 

“battered spouse syndrome.”13 Because the accused 

may not be compelled to submit to any psychiatric 

evaluation beyond that of a sanity board, any testimony on aggravating factors at sentencing is often 

limited to a review of collateral documents and obser-
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vation of the accused during the court-martial, which 

requires the military forensic psychiatrist to testify to 

this limitation.

Case Study 43-1 (continued): The sanity board did 

an extensive evaluation, including reviewing interviews of 

numerous witnesses, and a week-long assessment of the 

accused, including psychological testing. Although they 

agreed that he had PTSD, they did not think it rendered 

him not criminally responsible. The damage from the head 

wound did interfere with some of his activities of daily living. 

However, he knew the functions of the judge and jury and the 

basic elements of the case. He was able to cooperate with the 

defense attorney and to behave in the courtroom. Therefore 

he was found both competent and criminally responsible. 

Perhaps because of his diagnoses of PTSD and organic brain 

syndrome, he received a sentence of only 10 years. 

Board certification in the subspecialty of forensic psychiatry now requires completion of an accredited 1-year 

fellowship program, and then a board examination in 

forensic psychiatry. Currently only one forensic psychiatry program exists in the DoD—the National Capital 

Consortium’s Military Forensic Psychiatry Fellowship 

Program (in existence since 1992), located in Washington, DC. Recently a forensic psychology program 

was started there as well. In addition to the training 

requirements specified by the Accreditation Council for 

Graduate Medical Education, fellows receive training 

to serve as consultants and expert witnesses in courtsmartial involving military-specific offenses. 

Malingering

Case Study 43-2: A soldier presented to the combat 

stress control unit in Balad, Iraq. He had been in an improvised explosive device attack the day before. Two of his 

buddies had been severely wounded. He had hit his head 

against the hatch in the explosion, but was otherwise unhurt. 

His chief complaint was, “I just want to go home.” He said he 

might shoot himself if he could not. The brief screen for traumatic brain injury and for PTSD was negative. He also said 

he could not stop shaking. The junior psychologist thought 

he might have a factitious disorder (tremor).

Malingering has always presented a challenge for 

forensic psychiatrists, especially in the armed forces, 

where it can be a specific criminal offense under the 

UCMJ. Healthcare professionals are reluctant to label 

patients as malingerers for many reasons, including 

the perception that it is tantamount to accusing the 

individual of fraud and deceit. Clinicians, accustomed 

to using their skills to diagnose and treat those who 

seek help for problems, often feel uncomfortable when 

confronted with patients who seek not therapeutic 

assistance to improve their well-being, but rather 

“official” corroboration of an attempted deception. 

However, reluctance to diagnose an obvious case of 

malingering or, even worse, treating patients as if 

they had the feigned illness (perhaps seen as the path 

of least resistance), may actually violate the maxim of 

“primum non nocere” (first do no harm). Insulating the 

patient from the consequences of malingering might 

be tempting, with the shortsighted view that either the 

benefits accrued by a successful deception or avoiding 

the penalties associated with fraud would be in the 

patient’s best interest. This action may promote a dysfunctional psychosocial developmental process and 

foster longer-term negative effects. Military healthcare 

practitioners must find ways to make their ethical 

and fiduciary responsibility to act in the patient’s best 

interest coincide with the needs of the system. Such 

dual responsibilities, of course, are not limited to the 

military; therapeutic practice often requires balancing 

the individual needs of the patient with broader social 

obligations.

Malingering has a longstanding history of recognition in the military, as highlighted by “avoidance of 

military duty” topping the list of external incentives in 

its description in the Diagnostic and Statistical Manual of 

Mental Disorders.

14 This text describes malingering as 

the intentional production of false or grossly exaggerated physical or psychological problems, motivated 

by external incentives such as avoiding military duty, 

avoiding work, obtaining financial compensation, 

evading criminal prosecution, or obtaining drugs.14

Malingering may be viewed as adaptive behavior 

under extreme circumstances, for example, when a 

prisoner of war feigns illness to escape maltreatment. 

This issue has predictably come to the forefront of 

clinical practice during wartime. Malingering might 

increase in the attempt to avoid combat duty by 

service members who otherwise lack the antisocial 

tendencies usually associated with this behavior. In 

this context, malingering can also be seen as a maladaptive response in an extremely stressful situation.15,16

However, because military service in the United 

States is now voluntary, recruits know they are going 

to a theater of operations. In the author’s experience, 

soldiers are more likely to deny symptoms than to 

exaggerate them, a phenomenon known as “negative 

malingering.” 

The treatment of the malingering patient in combat 

is complicated by dual agency and ethical considerations. Although the motivation may appear as no 
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Combat and Operational Behavioral Health

more than a superficial attempt to return home, it is 

often predicated by a primal fear for personal safety. 

In either sense, individual malingering creates a concern for an “epidemic” of malingering within the unit. 

Furthermore, malingerers’ actions create a danger to 

the lives of their fellow soldiers, which creates a need 

for discipline and a duty to third parties when such 

deception has been detected. Military psychiatrists 

are challenged with balancing these considerations 

and the employment of limited therapeutic resources, 

including their own time and energies. Often the adage of “greatest good for the greatest number” dictates 

the type of treatment that can be offered in the combat 

zone, with substantial pressures to treat “bona fide” 

combat stress reactions, rather than “misconduct stress 

behavior.”

A “diagnosis” of malingering does not necessarily 

equate to the crime of malingering. Article 115 of the 

UCMJ describes the criminal offense of malingering 

as follows: 

Any person subject to this chapter who for the purpose 

of avoiding work, duty, or service (1) feigns illness, 

physical disablement, mental lapse or derangement; or 

(2) intentionally inflicts self-injury; shall be punished 

as a court may direct.10(p344)

Military law recognizes the two distinct forms of 

malingering—feigning illness and intentional selfinjury—with different punishments for each (greater 

for self-injury than for feigning illness). If the offense 

was committed in time of war or in a hostile-fire pay 

zone, the more serious offense of malingering to avoid 

combat duty brings even stronger penalties. Maximum 

prison sentences may range from 1 year for feigning 

illness in a noncombat situation to a maximum of 10 

years for intentional infliction of self-injury to avoid 

combat duty.

Again, although there is a perception that malingering is common, in today’s all-volunteer military malingering is probably much less common than believed. 

In actuality, it is the author’s belief that soldiers are 

far more likely to conceal psychiatric symptoms than 

to embellish. 

Case Study 43-2 (continued): The combat stress team 

treating soldiers in Balad was presented with a common 

dilemma. Should the team send him home, and therefore 

potentially have an epidemic of soldiers who had the same 

complaint of “I just want to go home”? The team members 

consulted with the division psychiatrist, who diagnosed a 

conversion disorder, rather than a factitious disorder. They 

elected to try the classic principles of combat psychiatry 

(eg, immediate treatment with the expectation of recovery 

and return to his unit). Unfortunately, the soldier did not 

respond and eventually had to be evacuated to Landstuhl. 

He was then evacuated to Water Reed Army Medical 

Center in Washington, DC, where he received numerous 

diagnoses. When he learned that he was going to be discharged from the Army, he ended his life by jumping off a 

bridge in Washington, DC. 

Psychological Autopsies

Before 2001, a report known as a “psychological 

autopsy” was required on every suicide in the US 

Army. After completion, it was submitted to the Army 

Surgeon General and the Walter Reed Army Institute 

of Research. These retrospective suicide investigations were designed to gather information from the 

soldier’s unit and family to provide lessons learned 

that might prevent future suicides. However, many 

of these postmortem investigations were performed 

by mental health officers who may not have had any 

specific training in this particular task. Investigators 

generated long narrative reports that seldom produced 

any feedback or change to the system. Furthermore, 

the report format made data extraction and analysis 

difficult. Another major issue of the psychological autopsies was who had access to their information. Before 

2001, psychological autopsies were accessible under 

the Freedom of Information Act, which resulted in violation of patient privacy. For example, a reporter from 

the Raleigh News and Observer published salacious and 

intimate details obtained from over 50 psychological 

autopsies from Fort Bragg, North Carolina.17

DoD changed the requirements for psychological 

autopsies first in a Health Affairs policy letter in 2001 

and later in a DoD directive in 2003.1,18 The policy requires a formal psychological autopsy only if the death 

were equivocal, that is, it was not known whether the 

death was a suicide, homicide, or accident. All suicides 

still must be evaluated. A DoD suicide event report 

is now generated for both attempted and completed 

suicides. If mental health personnel had been following 

the soldier, a quality assurance review—known as a 

root cause analysis—should be conducted. As part of 

the new requirement, practitioners must receive additional training in conducting psychological autopsies. 

The additional training should cover basics of crime 

scene investigation, physical autopsy procedures, 

toxicology, and understanding of suicidal behavior 

and determinants. Forensically trained psychiatrists 

have usually already received this training.19

Cases that require psychological autopsies tend to 

cluster in the following categories:

	 •	 an accidental or deliberate drug overdose;
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	 •	 an accidental or deliberate motor vehicle

accident;

	 •	 a gunshot wound, which may have been selfinflicted, accidental, or a homicide; or

	 •	 a hanging, which may have resulted accidentally from autoerotic asphyxia or intentionally 

from suicide. 

Case Study 43-3: A soldier in the Warrior Transition 

Unit was found deceased. In his room were found numerous pill bottles and an empty bottle of whisky, but no 

suicide note. The investigation found that he had recently 

gotten a divorce, but had seemed upbeat in the past several days. He had told his therapist that he was glad the 

divorce was finalized and was excited about the future. 

His command did not think it was a suicide. His family 

thought it might be a homicide, with his ex-wife giving him 

the pills for an overdose. The medical examiner agreed 

to a psychological autopsy. The results eventually supported an accidental overdose, although suicidal intent 

was suspected. 

BEHAVIORAL SCIENCE CONSULTATION TEAMS

Although psychologists have supported detention operations and interrogations for many years, 

the events of September 11, 2001 and the ongoing 

GWOT have required the unprecedented and sustained involvement of behavioral science consultants 

(BSCs) in support of both detention operations and 

intelligence interrogations/detainee debriefing operations. Prior to GWOT, support for these missions 

was provided by personnel organic to the intelligence 

and special operations communities. However, the 

expanded demand for BSCs to support these missions has required assignment of psychologists and 

forensic psychiatrists from other mission areas within 

the DoD. 

The Army is the executive agent for the administration of DoD detainee policy. The GWOT has resulted 

in the detention of large numbers of detainees by US 

forces. The intelligence interrogation and debriefing of 

detainees is a vital and effective part of the GWOT. It 

is designed to obtain accurate and timely intelligence 

in a manner consistent with applicable US and international laws, regulations, and DoD policy. Behavioral 

science personnel provide expertise and consultation 

to commanders to directly support the detention and 

interrogation/debriefing operations. 

BSCs are psychologists and forensic psychiatrists, 

not assigned to clinical practice functions, but to 

provide consultative services to support authorized 

law enforcement or intelligence activities, including 

detention and related intelligence, interrogation, 

and detainee debriefing operations. Because BSCs 

are not engaged exclusively in the provision of 

medical care, they may not qualify for special status 

accorded retained medical personnel or carry DoDissued identification cards identifying themselves 

as engaged in the provision of healthcare services. 

Analogous to behavioral science unit personnel of a 

law enforcement organization or forensic psychiatry 

or psychology personnel supporting the criminal 

justice, parole, or corrections systems, BSCs employ 

their professional training not in a provider-patient 

relationship but in relation to a person who is the 

subject of a lawful governmental inquiry, assessment, investigation, adjudication, or other proper 

action. 

BSCs function as special staff to the commander 

in charge of both detention and interrogation operations (ie, the Commander, Detainee Operations). BSCs 

should be aligned to report directly to this commander, 

not to one charged solely with command of the detention facility or Joint Interrogation Debriefing Center. 

This arrangement enhances the BSC’s ability to provide 

comprehensive consultation regarding all subjects 

within the BSC’s area of expertise on combined aspects 

of detention operations, intelligence interrogations, 

and detainee debriefings. Often behavioral science 

consultation to detention operations, intelligence 

interrogations, and detainee debriefings is conducted 

by individual BSCs working alone. 

“Behavioral drift”—the continual reestablishment 

of new, often unstated, and unofficial standards in an 

unintended direction—is commonly observed in detention and other settings in which individuals have 

relative control or power over others’ activities of 

daily living or their general functioning. It often occurs 

when established official standards of behavior are 

not enforced. Ambiguous guidance, poor supervision, 

and lack of training and oversight contribute to this 

change in observed standards. Certain psychological 

and social pressures can greatly increase the likelihood 

of behavioral drift. Drift is detrimental to the mission 

and may occur very quickly without careful oversight 

mechanisms and training 

The mission of a BSC is to provide psychological 

expertise and consultation to assist the command in 

conducting safe, legal, ethical, and effective detention 

facility operations, intelligence interrogations, and detainee debriefing operations. This mission is composed 

of two complementary objectives:

1. To provide psychological expertise in monitoring, consultation, and feedback regarding 
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the whole of the detention environment to 

assist the command in ensuring the humane 

treatment of detainees, prevention of abuse, 

and safety of US personnel. 

2. To provide psychological expertise to assess 

individual detainees and their environment 

and provide recommendations to improve 

the effectiveness of intelligence interrogations, detainee debriefings, and detention 

facility operations.

SUMMARY

The United States has historically been concerned 

about the successful adjustment of its military members returning from war. Although the greater population of war veterans will not be involved in criminal 

proceedings, a substantial minority will develop 

career-ending disabilities as a result of mental illness. 

In rare instances, these will be life-ending events. For 

a very small yet highly visible minority of returning 

veterans, questions about the cause, precipitants, 

and manner of death will necessitate psychological 

autopsies. This chapter highlighted recent updates 

in military forensic psychiatry and the mechanisms 

through which answers to questions of competency, 

criminal culpability, and motivation underpinning 

self-injurious behavior are determined within the 

US military. As the GWOT progresses, so, too, will 

the experience and study of combat-related mental 

health. Military judicial processes and the policies and 

procedures governing psychological autopsies must 

continue to evolve to meet increasing demands.

REFERENCES

1. Fontana A, Rosenheck R. The role of war-zone trauma and PTSD in the etiology of antisocial behavior. J Nerv Ment 

Dis. 2005;193:203–209.

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

Med. 2000;165(1):41–44. 

3. Epidemiological Consultation NO. 14-hk-ob 1 U 0-9. Investigation of homicides at Fort Carson, Colorado, November 

2008–May 2009, July 2009.

4. Lande RG, Armitage DT, eds. Principles and Practice of Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas 

Publishers, Ltd; 1997.

5. Lande RG. The history of forensic psychiatry in the US military. In: Lande RG, Armitage DT, eds. Principles and Practice 

of Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas Publishers, Ltd; 1997: 3–27.

6. Lande RG, Benedek DM. Forensic psychiatry in the United States military. J Am Acad Psychiatry Law. 1998;26(2):295–

304. 

7. Ritchie EC, Benedek D, Malone R, Carr-Malone R. Psychiatry and the military: an update. Psychiatr Clin North Am. 

2006;29(3):695–707.

8. Zonana HV. Legal regulations of psychiatric practice in the military. In: Lande RG, Armitage DT, eds. Principles and 

Practice of Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas Publishers, Ltd; 1997: 452–468. 

9. Gilligan FA. Military law. In: Lande RG, Armitage DT, eds. Principles and Practice of Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas Publishers, Ltd; 1997: 28–56.

10. US Department of Defense. Manual for Courts-Martial, United States. Washington, DC: DoD, Joint Service Committee 

on Military Justice, 2008. Available at: www.usapa.army.mil/pdffiles/mcm.pdf. Accessed December 4, 2009.

11. Uniform Code of Military Justice, 10 USC § 801–946 (2005).

12. Filbert BG. Disorder and syndrome evidence. In: Lande RG, Armitage DT, eds. Principles and Practice of Military Forensic 

Psychiatry. Springfield, Ill: Charles C Thomas, Ltd; 1997: 187–198.
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13. Ritchie EC. Reactions to rape: a military forensic psychiatrist’s perspective. Mil Med. 1998;163(8):505–509.

14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed, text revision. Washington, DC: APA; 2000.

15. Ritchie EC: Malingering and the United States military. In: Lande RG, Armitage DA, eds. Principles and Practice of 

Military Forensic Psychiatry. Springfield, Ill: Charles C Thomas, Ltd: 1997.

16. Malone RD, Lange CL. A clinical approach to malingering. J Am Acad Psychoanal Dyn Psychiatry. 2007;35:1,13–21.

17. Richissin T. When “tough it out” backfires. News and Observer. October 26, 1997:A1.

18. US Department of Defense. Armed Forces Institute of Pathology Operations. Washington, DC: DoD; 2003. DoD Instruction 

5154.30.

19. Ritchie EC, Gelles MG. Psychological autopsies: the current Department of Defense effort to standardize training and 

quality assurance. J Forensic Sci. 2002;47(6):1370–1372.
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703

Women, Mental Health, and the Military

Chapter 44

women, mental health, and the 

military

DEBORAH CROWLEY, MD*; TRISHA BENDER, MD†; ASHLEY CHATIGNY, DO‡; TINA TRUDEL, PhD§; and

ELSPETH CAMERON RITCHIE, MD, MPH¥

INTRODUCTION

PSYCHOSOCIAL STRESSORS IN MILITARY SERVICE

Physical Fitness

Job Assignment

Location and Social Support

Deployments

Pregnancy

MENTAL HEALTH DISORDERS IN WOMEN

Schizophrenia

Depression

Bipolar Disorder

Anxiety Disorders

TRAUMATIC BRAIN INJURY IN WOMEN

Background

Traumatic Brain Injury, Gender, and Outcome

Psychological Sequelae of Traumatic Brain Injury in Women

Family and Vocational Issues for Women Following Traumatic Brain Injury

SUMMARY

*Captain, Medical Corps, US Army; Child and Adolescent Psychiatry Fellow, Department of Psychiatry, Tripler Army Medical Center, 1 Jarrett White 

Road, Honolulu, Hawaii 96859

†

Major, Medical Corps, US Army; Division Psychiatrist, 25th Infantry Division Headquarters, Building 580, DIVSURG CELL, Schofield Barracks, 

Hawaii 95857-6000; formerly, Child and Adolescent Fellow, Tripler Army Medical Center, Honolulu, Hawaii 

‡

Captain, Medical Corps, US Army; Fellow, Department of Child and Adolescent Psychiatry, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, Hawaii 96859-5000

§

Site Director, Defense and Veterans Brain Injury Center at Virginia NeuroCare, 1101-B East High Street, Charlottesville, Virginia 22902; Assistant 

Clinical Professor of Psychiatry and Behavioral Neurobehavioral Sciences, University of Virginia Medical School, Charlottesville, Virginia 22902; 

formerly, Executive Director, Lakeview NeuroRehabilitation Center, Effingham Falls, New Hampshire 

¥

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

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

Avenue NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

Before the military operations in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation 

Iraqi Freedom [OIF]), reproductive and gynecological 

issues dominated the medical concerns of most women 

in uniform. What was important to female soldiers was 

how to juggle family and career, with the occasional 

deployment to Korea, Somalia, or Kosovo, for a period 

of 6 to 12 months. “How do I manage with a baby? 

How do I figure out breastfeeding when I go to the 

field? How do I keep clean when the porta potties are 

all stinky and I’m having my period in the field? How 

do I deal with that?” 

Since the terrorist attacks of September 11, 2001, the 

world for female soldiers has changed. Women still constitute about 15% of the military. In the US Army, women 

are not still assigned in technical combat units, such as 

infantry and artillery. However, they are definitely and 

clearly in combat. Women are military police and truck 

drivers, as well as involved in a wide range of other fields 

where they have to be prepared to defend themselves. In 

the other military services, they do have technically combat roles. Because there are no safe lines anymore and no 

rear areas, women are increasingly being wounded and 

killed, although clearly not as frequently as men. 

PSYCHOSOCIAL STRESSORS FOR WOMEN IN MILITARY SERVICE

It is no surprise that life in the military brings a 

unique set of psychosocial stressors to women who 

serve. A multitude of expectations need to be met to 

succeed in the military, including a high level of physical fitness, extended work hours, a far-reaching network of rules and regulations, and 24-hour availability 

for duty. Service members can also be deployed at short 

notice, for varying lengths of time, and to almost any 

continent around the globe. Many potential benefits to 

military service also exist, such as employment stability, financial incentives for higher education, a unique 

camaraderie, and family support. The following section addresses unique challenges that can affect female 

service members and can have a significant impact on 

their mental health.

Physical Fitness

All service members are expected to maintain physical fitness to perform their jobs. Although each service 

has its own particular standards of fitness, there are 

more similarities than differences. Physical aptitude is 

measured in an annual or semiannual formal fitness 

test that evaluates muscular endurance and aerobic 

capacity. 

Each service also has standards established for 

varying categories of height and weight of each member.1

 This is also based on age and gender. If service 

members exceed the maximum allowable weight, they 

must meet a standard body fat percentage. Soldiers, 

both male and female, will frequently use various 

methods to meet the weight standards. Some of these 

methods involve physician-approved diet and exercise 

regimens. However, various other methods are used, 

to include crash diets, extreme exercise regimens, 

and alternative approaches, such as body wraps and 

wearing sauna suits. In some cases, this can result in 

development of an eating disorder, which is addressed 

in more detail in other chapters. 

Physical fitness is an obvious requirement for successful military service, with different jobs requiring 

different levels of physical strength and endurance. 

Generally speaking, male soldiers are expected to 

run faster and have greater muscular strength than 

female soldiers. This is based on the physical differences in muscle mass and distribution between the 

sexes. However, male and female soldiers are often 

required to complete the same physical tasks. For example, soldiers on jump status are expected to bear a 

certain load when they exit an aircraft, and that load 

is the same whether the parachutist is male or female. 

During deployments, female soldiers are required to 

wear the same load of combat gear as male soldiers. 

Completing these tasks is generally more difficult for 

female soldiers than for male soldiers, again because 

of the differences in body composition, muscle mass, 

and average size of each gender. This often becomes an 

added stressor for female soldiers, expected to meet the 

same standards as their male counterparts, but beginning with a different physiological makeup. 

If service members exceed the maximum allowance 

for body fat percentage, they are enrolled in a weight 

control program, which can include monthly weighins, mandatory classes and meetings with a nutritionist, and a specialized physical fitness regimen. If they 

fail to meet the standards for the physical training test, 

they can be enrolled in specialized physical training 

regimens. For physical training failure, soldiers can 

be barred from favorable actions, which can prevent 

them from being promoted, going on leave, or receiving 

awards. Soldiers can also be administratively separated 

from the service if they consistently fail to meet physical fitness standards.2

However, compared to their civilian counterparts, 

female soldiers may actually have an advantage by being expected to be physically fit. Studies have shown 
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Women, Mental Health, and the Military

that regular exercise regimens decrease the incidence 

or severity of symptoms of depression and anxiety.3,4

Exercise can be a very valuable coping skill to deal with 

the other stresses that the military imposes, both in and 

of itself, as well as in its role in improving sleep.

Job Assignment

For enlisted service members, military job opportunities are often assigned based on a test score resulting 

from the Armed Services Vocational Aptitude Battery 

(ASVAB).5 Many enlistees enter the service with an 

idea of the type of job they would like to have, but there 

is no guarantee the service will offer them the specific 

job they desire. Many soldiers are offered a limited 

number of jobs, and it can be quite upsetting when it 

is not something they are interested in. This often sets 

the stage for how soldiers will either look forward to, 

or dread, the time for which they have committed to 

serve. This is in contrast to employment in the civilian world, where most people are able to turn down 

the job they do not want or simply interview with a 

different employer. 

These same job assignment constraints also apply 

to commissioned officers. Officer candidates are given 

the opportunity to submit a preference list for their 

branch assignment. These assignments, however, are 

first and foremost based on the needs of the military; 

officer preferences are secondary. It can be a significant 

long-term stressor for someone who, for example, 

wants to be an aviator but is instead assigned to the 

Quartermaster Corps. Female soldiers are restricted to 

the noncombat arms branches with a few exceptions—

such as aviation and field artillery. For some women 

this is frustrating because they believe that if they can 

meet the same physical and technical standards of the 

job as men, they should be given the opportunity to 

perform that job. For other women who do not desire 

these jobs, the restrictions are a relief because they, 

unlike their male counterparts, do not run the risk of 

being assigned to them.

Location and Social Support

The military is a culture in which its people are 

expected to adapt to change. This change appears 

in many different ways—living environment, daily 

routine, job assignments, command as well as peer 

composition, and structure. For some individuals, 

the change is welcomed, and for others the change is 

dreaded. For all, it poses a significant stressor.

Many people join the military as an opportunity 

to travel the world. Frequent moves are often experienced, whether desired or not. Soldiers can voice 

a preference in assignment location, but ultimately 

service members are distributed according to the needs 

of the military. For young enlisted service members, 

basic training is often the first time away from home 

for an extended period of time. This removes them 

from everything that is familiar to them—families, 

friends, homes, daily routines, jobs, and ways of life. 

They are limited in their contact with their main social support network, and placed in an environment 

where they are told how to dress, how to walk, how 

to behave, and what to value. Most of these soldiers 

are relatively young, without a firm idea of who they 

are or their plan for their lives. This is a stressful time 

for all service members, male or female.

The nature of the military requires soldiers to be 

mentally and physically strong, bold, and aggressive. 

Society has traditionally reserved these characteristics 

for men, but recently women in the military have assumed an increased presence in customarily male 

roles, both as a result of changes in the country’s social 

values and the needs of the military.6

 In these surroundings, young female soldiers away from home for 

the first time all too often succumb to the temptation to 

engage in unhealthy behavior to fit in and be viewed as 

part of the team. This is their attempt to develop a new 

social support network in this stressful environment, 

as well as to be accepted by male colleagues. 

Deployments

Deployments are another major source of change 

unique to military service. At short notice, soldiers 

can be taken from the daily routine they have been 

accustomed to and transported halfway around the 

world for months at a time. This usually includes 

time away from loved ones, although the military has 

greatly improved deployed soldiers’ opportunities to 

communicate with loved ones back home.

Deployments can also mean harsh field conditions 

or climates to which the soldier is not accustomed. 

These austere conditions have an impact on personal 

privacy on a daily basis. Most significantly, deployments can place soldiers in situations of unpredictable 

or even certain danger with a threat to their lives. Any 

field situation, whether a training exercise at their 

home station or a deployment abroad, poses significant 

difficulties in the area of personal hygiene for female 

soldiers, who have to be prepared to deal with daily 

hygiene associated with menstruation even while in 

the field. Facilities for changing and disposing of hygiene products are not always available in the field, 

and time availability to take care of hygiene is often 

an issue as well. In addition to menstruation, urination is another stressor for female soldiers. During a 

field exercise, this becomes a matter of both privacy 

and convenience. However, during a deployment it 
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Combat and Operational Behavioral Health

can be a significant safety issue as proper wear of 

protective gear and avoidance of hostile fire become 

considerations.7

Deployments have become more common and more 

frequent for military service members over the last few 

decades. Recent studies estimate that soldiers entering 

the service today will have an average of 14 deployments over a 20-year career.8

 These include both combat deployments and peacekeeping missions. Studies 

have shown that service members generally want the 

opportunity to do what they have been trained to do, 

and most will find meaning in serving on a deployment.9

 However, over time, the stressors of a deployment will begin to take their toll on the physical and 

mental well-being of soldiers.

Deployment length appears to be a factor in the 

development of mental health problems for service 

members. Several studies have indicated that the 

longer a deployment lasts, the more psychological 

stress soldiers will experience, which, in turn, leads to 

development of symptoms such as depressed mood, 

sleep disturbances, increase in anxiety, and impairment 

in concentration.10 Most of these studies, however, focused on male soldiers. A study done by Adler and colleagues demonstrated that this relationship between 

length of deployment and stress may not be true for 

female soldiers. This may be related to a physiologic 

difference in stress response between men and women, 

a topic that in itself needs further research.10

Pregnancy

Pregnancy is a major stressor to military and nonmilitary women alike. There are physical changes, potential health problems, hormonal variations, and the 

adjustment to becoming a mother. In accordance with 

service-specific regulations, pregnant service members 

are given a medical profile, excluding them from regular unit physical training.11 This makes them exempt 

from formal physical fitness testing during pregnancy 

and for 180 days after delivery of the baby. 

Restrictions are placed not only on physical fitness 

requirements, but also on duty hours and tasks. This 

is to prevent potential complications in the pregnancy, 

for which the rate is already higher for women in 

the military than for their civilian counterparts.12 For 

example, after the 28th week of pregnancy the Army 

limits female soldiers to 8 hours of work at one time 

and 40 hours of work in a week.12 There are also restrictions that prevent working in motor pool areas, 

rifle ranges, from heights, or on aircraft. This can have 

varying effects on service members, depending on 

their assigned job and unit. For instance, for a female 

military physician, although this will reduce work 

hours and prevent being on call overnight, otherwise 

there may be little change to the daily routine. For a 

mechanic, however, a temporary job reassignment 

may be needed. Not only would this require a service 

member to learn a new job and adjust to a new work 

schedule, but her work as a mechanic would still need 

to be done by someone else in the unit.

The scenario with the mechanic poses yet another 

stressor for pregnant service members—potential 

social conflicts with her unit mates. As service members can be overtasked and overworked at baseline, 

extra work left by a pregnant service member is rarely 

welcomed. This can lead to resentment of the pregnant 

soldier by the other soldiers in the unit. In some units, 

however, just the opposite can happen. In cohesive 

units, soldiers rally around teammates who are facing 

challenges, and the resulting support can be much 

greater than what is found in civilian workplaces. 

The combination of a pregnancy and a pending 

deployment presents unique challenges. Because 

pregnancy precludes female service members from 

deploying,12 there is sometimes a perception that the 

service member intentionally became pregnant to 

avoid deploying. Not only can this prevent deployment, but the military also offers administrative separation for enlisted members who become pregnant.13

This can be seen by other soldiers as an abandonment 

of duty and obligation, regardless of the true intent 

of the pregnancy.

After the baby arrives, if the pregnancy is without 

complications, the service member is allotted 6 weeks 

of maternity leave. After these 6 weeks, the service 

member is expected to return to regular duty hours 

with her assigned job, although she is still exempt from 

physical fitness testing for 180 days postpartum. If the 

delivery required a Caesarean section, she may have 

difficulties with sit-ups. Women may have additional 

challenges meeting the military’s weight standards 

following pregnancy, even when given this 180-day 

recovery period.14

The US Army Center for Health Promotion and 

Preventive Medicine has now developed and disseminated a pregnancy physical training program for 

female soldiers. The “long-range goal of this program 

is to reduce the impact of pregnancy on individual 

soldier fitness and unit readiness by mitigating losses 

from attrition and reduced fitness.”15 Service members 

also continue to be nondeployable for 6 months following delivery, after which time they are expected 

to deploy like any other service member. Soldiers can 

choose to waive this 6-month “bonding period” and 

deploy shortly after delivery.16

One psychiatrist related his experience of deploying with a unit that contained several female 

soldiers who had chosen to waive their option to 

remain behind during their allowed bonding pe-
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Women, Mental Health, and the Military

riod.17 These female soldiers cited various reasons 

for their decisions, including not wanting to let 

their fellow soldiers down and wanting to perform 

the jobs they were trained to do. However, once 

deployed these women had significant problems, 

both mentally and physically. They experienced 

the expected emotional issues associated with being separated from their newborns. Physically they 

had not yet recovered from 9 months of pregnancy 

and subsequent childbirth. Many of these soldiers 

developed depression, and for some this led to 

suicidality. Not only did this scenario have a significant impact on the individual soldiers, but in 

turn it became an additional stress to their units in 

the deployed environment.17

This section addressed some of the psychosocial 

stressors unique to women in the military; however, it 

is not comprehensive. Some female service members 

are readily able to adapt and cope with these stressors, 

but for others they can lead to development of a mental 

illness. The rest of this chapter will address specific 

diagnoses in further detail.

MENTAL HEALTH disorders IN WOMEN

Although women are affected by the same major 

mental illnesses as men, there have been key differences noted in studies and a review of the literature 

of women’s mental health. These differences, such as 

history of presentation and course of illness, have an 

important impact on diagnostic and treatment considerations for the female patient. Furthermore, pregnancy, breastfeeding, perimenopause, and menopause 

can complicate mental well-being. This section will 

first consider each major mental illness separately.

Schizophrenia

Even though the ratio does not differ between genders, the onset of the disorder occurs later in women 

than in men (20–29 vs 15–24). A small percentage of 

women have their first psychotic episode in their 

forties.18 Women are more likely to have a good premorbid functioning history prior to their illness and 

during the course of their illness, display more positive 

symptoms with affective signs, and experience fewer 

negative symptoms than men.

Treatment of schizophrenia in the female patient 

does not differ from the standard practice guidelines, 

but a few gender-specific situations do occur. Some 

antipsychotic medications (risperidone, haloperidol) 

can induce hyperprolactinemia (normal prolactin 

5–25 ng/ml), thus causing menstrual irregularities 

or amenorrhea (prolactin over 60 ng/ml). In cases in 

which the medication cannot be switched or lowered, 

the hyperprolactinemia could be managed by adding 

the dopamine agonist bromocriptine (2.5–7.5 mg twice 

daily) or cabergoline (0.5 mg/week).19 Alternatively, 

oral contraceptives could be used to restore the menstrual regularity disrupted by the hyperprolactinemia, 

in addition to providing contraception.

Women with schizophrenia are at high risk for 

unplanned pregnancy because of ineffective use of 

contraception and high rates of sexual assault. Prevention should include counseling about preferred 

choice of birth control, sex education, and psychosocial 

support. Patients with schizophrenia who do become 

pregnant require frequent monitoring. Reemergence 

of psychotic symptoms can lead to failure to obtain 

prenatal care, paranoid delusions about the medical 

team that prevent cooperation, poor self-care, and 

adverse pregnancy outcomes (ie, low birthweight, low 

Apgar scores, prematurity). These factors, in addition 

to previous functioning, must be considered when 

deciding treatment during pregnancy.

There are limited data on the effects of antipsychotic medications on the fetus. Some data showed 

no increased risk of congenital malformation with 

high-potency agents (haloperidol and trifluoperazine), although low-potency phenothiazines appear 

to have a higher incidence of nonspecific congenital 

anomalies and neonatal jaundice.20 The newer atypical antipsychotics have only a few case reports. These 

do not indicate adverse effects; however, with their 

small numbers, these reports give the clinician little 

guidance. With either the decision to treat with medication or to watch symptoms, the patient will need 

close follow-up and involvement of any psychosocial 

supports that the patient has enlisted.

Depression

The prevalence of unipolar depression for women 

is statistically higher (10%–25%) compared to men 

(12%).21 Dysthymia is twice as prevalent in women as 

in men.22 Similarly, seasonal affective disorder is also 

more prevalent in women than men.23 Although the 

symptoms of depression do not differ significantly 

between the sexes, women are at risk for depressive 

episodes during reproductive transitions such as 

premenstruation, pregnancy, postpartum, periomenopause, and menopause.

Premenstrual dysphoric disorder (PMDD) is listed 

as a mood disorder not otherwise specified in the 

fourth edition of the Diagnostic and Statistical Manual

(DSM-IV-TR) of the American Psychiatric Association, which describes the severe spectrum of recurrent 
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physical and emotional symptoms associated with 

the late luteal phase of the menstrual cycle, which 

resolve with the onset of menstruation. The physical 

symptoms include headaches, cramping, breast tenderness, and bloating, while the emotional symptoms 

include depression, irritability, anxiety, and insomnia. 

After ruling out other causes of symptoms (including other medical and psychiatric disorders such as 

unipolar depression, dysthymia, and anxiety), PMDD 

can be monitored with daily symptom charting over 

a 2-month period. Treatment is based on the severity 

of symptoms and ranges from nonpharmcological 

approaches, such as sleep hygiene, relaxation therapy, 

and cognitive-behavioral therapy, to the addition of 

selective serotonin reuptake inhibitors (SSRIs) for the 

more severe cases.

Maternal depression during pregnancy creates risks 

for both the woman and her children, such as alcohol 

abuse, poor nutrition, failure to obtain adequate prenatal care, and suicidal behaviors. Obstetrical complications have also been studied and have shown increased 

risk for slow fetal growth,24 small infant head circumference,25 and increased risk of preterm delivery.26

The US Food and Drug Administration (FDA) uses 

a pregnancy rating system27 to guide clinicians on 

potential safety of a medication during pregnancy or 

lactation (Exhibit 44-1). However, the rating system 

does not always reflect the available data. Also, there 

can be some lag time before new data are incorporated 

into the system. It is important to note that to date, 

in the absence of controlled trials, the FDA has not 

approved any medications for use during pregnancy 

or lactation. Thus, it is important to obtain informed 

consent with each patient about the risk-to-benefit ratio 

when using a psychotropic. 

When medications are used in pregnancy, the 

EXHIBIT 44-1

US FOOD AND DRUG ADMINISTRATION CATEGORIES and labeling requirements

FOR DRUG USE IN PREGNANCY

Pregnancy Category:

 A Studies in pregnant women have not shown that (name of drug) increases the risk of fetal abnormalities if 

administered during the first (second, third, or all) trimester(s) of pregnancy. If this drug is used during pregnancy, the possibility of fetal harm appears remote. Because studies cannot rule out the possibility of harm, 

however, (name of drug) should be used during pregnancy only if clearly needed.

B Reproduction studies have been performed in (kind(s) of animal(s)) at doses up to (x) times the human dose 

and have revealed no evidence of impaired fertility or harm to the fetus due to (name of drug). There are, 

however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly 

needed.

C (Name of drug) has been shown to be teratogenic (or to have an embryocidal effect or other adverse effect) in 

(name(s) of species) when given in doses (x) times the human dose. There are no adequate and well-controlled 

studies in pregnant women. (Name of drug) should be used during pregnancy only if the potential benefit 

justifies the potential risk to the fetus.

 D (Name of drug) can cause fetal harm when administered to a pregnant woman. (Describe the human data and 

any pertinent animal data.) If this drug is used during pregnancy, or if the patient becomes pregnant while 

taking this drug, the patient should be apprised of the potential hazard to a fetus.

X (Name of drug) may (can) cause fetal harm when administered to a pregnant woman. (Describe the human data 

and any pertinent animal data.) (Name of drug) is contraindicated in women who are or may become pregnant. 

If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient 

should be apprised of the potential hazard to a fetus.

Data source: Code of Federal Regulations,Title 21, Volume 4, Revised as of April 1, 2008 (21CFR201.57). Available at: https://www.

accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=201.57. Accessed September 2, 2009.
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Women, Mental Health, and the Military

minimal effective dose should be administered. That 

is, the dose that effectively treats a patient’s symptoms without unduly exposing the fetus to higher 

than necessary doses. To date, the SSRIs, in particular 

fluoxetine, have the most extensive published data 

about their use during pregnancy. One study on the 

long-term neurobehavioral effects of SSRIs during 

pregnancy compared children exposed to fluoxetine, 

or a tricyclic antidepressant, or no antidepressant. No 

significant differences between the three groups were 

noted.28 All SSRIs have FDA risk category of “C,” 

with the exception of paroxetine, which has a risk 

category of “D” and is not recommended for use during pregnancy. In the United States, physicians have 

increasingly prescribed bupropion during pregnancy 

to treat depression, apparently as a consequence of its 

FDA “B” risk category. However, there are currently 

no published data regarding its safety or tolerability 

during gestation.

The postpartum period can be a particularly vulnerable period for a woman, with up to 85% of women 

experiencing postpartum “blues” within the first 2 

weeks after giving birth. This condition usually remits 

spontaneously, and thus treatment is not required. 

However, psychoeducation of physician and patients 

to distinguish postpartum blues from a more serious 

condition, postpartum depression, is warranted. The 

prevalence of postpartum depression is about 10%. 

Any previous history of depression significantly increases the woman’s risk dramatically. A history of 

PMDD prior to conception increases her risk for developing postpartum depression to 24%. An episode 

of depression endured during pregnancy increases the 

risk of postpartum depression to 35%. Any woman 

with a prior history of postpartum depression has a 

50% to 60% risk of developing postpartum depression 

during subsequent pregnancies.29 Treatment is multimodal and includes psychoeducation, individual and 

group psychotherapy, support (community resources), 

and pharmacotherapy. Breastfeeding should be discussed thoroughly as all psychotropic medications 

pass through breast milk and there are limited data 

establishing the effects on the infant. For the patient 

whose depression is complicated by psychosis or suicidality, hospitalization is generally required until the 

patient is no longer dangerous to self or others. Postpartum psychosis is considered an acute emergency 

and reason for acute admission, as it carries a risk of 

infanticide (1/1,000) if left untreated, in addition to the 

risks to the mother associated with psychosis.

Bipolar Disorder

 Bipolar disorder occurs in 1% of the population and 

is equally prevalent in men and women. Women tend 

to experience more depressive and mixed episodes 

than men, with fewer manic episodes. This may lead 

to diagnosis of unipolar depression and treatment with 

antidepressants, which then exacerbates the condition 

and results in rapid cycling—a condition seen more 

often in women than in men.30 Another precipitation 

of rapid cycling is thyroid dysfunction, which can be 

caused by lithium-induced hypothyroidism. Women 

are at greater risk for thyroid dysfunction than men, 

thus levels of thyroid stimulating hormone should 

be checked every 6 months for any woman receiving 

lithium.

Management of bipolar disorder can be particularly 

challenging during the perinatal period because the 

current first-line agents either have known teratogenicities, are associated with congenital malformations, or have little data to support their safety during pregnancy or lactation. In particular, lithium has 

been demonstrated to increase the risk for Ebstein’s 

anomaly (also called Ebstein’s malformation, in which 

the tricuspid valve is abnormally formed) from 1 in 

20,000 to 1 in 1,000 when the fetus is exposed during 

organogenesis.31 Exposure later in gestation can lead to 

fetal or neonatal cardiac arrhythmias, fetal hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, 

or premature delivery.32,33 The American Academy of 

Pediatrics discourages the use of lithium during lactation. This recommendation is based on a study that 

revealed that infant serum levels are double maternal 

serum levels postbreastfeeding. Lithium use during 

lactation is also correlated with adverse events such 

as lethargy, hypotonia, hypothermia, and electrocardiogram changes.34

Prenatal exposure to valproate is associated with 

neural tube defects and craniofacial, cardiovascular, 

and limb anomalies.35 A metaanalysis revealed the risk 

for neural tube defect during valproate exposure to be 

3.8%—38 times greater than prevalence in the general 

population.36 There is a paucity of data regarding the 

use of the atypical antipsychotics during pregnancy 

and lactaction. 

Anxiety Disorders

Overall, anxiety disorders are more prevalent in 

women than in men (with the exception of obsessivecompulsive disorder, which has equal prevalence). 

Compared to men, women are twice as likely to suffer 

from posttraumatic stress disorder (PTSD), three times 

as likely to experience panic disorder with agoraphobia, and four times as likely to have social phobia.37,38

Although other comorbid psychiatric disorders occur in 91% of patients with panic disorder, and 84% of 

patients with panic disorder and agoraphobia, panic 

disorder with agoraphobia is more common in alco-
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Combat and Operational Behavioral Health

holic women than alcoholic men.39 The treatment for 

panic disorder does not differ between the genders, 

with the most effective treatments consisting of cognitive behavioral-therapy and pharmacotherapy. 

Comprehensive evaluation to rule out disorders 

that mimic anxiety, to include thyroid disorders, lupus, iron deficiency anemia, cardiovascular disease, 

and periomenopause, should be included in the work 

up. Other causes of anxiety—such as alcohol use, 

nicotine, caffeine, nonsteroidal decongestants, herbal 

supplements, and appetite suppressants—should also 

be ruled out.

TRAUMATIC BRAIN INJURY IN WOMEN

Background

Traumatic brain injury (TBI) is one of the most 

complex conditions of high risk to military personnel, 

affecting physical, cognitive, and behavioral health. 

Rates of TBI in the general population and military 

are high, making this condition a major public and 

military health problem. In the current war on terror, 

brain injury has become a predominant injury for 

military men and women in a wide variety of roles. 

The focus on TBI has increased with the occurrence of 

such injuries in OIF and OEF. With regard to OIF, the 

Office of The Surgeon General of the Army notes that 

64% of wounded-in-action injuries have occurred as 

a result of blast from improvised explosive devices, 

rocket-propelled grenades, land mines, and mortar or 

artillery shells.40 Improvements in helmet design and 

body armor have resulted in reductions in penetrating 

injuries, including penetrating head trauma. As a direct 

result of the improved survivability of blast injuries, 

closed-head trauma has become the signature injury 

of these military operations. 

The detailed review of military TBI—from moment 

of injury through medical and rehabilitation setting 

and finally to vocational and family outcome—has 

been addressed in a prior volume of the Textbooks of 

Military Medicine.

 41 Therefore, this section will only focus on familiarizing the reader with research findings 

regarding gender differences and their implications for 

women. Even though male TBI outnumbers female TBI 

approximately 2:1 in the general population, and men 

in the military population far outnumber women, the 

rates of female TBI and female service members have 

both increased over the past decade. Understanding 

the implication of female gender in all aspects of TBI 

has developed during this time, although it is still in 

its infancy.

Traumatic Brain Injury, Gender, and Outcome

The analysis of gender as a variable in neurotrauma 

is a fairly recent phenomenon, with discrepant results 

across a number of studies. Animal models suggest 

positive effects of hormone treatment (progesterone, 

estrogen) on outcome, and potential differential risk/

benefit for women who are either pre- or postmenopausal. Progesterone modulates gamma-amino butyric 

acid and inhibits apoptosis, gliosis, and production of 

inflammatory agents, thereby reducing brain edema. 

Estrogen is known as a powerful antioxidant with 

vasoprotective action. However, in animal models, 

although exogenous administration of estrogen was 

beneficial to males, administration to females was 

detrimental, and increased rates of injury-related 

mortality.42–44

Hormonal issues may also play a significant role in 

mild TBI diagnosis among periomenopausal, menopausal, and postmenopausal women, due to symptom overlap. For example, in examining population 

base rates, in excess of 20% of these women report 

concentration difficulties, sleep disturbance, anxiety, 

depression, and irritability, all symptoms common to 

mild TBI. In excess of 30% of these women also report 

fatigue and nervousness.45

A metaanalysis on gender differences in TBI outcome identified only nine studies where data were 

reported based on gender. In analyzing these available 

studies, women were observed to have worse outcome 

on 85% (17 of 20) of the variables discussed.46 Other 

individual studies, often with relatively small samples 

of women, present conflicting results wherein women 

demonstrated greater response to coma stimulation,47

gains in postacute rehabilitation,48 maintenance of 

cognitive level relative to age norms,49 and lower risk 

for dementia.50

Among those with moderate to severe TBI, female 

survivors were noted to have a 1.28 times higher mortality rate and a 1.57 times higher poor-outcome rate 

than male survivors.51 Research regarding the much 

more common concussion/mild spectrum of TBI 

demonstrates that female gender is associated with a 

greater likelihood of subjective cognitive complaints.52

Women were also noted to have significantly higher 

rates of postconcussive syndrome at 1-month postinjury, with continued trends in this direction at 3 and 6 

months postinjury.53 Women sustaining sports-related 

concussions demonstrated significantly greater decline 

in simple and complex reaction time and reported 

more postconcussion symptoms than male peers. In 

this sports-related concussion study, female subjects 

were cognitively impaired roughly 1.7 times more 

often than comparison male subjects. They also expe-
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Women, Mental Health, and the Military

rienced more subjective and objective adverse effects 

from concussion, even with adjusting for helmet use 

(such as comparison male football players).54 Thus, 

especially in mild TBI, it is critical that women have 

thorough evaluation and follow-up to reduce risk of 

complications, avoid repeat injury, and ensure optimal 

recovery.

Psychological Sequelae of Traumatic Brain Injury 

in Women

Results related to gender, overall outcome, and 

quality of life are also mixed, because few of the many 

TBI studies present results by gender. A recent larger 

sample study contradicts early findings of higher 

perceived quality of life among females post-TBI.55

A number of studies specifically examining depression post-TBI demonstrate a significant association 

between female gender and post-TBI depression.56–58

The finding of higher rates of post-TBI depression 

among women is not unexpected given the higher 

rates of depression among them in the general population. Thus, detailed depression screening is strongly 

recommended.

TBI with concomitant PTSD is a particular concern 

in military settings. When experiencing the same 

trauma, women have higher rates of PTSD than men 

in the general population. This finding appears to hold 

true for PTSD post-TBI. A number of studies report that 

women manifest higher rates of post-TBI PTSD.59–61

One study noted that symptoms increased over time, 

and that both the severity of the TBI and memory for 

the event were not associated with the PTSD diagnosis, 

which involved predominant intrusion and avoidance 

symptoms.62 Complicating factors associated with 

PTSD and female TBI survivors include a premorbid 

history of sexual trauma and abuse, which occurs at 

a significantly higher rate for women in population 

studies. 

In some instances, the experience of TBI is noted 

to trigger reemergence of intrusive recollections and 

symptoms associated with abuse, at times after years 

of nonoccurrence. This PTSD-related complication can 

disrupt the rehabilitation process through flashbacks, 

behavioral and affective disturbance, nightmares, and 

hypervigilance. Issues related to prior sexual trauma 

and abuse should be proactively addressed in the history and treatment planning process.62 Also related to 

post-TBI psychological status and PTSD risk is the high 

rate of TBI from domestic violence, wherein women 

are more frequently the victims. Studies of battered 

women indicate extremely high frequency of blows to 

the head (92%) and loss of consciousness (40%), with a 

significant correlation between frequency of blows to 

the head and severity of cognitive symptoms.63 Along 

with blows to the head, battered women also may 

experience anoxic injuries from choking, and are very 

likely to suffer from multiple brain injuries. Women 

sustaining brain injuries in the context of domestic 

violence often present both cognitive impairment as 

well as psychological symptoms, including generalized distress, depression, anhedonia, worry, anxious 

arousal, and PTSD.64 Screening for TBI following domestic violence, and for domestic violence risk among 

those women presenting with TBI, is advised.

Family and Vocational Issues for Women Following Traumatic Brain Injury

Examination of the burden of TBI on family members indicates spouses and primary caregivers typically experience the most stress. Divorce and family 

dysfunction are extremely common occurrences postTBI. Research indicates that male caregivers of female 

relatives with TBI displayed more distress on clinical 

inventories than any other gender combination. Time 

since injury and days in coma (a measure of severity of 

injury) did not affect family caregiver distress ratings.65

Thus, family treatment and support should be initiated 

as early and as intensely as possible, especially in those 

circumstances where the woman with TBI will likely be 

dependent to some degree on a family caregiver. 

Women with TBI additionally may have difficulty 

functioning in their spousal role, as the injury may 

affect satisfaction with gender role, body image, selfesteem, and sexuality. Gender-role satisfaction relates 

to a woman’s ability to engage in preinjury activities 

that defined and supported her sense of femininity and 

womanhood. It is particularly beneficial for women to 

reconnect with rites of passage and developmental lifestage transitions, such as partnership with another or 

parenting children, or both, as a means of expressing 

the ability to participate.66 In moderate to severe TBI, 

rehabilitation may be extended and involve stays in 

various settings, all of which may separate the female 

service member from military, family, and gender 

roles—an experience associated with diminished 

personal satisfaction and self-esteem. Nontraditional 

rehabilitation and therapeutic activities may be needed 

to enhance ability to function in the multitasking role 

as mother for those service women with children at 

home and parenting responsibilities.

Body-image concerns and sexual dysfunction also 

adversely affect self-esteem and may contribute to depression. Following TBI, body image difficulties may 

influence feelings of attractiveness and comfort being 

seen by a partner; physical difficulties may impact 

sexuality through body positioning, sensation, and 

movement; and physiological problems may reduce 

energy for sex, sex drive, ability to initiate sex, and 
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Combat and Operational Behavioral Health

ability to achieve orgasm. Predictors of women’s sexual 

dysfunction post-TBI include degree of depression and 

evidence of endocrine disorders. Significant problems 

reported by women with TBI include difficulties with 

sexual arousal; pain with sexual activity; decreased 

ability to masturbate; diminished vaginal lubrication; 

and altered, delayed, or lack of orgasm.67 Rehabilitation and psychotherapy professionals must be able 

and willing to engage in frank discussion of sexuality 

post-TBI. They must also have some familiarity with 

treatment approaches and resources, because problems 

in this area are associated with depression, loss of selfesteem, and increased family strain.

Successful recovery from TBI results in return to 

work for military personnel with TBI. Some soldiers 

are even able to return to active duty. Others may no 

longer be able to serve in such roles and may require 

vocational rehabilitation to achieve community 

reintegration. Studies have demonstrated worse vocational outcome for women post-TBI than for men. 

At times data suggesting good outcome for women 

are deceiving, in that successful vocational outcomes 

have included the category of “homemaker,” often 

with minimal definition or analysis of tasks and 

function. Significantly fewer women return to work 

full-time post-TBI.68 A review of state vocational 

rehabilitation services was conducted comparing 

men and women with similar injuries, neuropsychological test results, and demographics. Women 

were noted to have vocational rehabilitation services 

terminated after being accepted, but before successfully initiating active services, almost 50% more often 

than men; women received vocational rehabilitation 

maintenance services half as often as men; and only 

4.4% of women (vs 23.6% of men) were employed 

successfully through vocational rehabilitation.69 The 

return-to-work outlook is challenging for anyone 

post-TBI. However, the vocational outlook for women 

is particularly disconcerting, and may necessitate 

extra efforts on the part of vocational rehabilitation 

counselors and advocates.

Thus, the sequelae of TBI are complex and may 

involve rehabilitation of cognitive, physical, and behavioral impairments. Women with TBI are especially 

vulnerable to cognitive complaints and problems such 

as depression and PTSD. It may be difficult for women 

post-TBI to return to family and vocational roles. The 

clinician is advised to be aware of, and proactive 

regarding, women’s unique issues post-TBI, because 

early intervention may improve outcome and reduce 

risks of long-term disability and the emergence of 

comorbidities.

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This chapter has discussed the unique and challenging situation that women face in today’s military. 

From childbirth to specific disease pathology, women’s 

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injury: a 30-year follow-up study. Neurol. 2006;66:187–192.

50. Starkstein SE, Jorge R. Dementia after traumatic brain injury. Int Psychogeriatr. 2005;17(suppl 1):S93–S107.

51. Kraus JF, Peek-Asa C, McArthur D. The independent effect of gender on outcomes following traumatic brain injury: 

a preliminary investigation. Neurosurg Focus. 2000;8:e5.

52. Chamelian L, Feinstein A. The effect of major depression on subjective and objective cognitive deficits in mild to 

moderate traumatic brain injury. J Neuopsychiatry Clin Neurosci. 2006;18:33–38.

53. Bazarian JJ, Wong T, Harris M, Leahey N, Mookerjee S, Dombovy M. Epidemiology and predictors of postconcussive 

syndrome after minor head injury in an emergency population. Brain Inj. 1999;13:173–189.

54. Broshek DK, Kaushik T, Freeman JR, Erlanger D, Webbe F, Barth JT. Sex differences in outcome following sports-related 

concussion. J Neurosurg. 2005;102:856–863.

55. Steadman-Pare D, Colantonio A, Ratcliff G, Chase S, Vernich L. Factors associated with perceived quality of life many 

years after traumatic brain injury. J Head Trauma Rehab. 2001;16:330–342.

56. Ruddle JA, Coetzer BR, Vaughan FL. Grief after brain injury: a validation of the Brain Injury Grief Inventory (BIGI). 

Illness Crisis Loss. 2005;13:235–247.

57. Glenn MB, O’Neil-Pirozzi T, Goldstein R, Burke D, Jacob L. Depression amongst outpatients with traumatic brain 

injury. Brain Inj. 2001;15:811–818.

58. Levin HS, Goldstein FC, MacKenzie EJ. Depression as a secondary condition following mild and moderate traumatic 

brain injury. Semin Clin Neuropsychiatry. 1997;2:207–215.

59. Greenspan AI, Stringer AY, Phillips VL, Hammond FM, Goldstein FC. Symptoms of post-traumatic stress: intrusion 

and avoidance 6 and 12 months after TBI. Brain Inj. 2006;20:733–742.

60. Levin HS, Brown SA, Song JX, et al. Depression and posttraumatic stress disorder at three months after mild to moderate traumatic brain injury. J Clin Exp Neuropsychol. 2001;23:754–769.

61. Ohry A, Rattock J, Solomon Z. Posttraumatic stress disorder in brain injury patients. Brain Inj. 1996;10:687–695.

62. Reeves RH, Beltzman D, Killu K. Implications of traumatic brain injury for survivors of sexual abuse: a preliminary 

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Accessed November 13, 2008.

63. Jackson H, Philp E, Nuttall RL, Diller L. Traumatic brain injury: a hidden consequence for battered women. Prof Psychol Res Pract. 2002;33:39–45. Available at: http://www.lscny.org/TBIMaterials/TbiDVConsequence.pdf. Accessed 

November 13, 2008.

64. Valera EM, Berenbaum H. Brain injury in battered women. J Consult Clin Psychol. 2003;71:797–804.
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65. Gervasio AH, Kreutzer JS. Kinship and family members’ psychological distress after brain injury: a large sample study. 

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66. Gutman SA, Napier-Klemic J. The experience of head injury on the impairment of gender identity and gender role. 

Am J Occup Ther. 1996;50:535–544.

67. Hibbard MR, Gordon WA, Flanagan S, Haddad L, Labinsky E. Sexual dysfunction after traumatic brain injury. NeuroRehabilitation. 2000;15:107–120.

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Mental Health Support to Operations Involving Death and the Dead

Chapter 45

MENTAL HEALTH SUPPORT TO 

OPERATIONS INVOLVING DEATH AND 

THE DEAD

JAMES E. MCCARROLL, PhD, MPH*, and ROBERT J. URSANO, MD†

INTRODUCTION

MILITARY CARE-OF-THE-DEAD POLICY AND TRAINING

STRESSES OF EXPOSURE TO REMAINS

Physical Characteristics of Remains

Personal Safety

Emotional Involvement

PSYCHOLOGICAL EFFECTS OF CARING FOR REMAINS

ROLE OF THE MENTAL HEALTHcare PROVIDER IN MASS DEATH SITUATIONS

Recognizing Signs of Stress 

Assisting Soldiers With Exposure to Mass Death 

Social Effects of Proper Care of the Dead

SUMMARY

*Colonel, US Army (Retired); Psychologist, Center for the Study of Traumatic Stress and Department of Psychiatry, Room B3068, Uniformed Services 

University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; formerly, Psychologist, Walter Reed Army Institute of Research, 

Silver Spring, Maryland

†

Colonel, US Air Force (Retired); Director, Center for the Study of Traumatic Stress, and Chair, Department of Psychiatry, Room B3068, Uniformed 

Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814
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Combat and Operational Behavioral Health

INTRODUCTION

Exposure to the dead and death is common in military and civil conflict, disaster, crime, and other violent 

events such as transportation accidents. “Exposure to 

the dead” means the viewing and handling of human 

remains. “Exposure to death,” on the other hand, refers to connotations associated with the deceased that 

bring forth cognitive and emotional reminders of the 

individual to the family and to other groups such as 

military units, communities, and even nations.

Many publications have addressed the effects of 

traumatic death on posttraumatic symptoms,1 but 

none has focused on the role of the mental health 

provider in assisting soldiers and commanders with 

adjusting to the stress of caring for deceased soldiers 

on the battlefield or at a site of mass casualties. Mental 

health personnel should be familiar with this topic 

for three major reasons: (1) to understand the nature 

of distress in personnel exposed to the dead; (2) to 

recommend policies to medical and line commanders 

to reduce soldier distress; and (3) to understand their 

own vulnerability to these same stresses. 

In the medical field, mental health personnel are 

probably among the most insulated from death. Psychiatrists dissect cadavers as medical students and 

attend medical school lectures about confronting the 

deaths of patients, but are unlikely to be exposed to 

traumatic death or even surgical or medical deaths 

on a routine basis. Psychologists and social workers 

may never have seen the dead outside of funerals. As 

a result, many, if not most, mental health personnel 

are largely unprepared to understand the nature of 

contact with the dead from mass disasters or war. 

These situations often involve large numbers of 

casualties, and most of the remains will not appear 

like those prepared for viewing in funeral homes. In 

the US Army mortuary affairs community, the term 

“remains” is used to refer to the dead; other terminology is often considered disrespectful. The term 

“bodies” is frequently used in the medical field and 

is occasionally used here to avoid repetition, but no 

disrespect is intended.

The purposes of this chapter are to (a) explain the 

stresses of handling remains, (b) describe common 

feelings and responses of persons who have handled 

or seen the dead, (c) provide procedures to help mental 

health workers support personnel exposed to the dead, 

and (d) prepare mental health workers to effectively 

communicate the situation of those caring for the dead 

to higher authorities, who may fail to understand the 

nature of the services of both the remains’ handlers 

and mental health professionals.

Persons who encounter remains may themselves 

have had a variety of previous experiences with the 

dead or no experience at all. Some gain experience 

through their professions. Among these are medical 

personnel such as pathologists, nurses, and some 

technicians; police, firefighters, and emergency service workers; and professionals who attend the dead 

such as military personnel who recover bodies from 

the battlefield, morticians, funeral directors and their 

staffs, and forensic investigators. Professional groups, 

for the most part, are protected from distress by their 

roles and identities. For example, pathologists are still 

serving a patient and achieve professional satisfaction 

in solving a mystery; they routinely provide the final 

medical procedures for their patients. The major goal 

of public service workers is to save lives, but over 

time their professionalism and frequent exposure to 

the dead generally protects them from the adverse 

consequences of such encounters.

A second group has encountered the dead episodically. Among these are people who have lived in a 

violent community, those involved in a natural or community disaster such as a building explosion or fire, 

victims of violent crime or violent civil disturbance, 

and military personnel whose regular job is handling 

the dead. A third group is composed of people who 

have rarely or never encountered the dead except at 

funerals or, secondarily, through the media. Members 

of these groups anticipate and experience exposure 

to the dead in a different manner.2

 Because of their 

relative lack of experience, the two latter groups usually need more preparation before exposure and more 

assistance afterward.

MILITARY CARE-OF-THE-DEAD POLICY AND TRAINING

The history and documentation of wartime care 

for the dead is very limited, although some official 

records of these services are publicly available.3

 A 

recent history, prompted by the invasion of Iraq in 

2003, has updated the record with personal stories 

and photographs.4

When a service member dies, the remains are no longer the responsibility of the Army Medical Department, 

but are handled through the military logistics system. 

Enlisted Army soldiers whose military profession is 

to collect, process, and return remains to the families 

are in the military occupational specialty of mortuary 

affairs and belong to the Army Quartermaster Corps. 

Following their basic training, they attend a 7-week 
719

Mental Health Support to Operations Involving Death and the Dead

course at the Mortuary Affairs Center and School at Fort 

Lee, Virginia. The course curriculum consists of familiarization with the physical and psychological aspects 

of dying and death, search and recovery operations, 

tentative identification, decontamination, and accountability for the personal effects of the deceased. Students 

receive classroom and field experience at a morgue or 

mortuary where they are exposed to remains. They are 

also trained in the numerous Army procedures for the 

care of the dead, which helps ensure that the dead are 

handled in a dignified, reverent, and respectful manner, 

principles that are continually emphasized in the training. Following their initial training, mortuary affairs 

personnel can obtain additional experience in a variety 

of military and civilian mortuaries where they observe 

and sometimes assist in autopsies. Unfortunately, 

however, mortuary affairs operations are not usually 

included in Army training exercises, which limits the 

ability of commanders to understand mortuary affairs 

functions and operations in wartime.

Quartermaster Corps officers receive familiarization training in mortuary affairs and may command a 

mortuary affairs company, but this command is only 

one of a variety of positions these officers are expected 

to assume. Of the other US military services, only the 

Navy has a dedicated career field for persons who 

handle remains. The Navy requires that personnel 

at sea who handle remains be licensed embalmers to 

care for bodies that cannot be returned quickly to the 

United States.

Stresses of exposure to remains

Research on groups of experienced (mortuary affairs soldiers) and inexperienced (those whose military 

profession did not require exposure to the dead) soldiers found three main concerns about working with 

remains5

: (1) physical characteristics of the remains, 

(2) personal safety, and (3) emotional involvement 

associated with the remains. 

Physical Characteristics of Remains

Senses seem to serve different cognitive and emotional processes. Each sense has special qualities that 

may produce distress in an individual. 

Smell

The odor sensation has many special qualities6; 

aside from being immediately unpleasant, the smell 

of remains has additional effects. Smell is the most 

likely of the senses to trigger reminders at a later time. 

Odor memory is highly resistant to extinction, that is, 

there is long-term recognition of odors. A smell cannot 

be conjured up from the past, but can be recognized 

almost instantly (although a lemon’s smell cannot be 

mentally conceptualized, its appearance can be visualized). Also, the strength of the memory varies with the 

involvement a person has with the odor.

People working with remains often try to mask 

odors by some means, such as wearing a mask laced 

with a strong fragrance. However, this strategy can 

be problematic for several reasons. Fragrances may 

not always be available, and the use of an additional 

olfactory stimulus adds another scent to the mix already present, which may also bring back unpleasant 

associations later. Breathing through the mouth is an 

effective way of avoiding unpleasant odors. 

Sight

The sight of grotesque remains (burned, mutilated, 

dismembered, decomposed) may be the most dramatic 

aspect of casualties. Scenes of death are likely to be 

remembered and form the basis of conscious or intrusive memories. However, the most grotesque remains 

may not be the most bothersome to all observers. A 

body that looks natural with no or few visible signs 

of wounds may cause more distress than damaged 

remains. In addition, bodies that are badly burned 

or otherwise grossly distorted may not look human, 

which may make it easier for the handler to gain cognitive and emotional distance.

Touch

Tactile qualities of remains are disturbing to some 

workers, even when wearing gloves. For example, 

the skin of decomposing bodies will easily slip off the 

underlying tissue. Some tactile sensations are familiar, 

some are unfamiliar, and each has the capacity for 

disturbance.

Sounds

Dropping a body on a floor, truck bed, or table may 

remind the remains handler of sounds that would be 

painful to a living person. An example of such a sound 

is that of a head making a cracking noise against a hard 

surface. Autopsy equipment also produces potentially 

distressing sounds. 

Taste

Sensations of taste are usually associated with 
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Combat and Operational Behavioral Health

smell. Some remains handlers have an aversion to 

grilled meats after handling burned remains, but this 

reaction is not universal. People react individually to 

foods following exposure to remains, just as they have 

individual food references in other circumstances. 

Types of Remains

What will bother individuals, or what will relieve 

their distress, is not completely predictable. However, 

with varying degrees of certainty, the categories that 

bother almost everyone can be enumerated and described, providing a framework for understanding 

situations and reactions peculiar to one person or 

another. Almost without exception, caring for the bodies of children is the most distressing type of exposure 

to the dead. Also distressing to most people are the 

remains of torture victims, innocent persons (such 

as casualties of friendly fire in the military), women 

who died in combat, and persons killed in a grotesque 

manner, as well as body parts and large numbers of 

remains. On the other hand, some types of remains, 

or some scenes or situations, are bothersome to some 

people but not others. In one case, remains wrapped 

in gauze in preparation for casketing reminded an 

experienced handler of a rag doll.

Each military conflict is likely to involve a unique 

type of death or types of remains and situations. Examples from the current wars in Iraq and Afghanistan are 

torture victims, fragmented remains from bombings, 

mass graves, and civilian casualties including children. Additionally, cultural differences in procedures 

for handling remains are often poorly understood by 

Americans.

Personal Safety 

Remains handlers must protect themselves against 

battlefield dangers, disease, contamination, and occupational hazards. Battlefield recovery of remains 

can be hazardous. For example, remains can be boobytrapped with explosives. Local populations can be 

hostile, and the possibility of combat cannot always 

be ruled out. Physical contact with remains requires 

the same personal protective measures as are routinely 

taken by doctors and dentists to protect themselves 

from blood products and other sources of contamination. In addition to naturally occurring contamination, 

the enemy can contaminate remains with toxins such 

as chemical, biological, or radiological substances. 

Decontamination of remains and of the handler pose 

similar hazards.

In areas where certain diseases are endemic, remains 

handlers should be aware of necessary protective 

measures. Persons who die due to combat or disasters 

rarely have medical conditions that cause epidemics. 

Remains (including animal remains) do not cause 

disease except under certain circumstances. This point 

is especially important for commanders, supervisors, 

and medical personnel to understand because misconceptions can cause errors in the handling and processing of remains.7

 For example, if commanders or public 

officials incorrectly believe that remains can cause 

disease, a rush to bury or cremate them can occur, 

preventing the bodies from being returned to families 

or investigated for cause and manner of death. 

Remains can cause disease when diseases are present in the area—microorganisms causing disease can 

survive in remains after death, and environmental 

conditions can facilitate the microorganisms’ growth. 

Examples of such conditions are overcrowding, 

contaminated water, poor sanitation, and endemic 

disease. Some diseases that can be spread by remains 

are blood-borne diseases such as hepatitis B and C, 

human immunodeficiency virus, gastrointestinal diseases such as hepatitis A, Escherichia coli, cholera, and 

respiratory diseases such as tuberculosis. However, 

the most common risks to the remains handler are 

occupational hazards such as cuts, spills, sprains and 

strains, fatigue, and dehydration.

Emotional Involvement 

Emotional involvement refers to the feeling of distress by the remains handlers when some quality of the 

remains creates a sense of shared humanity, weakening 

or destroying the handlers’ psychological distance. 

The remains lose some of their inanimate quality, and 

the handler feels some sense of the loss of the life of 

another person. Emotional involvement often occurs 

when the handler is of similar age as the remains or 

has a child the same age. Other circumstances that can 

create a sense of emotional involvement are obtaining 

or preparing personal documents for deceased, media 

reports on the individual or situation that caused the 

death, contact with unit members in which more is 

learned about the history of the deceased, and contact 

with the family. These situations make the remains 

“like me.” Emotional involvement is sometimes referred to as identification with the deceased.8

The personal effects of the deceased are highly 

likely to create a sense of emotional involvement with 

the deceased and, often, with the survivors of the deceased.9

 Pictures, letters, and personal possessions and 

mementoes all help contribute to building a picture 

of the life of the deceased and a sense of loss or even 

threat for the handler (“it could have been me”). In the 

military, personal effects are given the same degree of 
721

Mental Health Support to Operations Involving Death and the Dead

care and concern as the remains. Personal effects are 

sent to a personal effects depot where they are sorted, 

catalogued, inventoried, cleaned, and shipped to the 

next of kin. Mortuary affairs personnel staff these 

depots and are exposed in detail to the lives of the 

deceased. Policy requires that mortuary affairs staff 

read letters before they can be returned to the family 

to ensure that the material is returned to the correct recipient and to remove material that might be sensitive 

or embarrassing to the family. Government property 

and morbid material (such as blood-soaked clothing) 

are not returned to the next of kin. A summary court 

officer is appointed to review all personal effects and 

to assure that all legal matters are observed. 

Psychological effects of caring for remains

Reactions to death and the dead are varied and 

difficult to catalogue or predict. Some reactions are 

immediate, and others may not appear until later. 

Typical immediate reactions are surprise and shock, 

withdrawal, nervousness, and shame at one’s own 

reactions. Overworking is also common and leads 

to fatigue and errors. Other reactions are intrusive 

thoughts, avoidance of reminders of the situation, 

feeling “keyed up,” and problems with daily functioning. These reactions are normal and expected unless 

prolonged. More extreme reactions can impact negatively on health, including substance abuse, excessive 

smoking, failure to seek needed medical care, and 

other behaviors that indicate a lack of self-care. 

Additional behaviors can be expressed, and people 

respond differently and at different times. A longitudinal study of posttraumatic responses over a 13-month 

period in a group of mortuary workers found that 

intrusive and avoidance symptoms were elevated at 

1, 4, and 13 months, but decreased over time. The level 

of probable posttraumatic stress disorder symptoms 

was 11% at 1 month, 10% at 4 months, and 2% at 13 

months. Depression was not increased. Marital status 

was a factor in response: single remains handlers reported more avoidance and somatization than married 

remains handlers.10

Anticipation of exposure to traumatic death is 

stressful. In any remains-handling situation, anticipation of one’s own reaction must be considered,2

especially for inexperienced people. Training and 

experience can reduce anticipated stress and result in 

improved performance, decrease fatigue, and decrease 

the risk of adverse psychological effects. For example, 

inexperienced forensic dentists working with the remains of the badly burned victims of a fire reported 

more distress from handling decomposed, burned, 

and fragmented remains than the experienced dentists.11 However, both experienced and inexperienced 

dentists reported distress from handling the remains 

of children. These findings challenge the common 

belief that highly trained professionals are immune 

to distress. 

In most circumstances, the groups with the most 

exposure have the most distress. For example, the distress for forensic dentists who handled burned remains 

was related to the hours of exposure to the remains.11

In another study, the responses of mortuary workers 

were measured before and after exposure to the remains of service members killed in war.12 When age, 

sex, volunteer status, and experience were controlled, 

intrusion symptoms increased significantly for all 

groups exposed to the dead, and avoidance symptoms 

increased in the two groups with the most exposure. 

Even after controlling for symptoms expressed in 

anticipation of exposure to the dead, exposure itself 

increased posttraumatic symptoms. 

Role of the mental healthcare provider in mass death situations

To be maximally effective in assisting soldiers, the 

mental health provider must be knowledgeable about 

the stresses of operations and their likely effects on 

exposed personnel; be available, known, and trusted; 

and coordinate efforts with the local chaplain or other 

first lines of support outside the military unit or civilian organization.

Recognizing Signs of Stress 

No particular reactions or signs of distress shown 

by remains handlers differ from reactions of other 

persons. Experienced supervisors have reported witnessing or hearing about many common stress-related 

behaviors and feelings (Exhibit 45-1). It cannot be 

overemphasized that these reactions are usually normal signs of understandable distress about a difficult 

situation. Only when these reactions are prolonged 

should mental health workers seek to intervene. For 

day-to-day distress reactions, first-line supervisors 

and colleagues should offer understanding and allow 

respite for a reasonable period of time. Mission demands rarely prevent such temporary respite. Mental 

health workers can assist in preparing supervisors to 
722

Combat and Operational Behavioral Health

EXHIBIT 45-1 

SIGNS OF STRESS IN MORTUARY OPERATIONS AND COPING WITH THE WORK

Behavioral signs of stress

•	 Fatigue, agitation, withdrawal, sleeplessness

	 •	 Loss of, or gain in, appetite

	 •	 Quitting (not reporting for work)

	 •	 Extreme agitation or crying

Psychological signs of stress

•	 Depression, sadness, apathy

	 •	 Major change of personality

	 •	 Other feelings

 ° Anxiety

 ° Frustration

 ° Anger

 ° Feeling sick and nervous

 ° Fear

 ° Loneliness

recognize the normal stresses of working in a mass 

casualty environment and provide temporary relief. 

Exhibit 45-2 provides examples of ways mortuary affairs soldiers deal with stress.

Assisting Soldiers With Exposure to Mass Death 

The plan recommended here for mental health professionals to assist soldiers, commanders, and other 

medical personnel after a mass death is based on a 

EXHIBIT 45-2 

HOW DO MORTUARY AFFAIRS SOLDIERS 

SAY THEY DEAL WITH STRESS?

	 •	 “Stay focused” (concentrate on doing their

job)

	 •	 Exercise or engage in sports

	 •	 Keep busy

	 •	 Read and write letters

	 •	 Talk to others

	 •	 Listen to music

	 •	 Get away from the mass death scene

	 •	 Communicate with family back home

three-stage model: (1) preparation, (2) on-site actions, 

and (3) follow-up (Exhibit 45-3). Commanders should 

be visible and available to soldiers for at least part of 

EXHIBIT 45-3 

GUIDELINES FOR ASSISTING SOLDIERS 

AND COMMANDERS in CARING FOR 

THE DEAD

Before: Anticipate operational procedures and 

train for them

	 •	 Obtain and share information

	 •	 Brief plans up (command) and down (soldiers) the chain of command

	 •	 Expose inexperienced personnel gradually

	 •	 Practice

	 •	 Anticipate reactions and prepare for them

During: Limit exposure to the remains and scene 

and support the soldier

	 •	 Avoid or decrease exposure to strong stimuli

	 •	 Provide respite: breaks, food, sleep

	 •	 Provide supervision

	 •	 Pair inexperienced with experienced person

	 •	 Encourage talk among workers and supervisors

	 •	 Recognize signs of stress and act

	 •	 Provide respectful and visible command or

authority

	 •	 Emphasize job and role of remains handlers

After: Inform, talk, and listen

	 •	 Provide operational debriefing and education on the facts of the event

	 •	 Acknowledge the existence of intense personal feelings

	 •	 Encourage family and organizational support systems

	 •	 Reinforce the positive aspects of the work

accomplished

Long-term: Follow-up guidelines for soldiers and 

commanders

	 •	 Posttraumatic symptoms are usually not

lasting—most people “move on”

	 •	 Time is the most effective treatment for most

people

	 •	 Watch for problems that do not go away

	 •	 Problems that persist should not be neglected
723

Mental Health Support to Operations Involving Death and the Dead

the operation and ensure that all necessary logistic 

support has been provided. In the follow-up phase, 

they should speak to soldiers as a group about their 

work, reinforcing the soldiers’ role and the importance 

of their work. The question usually arises as to when 

soldiers should be ready to go back to work. Although 

there is no firm answer to this, it is recommended that 

soldiers be given some time off after the operation to 

rest and attend to personal matters. Several days of respite is common following a difficult mission. Sending 

soldiers back to work immediately, unless absolutely 

necessary, is likely to be detrimental to their functioning and may be interpreted as a lack of appreciation 

for them and their work. Support of soldiers in mass 

death operations involves three domains: (1) personal, 

(2) organizational, and (3) logistical. 

Personal Support 

In addition to normal social support, the supervisor and the mental health worker should attempt to 

reinforce in the soldier a pride of accomplishment 

whether the individual is distressed or not. Exhibit 

45-4 lists many points that can be made by the mental 

health worker, the supervisor, and the commander. 

The exhibit includes unique military aspects of caring 

for remains with which the individual, particularly 

the lower ranking soldier, should be aware. Immediately obvious are the services to the deceased and the 

family of the deceased. Less obvious are the honor of 

upholding military service traditions and fulfilling 

the nation’s cultural expectations. It is also vital that 

persons outside the mortuary affairs field understand 

the importance of recognizing these principles.

Personal support of soldiers also includes access to 

mental health and spiritual care. Because of the broad 

dispersion of mortuary affairs collection points and 

interruptions in transportation capabilities, mental 

health teams in the current Middle East conflicts 

often have difficulty establishing relationships with 

soldiers. Also, contact between soldiers and mental 

health personnel can be a touchy issue. In spite of the 

competency, good will, and attempts of mental health 

workers to be helpful, soldiers will not often engage 

with them if they are not known and trusted. Being 

credible requires frequent contact. Chaplains are often the primary resource for personal assistance, and 

mortuary affairs personnel report that chaplains from 

all the services are available and often spend time with 

them eating meals and staying overnight. Chaplains, 

medics, and mental health workers must be known as 

regular visitors to achieve credible status with soldiers. 

Regardless of these relationships, however, the commander or other supervisor who has the authority to 

EXHIBIT 45-4 

REINFORCE THE POSITIVE

Common individual reasons for care of the dead 

in war

•	 Upholding American military service traditions

	 •	 “Everybody comes back home”

	 •	 “If I do it for them, somebody will do it for

me”

Personal pride in care of the dead in war

•	 Doing something important forthe deceased

soldier

	 •	 Doing something important for the families

	 •	 Doing a job that others cannot do

	 •	 Personal mastery of a difficult job

Practical considerations of families in having 

remains returned

•	 Document place and cause of death

	 •	 Assist with grieving

	 •	 Resolve legal and personal issues

 ° Wills and inheritance

 ° Remarriage

 ° Government compensation

 ° Insurance

Effects on society

•	 Respect for and care of the dead as anAmerican tradition

	 •	 Social identity of the dead

	 •	 Funerals, memorials, and monuments

	 •	 National pride or shame

refer a soldier to mental health personnel should do 

so when the situation warrants.

Organizational Support

For mortuary affairs soldiers, the presence of commanders and their respectful attitude are extremely 

important when remains are being cared for. It is 

considered highly disrespectful for commanders and 

other visitors not to remove headgear or wipe their feet 

before entering the processing area when remains are 

present. Commanders and mental health personnel 

can assist the soldiers by adhering to these practices 

and preparing visitors to do the same.

Other forms of organizational support are related 

less to the stress of handling remains and more to oc-
724

Combat and Operational Behavioral Health

cupational functioning. In widely dispersed conflicts 

such as Iraq and Afghanistan, soldiers operate many 

collection points, often with minimal personnel. Soldiers may be required to recover remains from distant 

locations and are always on duty. Processing remains 

requires physical work in lifting and moving the 

deceased as well as the transfer cases in which they 

are shipped. A large number of remains can require 

several hours to process. As a result, opportunities 

for rest, recreation, and personal time are limited. 

Commanders must ensure that soldiers have time for 

sleep and recuperation. Finally, collection points and 

mortuaries are often located at air fields away from 

Army support or are isolated to prevent unnecessary 

troop exposure. This isolation can have a positive effect in the freedom to accomplish the work without 

interference, but isolation can sometimes result in the 

mortuary affairs soldiers being shunned by others. 

Such situations require a great deal of command support for the soldier. 

Logistical Support

The psychological stress of mortuary affairs work 

can be greatly reduced if soldiers have the necessary 

supplies and equipment, adequate transportation, and 

good area or unit support. Mortuary affairs soldiers 

often do not operate at an organic organizational level 

(platoon or company) in war. In the current Middle 

East conflicts, soldiers who staff collection points in the 

field are usually assigned to other Army organizations, 

such as a division, or even to other military services. 

Soldiers returning from Iraq and Afghanistan have 

reported excellent support from the US Air Force and 

Marine Corps. However, occasionally collection points 

lacked some logistic support, including refrigeration 

equipment and vehicles for transporting personnel 

and remains. Army command authorities may have 

limited control over mortuary affairs personnel when 

those personnel are attached to another Army unit or 

military service. However, they can take steps to ensure 

that the organizations to which the mortuary affairs 

soldiers are attached provide them proper support.

Social Effects of Proper Care of the Dead

The effects on society are far from the battlefield 

but should be impressed on mortuary affairs soldiers to reinforce the positive aspects of their work. 

The requirement for dignified care of remains is not 

only doctrine, but becomes a creed for these soldiers. 

Members of American society must have faith that 

this tradition is carried on and that mortuary affairs 

soldiers accomplish this mission.

The social identity of the dead has meaning for 

the survivors of the deceased.4

 Social identity refers 

to the place that the deceased will have in the minds 

of survivors such as fellow soldiers, the family, and 

others who may or may not have known the individual. After death, an identity can be broader than 

the identity the individual had in life. This identity 

includes, but is not limited to, knowledge of the place 

and manner of death, the place of burial, and how the 

individual is remembered. The return of the remains 

and personal effects contribute greatly to the formation 

of this identity. 

Wartime funerals and memorials are legion. 

Whether humble or grand, funerals and memorials are 

less than complete without remains to memorialize. 

Families, without exception, want a remembrance of 

the deceased; if the remains are unrecoverable, then a 

memento is required. The memento can be a personal 

effect, soil from the area of death, or a symbol of the 

individual’s life or death.

SUMMARY

The mortuary affairs soldier has an important role in 

the long chain of events that support the recovery and 

return of the dead from war. The soldiers who perform 

this role obtain support primarily from each other, but 

also from their organization and those above them. The 

job stresses are largely compensated for by the soldiers’ 

own sense of accomplishment in performing an honorable but difficult task. Support from mental health 

workers, chaplains, or commanders, comes from (a) 

recognition of the work, including an understanding 

of the duties; (b) respect for the remains-handling process; (c) spending time with personnel to decrease any 

possible isolation caused by the nature or location of 

the work; and (d) understanding how the stress of this 

particular job interacts with those stresses that affect 

all soldiers in a deployed environment. 

The way a country cares for the remains of its war 

dead contributes to national pride or shame. This is 

reinforced in the soldier by the credo, “no one left behind.” The commander, the mortuary affairs soldier, 

and the mental health provider all play important roles 

in ensuring the endurance of this tradition.
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Mental Health Support to Operations Involving Death and the Dead

Acknowledgment

Thanks to Mr Tommy D Bourlier and Mr Douglas L Howard, Director and Deputy Director, respectively, 

of the US Army Mortuary Affairs Center and School, Fort Lee, Virginia, for their reading and comments 

on the manuscript. Thanks also to Jodi McKibben, PhD, Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, for her reading 

and commentary on the manuscript. And, finally, a special thanks to the many soldiers who shared their 

time and stories with the authors.

REFERENCES

1. Ursano RJ, McCarroll JE, Fullerton CS. Traumatic death in terrorism and disasters: the effects on posttraumatic stress 

and behavior. In: Ursano RJ, Fullerton CS, Norwood AE, eds. Terrorism and Disaster. New York, NY: Cambridge University Press; 2003: 308–332.

2. McCarroll JE, Ursano RJ, Ventis WL, et al. Anticipation of handling the dead: effects of gender and experience. Br J 

Clin Psychol. 1993;32:466–468.

	 3. 	 Risch E, Kieffer CL. Care of the dead. In: United States Army in World War II. The Technical Services. The Quartermaster 

Corps: Organization, Supply, and Services. Washington, DC: US Government Printing Office; 1955: 361–494.

4. Sledge M. Soldier Dead. New York, NY: Columbia University Press; 2005.

5. McCarroll JE, Ursano RJ, Fullerton CS, et al. Gruesomeness, emotional attachment, and personal threat: dimensions 

of anticipated stress of body recovery. J Trauma Stress. 1995;8:343–347.

6. Engen T. Remembering odors and their names. Am Scientist. 1987;75:497–503.

7. Pan American Health Organization and World Health Organization. Management of Dead Bodies in Disaster Situations.

Disaster Manuals and Guidelines Series, No 5. Washington, DC: PAHO and WHO; 2004: 71–83. Available at: http://

www.paho.org/english/dd/ped/DeadBodiesBook.pdf. Accessed November 18, 2008.

	 8. 	 Ursano, RJ, Fullerton CS, Vance K, Kao TC. Posttraumatic stress disorder and identification in disaster workers. Am 

J Psychiatry. 2003;156:353–359.

	 9. 	 McCarroll JE, Blank AS, Hill K. Working with traumatic material: effects on Holocaust Memorial Museum Staff. Am 

J Orthopsychiatry. 1995;65:66–75.

	 10. 	 Ursano RJ, Fullerton CS. Vance K, Kao TC, Bhartiya VR. Longitudinal assessment of posttraumatic stress disorder and

depression after exposure to traumatic death. J Nerv Ment Dis. 1995;183:36–42.

11. McCarroll JE, Fullerton CS, Ursano RJ, Hermsen JM. Posttraumatic stress symptoms following forensic dental identification: Mt. Carmel, Waco, Texas. Am J Psychiatry. 1996;153:778–782.

12. McCarroll JE, Ursano RJ, Fullerton CS, Liu X, Lundy A. Effect of exposure to death in a war mortuary on posttraumatic 

stress symptoms. J Nerv Ment Dis. 2001;189:44–48.
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727

Ethics and Military Medicine: Core Contemporary Questions 

Chapter 46

Ethics and Military Medicine: 

Core Contemporary Questions 

EDMUND G. HOWE, MD, JD*; ROBERT C. McKENZIE, DO†; and CHAD BRADFORD, MD‡

INTRODUCTION

ISSUES ARISING PRIOR TO DEPLOYMENT

Recruitment Issues

Treatment Concerns

ISSUES ARISING DURING DEPLOYMENT

General Questions Regarding the Nonmedical Treatment of Detainees

How Should Military Medical Care Providers Be Involved With Detainees, If At 

All?

How Should Military Care Providers Respond When Detainees Refuse to Eat?

POSTDEPLOYMENT PROBLEMS

Posttraumatic Stress Disorder

Head Injuries

Decisions “Outside the Box”

SUMMARY

*Professor of Psychiatry, Associate Professor of Medicine, and Director, Programs in Medical Ethics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; and Senior Scientist, Center for the Study of Traumatic Stress, Bethesda, Maryland; formerly, 

Major, Medical Corps, United States Army 

†

Lieutenant Colonel, Medical Corps, US Army; Department of Behavioral Health, US Army Health Clinic-Vicenza, Caserma Ederle, Italy, Unit 31401, 

Box 13, APO AE 09042

‡

Commander, Medical Corps, US Navy; Division Psychiatrist, 2nd Marine Division, Division Surgeon’s Office, Attn: Division Psychiatry, HQBN 2MAR 

DIV, Camp Lejeune, North Carolina 28547; formerly, Forensic Psychiatry Fellow, National Capital Consortium, Washington, DC
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Combat and Operational Behavioral Health

INTRODUCTION

Numerous new ethical issues have arisen in the 

past few decades as a result of developments in biology and technology. Others have arisen as a result of 

different kinds of warfare, as manifested by the terrorist attacks of September 11, 2001.1

 These changes 

have resulted in a need for reevaluation of traditional 

military medical ethics and some unprecedented 

paradigm shifts.2–6

The need for military behavioral healthcare providers to have a sound, basic understanding of these 

issues has also increased and is much wider in scope. 

Military physicians must now, more than ever, be 

aware of ethical considerations that may affect their 

clinical practices. They must also be cognizant of how 

ethical considerations can bear on policies the military 

is developing, whether these are behavioral or medical 

in intent. Furthermore, because military behavioral 

healthcare providers may be involved as ethics consultants or on ethics committees, they must understand 

core ethical arguments that have to be taken into account in these relatively new practices.

Consequently, this chapter will seek to address those 

major issues in which it can reasonably be expected 

that military behavioral healthcare providers might 

be involved. When appropriate, this discussion will 

describe specifically how these military behavioral 

healthcare providers might become involved in the 

topic areas discussed. This chapter also will highlight 

areas in which the need for de novo analysis has been 

posed. It will do this in the same order as the sections 

presented in this book—prior to, during, and after 

deployment.

ISSUES ARISING PRIOR TO DEPLOYMENT

Recruitment Issues

During the initial years of the ongoing war on terror, 

with mounting casualties, sustaining the needed flow 

of volunteers to enter the military became problematic. 

The need to meet recruiting goals led to a relaxation 

of enlistment standards. Changes included increasing 

the number of waivers being given for individuals 

with legal difficulties, lowering the Armed Services 

Vocational Aptitude Battery (ASVAB) scores, and becoming more permissive concerning tattoos that have 

specific pejorative connotations for some target groups. 

It is unclear what the effects will be on individuals 

recruited under the new conditions and how these 

precedents will affect short-term and more long-term 

military standards. However, since the overall economy worsened in 2008 recruits have been plentiful, and 

standards for waivers have again tightened.

One ethical dilemma here involves the competing 

factors of individuals’ right or wish to serve their 

country, the mission’s requirements, and the military’s 

need to maintain standards among soldiers who enlist. 

A second dilemma concerns how much recruits should 

be screened prior to being accepted. Individuals with 

lower ASVAB scores or criminal histories may become 

more of a burden on units as limitations are reached 

or antisocial behaviors recur. These outcomes may 

lead to situations in which unit efficacy is compromised or atrocities are committed. However, it might 

be an ethical error to exclude 100 individuals with 

previous legal difficulties if only one would reoffend. 

Furthermore, recent data have shown that individuals 

who have waivers are actually less likely to commit 

violent crimes. They also have a higher retention and 

promotion rate than the majority of soldiers, perhaps 

because these cases are scrutinized much more closely.7

Individuals with prior misdemeanor convictions, a 

lower ASVAB score, or a previous gang or racist group 

affiliation may want to serve their country or better 

their own financial or educational standing through 

military service. Allowing these individuals to serve 

may be in their best interests, but they may encounter 

continued difficulties within the services, possibly 

ending up with a shortened enlistment or a less than 

favorable discharge.

In addition, a military unit’s morale and readiness 

can suffer directly when standards are lowered. Having an individual with extreme racist views or a gang 

affiliation can divide and undermine the cohesion in a 

military unit, in which every member must be willing 

to save or assist every other member. Individuals with 

racist views may only be willing to pull individuals 

they like out of harm’s way, while allowing those of a 

“different persuasion” to remain exposed. Anything 

short of a completely integrated team may not operate effectively in high-stress combat environments. 

The potential complications that may occur as these 

individuals rise in the ranks and take over positions 

of leadership could also increase. In these positions, 

their choices could be based on affiliations or ethnicities, rather than abilities, which would erode the principles of equality and fairness. One possible solution: 

an additional probationary period for these special 

populations. This is already done for recruits who are 

obese or do not fit fitness standards so that they can 

meet fitness standards prior to basic training.
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Ethics and Military Medicine: Core Contemporary Questions 

The questions of what level of screening needs to be 

implemented and whether there should be a special 

“probational” track to allow these individuals into full 

service may need to be addressed. As there is no current empirical data to use to assess these arguments, 

this may remain an ongoing dilemma.

Treatment Concerns

Suicidal Depression During Basic or Preliminary 

Combat Training 

An ethical problem of an entirely different sort, 

but which also may occur before deployment, is what 

military behavioral health providers should do when 

soldiers state that they feel suicidal during basic or 

early training. Providers may believe that sometimes 

this is because these soldiers don’t want to be in the 

military, and not because they are truly suicidal. Wellknown procedures are in place for soldiers to request 

discharge. Soldiers may, however, not elect to take 

these, for various reasons, such as to save face. Indeed, 

sometimes soldiers may try to get out of the military 

by presenting with suicidal ideation; however, this is 

less common in today’s all-volunteer Army.

Military psychiatrists or other mental health workers to whom these soldiers present may over time: 

(a) initiate measures to give them an administrative 

separation to release them from service, because they 

see their depression as a preexising condition not 

responsive to treatment, (b) judge them to have a personality disorder, or (c) discharge them back to duty. 

Customarily, providers respond by giving the soldier 

a trial of psychotherapy and/or antidepressants.

The ethical problem primarily posed to providers 

stems from the fact that soldiers presenting during basic 

or advanced indivitual training, and before deployment, 

may (as at any other time) be genuinely depressed and 

suicidal.8,9 Thus, if military care providers don’t take 

all the precautions they could, this may increase the 

likelihood that some, even if only a few, of these soldiers 

will commit suicide. To the degree that providers take 

all possible precautions, they are acting in support of 

military needs as well as those of the soldiers.

The possibility of other soldiers temporarily or 

permanently feeling they want out of the military, 

and thus pursuing this same psychiatric out, may lead 

to military physicians treating soldiers with combat 

fatigue as they now do; that is, they treat most such soldiers with the expectation that they will return to their 

units in combat. If providers instead released these 

soldiers from their units and from further combat duty, 

inordinate numbers of soldiers could follow suit. 

A reason often given as an ethical justification for 

treating soldiers with the expectation of return to duty 

is that if soldiers return to their unit, they will be less 

vulnerable to having permanent psychiatric symptoms 

later because of survivor guilt, should the unit eventually lose members in combat. Factually this may be 

true, but as an ethical argument, this reasoning is fallacious. Respecting soldiers’ autonomy would in other 

contexts prevail over the value of doing what is best 

for these soldiers’ later symptoms. Respecting their 

autonomy “normally,” or in civilian contexts, would 

require military physicians to give soldiers the choice 

of risking these symptoms or risking death. 

The justification for military physicians to treat 

soldiers with combat fatigue with the expectation 

that they will return to their unit is both for the sake 

of the mission and the individual soldier in one sense, 

though not in another. That is, soldiers may do better 

in both the short and longer run if they can return to 

their unit. They may, for example, feel better being 

back among those they have known and be less prone 

to later psychiatric symptoms that would be due, most 

likely, to their previously having left their unit and 

never having returned.

Soldiers who are evacuated out of the theater 

usually do not stay in the Army, and they often 

do not remain in contact with the “buddies” they 

left behind. The loss of their social networks, the 

structure of the military, and associated healthcare 

may lead to a downward spiral into joblessness and 

even homelessness. Still, their being treated with 

this return-to-duty expectation is to some extent coercive and, thus, differs from what civilians seeking 

psychiatric treatment after trauma will encounter; 

indeed, this expectation deprives them of a source 

of additional autonomy.

A similar rationale supports military care providers 

treating soldiers in basic training who present with 

suicidal depression. Treating them with psychotherapy 

and medications, when there is a possibility that they 

are genuinely depressed, has a good likelihood of 

keeping these soldiers from leaving the Army and/or 

possibly ending their lives, even if at the time this does 

not seem the best that providers could do for patients 

who say they feel suicidal. In civilian settings, providers might try more to eliminate or reduce the source 

of ongoing stress. Military physicians treating these 

patients as they do now, in any case, reduces the possibility that too many other soldiers in basic training 

or other predeployment settings will present with suicidal depression, again for unconscious or conscious 

reasons, as a means for seeking a way out.

A final, additional ethical dilemma here is whether 

military behavioral healthcare providers should inform soldiers presenting in this manner of the “ground 
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Combat and Operational Behavioral Health

rules” of seeking discharge by this means. They could 

tell soldiers that to be discharged for depression, they 

must generally first undergo a trial of psychotherapy 

and medication for approximately 6 months. However, 

in the current climate of increasing suicides during 

the last 6 years, this option is unlikely to be politically 

palatable. Nonetheless, there is an ethical obligation to 

disclose such facts, as opposed to allowing outcomes 

to be determined or significantly affected by keeping some information unknown. The question then 

becomes: Should providers regard soldiers reporting 

suicidal depression in this same category and not inform them of the ground rules or should they inform 

them? 

The optimal compromise between military physicians meeting the needs of the mission and those of 

these soldiers may be somewhat contradictory and 

paradoxical. It may be that optimally they should insist 

on treating and even giving these patients medication 

for 6 or more months while at the same time giving 

them full information concerning how these ground 

rules work. Providing this information may, in addition, be the only way in which they can treat these 

patients most successfully by gaining their trust. If this 

practice stems the potential flood of soldiers gaining 

discharge by this means (as it appears it would), treatment with disclosure in this manner should suffice to 

support the mission needs.

Predeployment Distress

The policy of deploying soldiers who are not emotionally prepared, or who have certain home-front 

issues to resolve, may cause undue distress to these 

soldiers and their families. A more liberal deployment policy may be in the best interests of soldiers 

and their units. The ethical dilemma of weighing the 

readiness needs of military units against the individual needs of such soldiers and/or their families 

can be problematic. Certainly, military units need to 

be at maximal strength, but having several soldiers 

“whose heads aren’t in the game” will be counterproductive. Individual soldiers may themselves be 

at risk or, because of distraction, they may put their 

team members at risk, and they may ultimately compromise a mission.

During the current war on terror, enlisting soldiers, 

all voluntary, know the potential risks of pending deployments. In the current situation it is just a matter 

of time until a soldier deploys; whether a soldier will 

deploy is not in question. Despite this knowledge, 

some individuals are less prepared to deploy than 

others. These individuals may be struggling with 

short-term adjustment issues, or they may have a family circumstance that could be resolved if they were 

just given a short period of time. Perhaps as little as 

30 days would be required to get them emotionally 

prepared to deploy, or to get their family circumstances 

resolved. Examples of the latter would be moving a 

wife stateside from Germany or making sure all financial matters are in order.

The risk to military units from such a “lenient” 

approach is 2-fold. First, allowing exceptions to, or 

delaying, individual deployments may violate the 

fundamental premise of fairness, in that the rest of their 

team is expected to be ready to deploy and to deploy 

on orders. Presumably, many other members of their 

unit would also prefer to delay, or even avoid, the deployment. Second, a military unit is only as good as its 

members, and if they aren’t present, the unit suffers. 

If some members are allowed to delay their deployment, this may be critical to the mission, as when the 

soldier not deployed is a generator mechanic, or the 

most competent communications specialist.

It may be ethically optimal to develop a way to 

deal with each individual circumstance on a caseby-case basis, with the general presumption that all 

units would deploy in entirety, as much as possible. 

A multitracked system to evaluate and clear deploying soldiers, with one track for those who require a 

short period of reconstitution or to accomplish familyrelated issues, another track for those soldiers who 

should not be deployed, and a third track for those 

ready to deploy may be the best of all options. By 

keeping commands informed about the process and 

the status of their soldiers, the needs of individuals 

and the needs of military units may jointly be best met. 

Current policy is to only deploy service members who 

have been stable for at least 3 months; otherwise they 

must get a waiver from the combatant surgeon, who 

is usually the Central Command surgeon.

Further Treatment Issues

Military behavioral healthcare providers must 

consider how social and emotional distance from 

members of their unit may affect treatment of potential unit member patients. Both at work and outside 

of work, military behavioral healthcare providers are 

likely to interact with their future patients on a regular basis. Maintaining too much distance from their 

units may give the impression of their being aloof and 

unapproachable, decreasing the likelihood of future 

referrals. Maintaining too close a relationship may 

establish a friendly, rather than a therapeutic, relationship. Close relationships may also hinder military 

behavioral healthcare providers’ ability to make an 

accurate diagnosis.

Military behavioral healthcare providers and their 

future patients are likely to be stationed on the same 
731

Ethics and Military Medicine: Core Contemporary Questions 

base, in the same unit, and may frequent common 

work areas. Military bases tend to be insular, with 

those on the base frequently coming into contact with 

each other. They may share similar collateral duties 

such as command committees or other work projects. 

They may frequently cross paths and interact with each 

other at military functions such as awards ceremonies, 

formations, and command education and training. 

Outside of work they may frequent the same stores 

or use the same daycare. 

Vignette 47-1: A military psychiatrist maintained a distinct 

social and emotional distance from those in his unit. It was not 

his practice to socialize with staff or interact at command functions. When not in session with a patient, he would remain 

in his office with the door shut. When approached about this 

behavior the psychiatrist explained that he was indeed not 

socially phobic, but was rather purposefully maintaining his 

social and emotional distance from others in the command in 

case one day they should become his patients. He explained 

that if he were to get too close, he might be expected to be 

a “friend” to his patients; they might expect him to do the 

things that a friend might, such as to socialize together and 

share personal details of his life. Both of these, he reasoned, 

could be harmful to treatment. He also reasoned that if he 

became too close to his unit, he may have more difficulty 

recommending that they go to combat should the need arise. 

He also reasoned that this might hinder his ability to make 

an accurate diagnosis; that his pretreatment conceptions of 

the person might cloud his ability to perceive mental illness; 

and that this might lead him to diagnose mental illness that 

is not there.

Is this psychiatrist’s social behavior ideal or does it 

go too far? Or is it altogether inappropriate and unnecessary? Why? 

Although it is important to maintain the appropriate social and emotional distance, it is also important 

for military behavioral healthcare providers to be approachable and to facilitate referrals. It is difficult for 

military behavioral healthcare providers to help if no 

one is willing to make appointments with them. Military behavioral healthcare providers interacting with 

the unit while maintaining their professional bearing 

may be ideal. Keeping a “finger on the pulse” of unit 

morale is important to maintaining the fighting ability of the unit, and often is one of the jobs of military 

behavioral healthcare providers. Military behavioral 

healthcare providers should be educated about how 

their relationship to their unit may affect their treatment should such soldiers become their patients. The 

goal for these providers should be to offer appropriate 

treatment to their patients while maintaining maximum unit combat effectiveness. In order to achieve 

these goals military behavioral healthcare providers 

must maintain objectivity despite their social and 

emotional relationships with their unit.

ISSUES ARISING DURING DEPLOYMENT

One of the most important medical considerations 

that has arisen is how military physicians should treat 

prisoners of war (POWs). Under the Geneva Conventions, it is clear that military physicians should treat 

POWs equally to allied soldiers, but it is unclear how 

this equal treatment should be carried out. Suppose, 

hypothetically, that US soldiers and POWs have identical injuries. Military physicians could treat each on 

an alternating or random basis, or they could treat all 

US soldiers with identical injuries first. Or, military 

physicians using this second approach could use broad 

categories of injuries so that they could treat more US 

soldiers first and still, in a technical sense, treat both 

US soldiers and POWs equally.2

An ethical question arising in regard to detainees is 

whether military physicians should also treat detainees 

equally, even though from a legal standpoint, detainees 

may not meet criteria to be POWs, and the Geneva 

Conventions may not apply. Leaving aside the practical difficulty of determining who is a POW and who 

is a detainee, a key question regarding the treatment 

of detainees is the extent to which military physicians’ 

obligations as medical professionals should take precedence over their duties as military officers.

At a seminar on military medical ethics, a group of 

military physicians who recently served in Iraq were 

asked what they thought they should do if an enemy 

were brought in injured, they knew that US soldiers 

with “identical injuries” were on the way, and their 

commanding officer ordered them to withhold treatment until their own soldiers arrived and then to treat 

them first. All the military physicians present felt that 

they should refuse the commanding officer’s order. 

They thought that they should treat first whoever was 

before them because this was what, as physicians, they 

should do.

Legally and ethically, the military holds that all 

service persons should disobey an illegal or unethical 

order. Difficulties may exist, however, in determining 

what constitutes “illegal” or “unethical.” The integrity 

of the military system would require that military physicians, like other service persons, defer to orders when 

ambiguity exists in urgent situations. Afterwards, they 

should have these decisions reviewed as widely and 

quickly as possible.

Ethically, however, it may be possible to establish in 

advance when an order would conflict with a priority 

that military physicians hold as medical profession-
732

Combat and Operational Behavioral Health

als and to decide then which priority should prevail. 

This endeavor could favor two outcomes. First, the 

military’s mission might undergo less risk of being significantly compromised. Second, it might help ensure 

that the highest medical standards were upheld.

Since the disclosure of abuses of detainees at Abu 

Ghraib, numerous concerns regarding detainees have 

been raised.10,11 The US government has invited experts 

on human rights from the United Nations and others 

to visit the detainee facility at Guantanamo Bay, Cuba, 

to inspect the activities there and confirm that present 

policies meet appropriate ethical standards. The results 

of these visits can become more conclusive, of course, 

only if all aspects of all operations there can be fully 

examined.

One core concern that has received particular 

public scrutiny and attention is the way in which 

military health professionals, especially psychiatrists, 

psychologists, and other medical care providers, have 

interacted with, and should interact with, detainees. 

The underlying presupposition is that care providers, 

being devoted to healing, should set the highest ethical standards in this as in all military contexts.12 Some 

healthcare professionals, however, question even this 

presupposition. Michael Gross, who wrote a recent text 

on military medical ethics, believes that military care 

personnel owe a higher duty to their country than to 

their profession.4 The converse of this position is that 

if there is a moral value that care providers should 

hold, presumably this value is important enough that 

it should also be held by all.

This second section of this chapter will examine 

core ethical questions that military care providers’ 

involvements with detainees pose. It will do this in 

three parts. The first part will consider basic questions regarding detainees, such as what approaches 

should be permitted during interrogations, whether 

a mechanism should be provided to allow exceptions 

to practices proscribed during interrogations, whether 

the permissible approaches should be enumerated 

specifically beforehand, whether detainees’ conditions 

should be made better over time, and who should decide all of these issues. These basic questions must be 

considered first because those that follow and involve 

care providers are to some extent contingent on these 

initial answers. 

The second part of this section of the chapter will involve questions specifically related to military medical 

personnel. These will include healthcare provider involvement in interrogations, if they should be involved 

at all, and confidentiality when treating detainees 

as patients. The third part will concern what is now 

the most difficult ethical problem faced by military 

healthcare providers treating detainees: what to do 

when detainees refuse to eat. This section will include 

a brief discussion of whether military care providers 

should have more opportunity to express their views 

and the nature of any special duties as military physicians during combat.

The ethical issues military psychiatrists may face 

in regard to detainees’ care are numerous. Military 

psychiatrists may be asked to serve as consultants 

during interrogations under the present Department of 

Defense (DoD) regulations (though psychologists, usually, will take on this role); they must, however, treat 

detainees solely and exclusively as clinicians would. 

This discussion will not attempt to provide the 

“right” answers to these ethical questions. Rather, it 

will presume that ethical analysis can’t provide these 

answers, because the values that should warrant highest priority may reasonably differ. It will, however, 

attempt to provide useful frameworks for considering 

the more difficult questions these situations pose. It 

will also present key considerations that those making 

these determinations should consider. It will finally 

suggest values that the ethical solutions eventually 

reached should take into account, regardless of what 

these solutions will be. 

General Questions Regarding the Nonmedical 

Treatment of Detainees

The core question involving detainees is the extent 

to which they should be regarded and, accordingly, 

treated primarily as persons who could have information that could save many lives, or as persons 

who no longer pose an immediate threat, and thus, 

like POWs, should be warranted optimal respect and 

care as persons who are no longer combatants. When 

detainees are first incarcerated, the ethical justification 

for treating them primarily as persons who may have 

information that could save others’ lives is greatest. 

Over time, increasingly, the strength of this justification 

will probably decrease. 

Three more specific key questions raised by nonmedical treatment of detainees concern (1) what 

approaches should interrogators be permitted to use 

during interrogations, (2) should the conditions under 

which detainees are incarcerated change over time, and 

(3) who should decide both of these questions.

What Approaches Should Interrogators Be 

Permitted to Use?

Widespread agreement exists that, ethically and 

legally, the United States should be prohibited from 

engaging in cruel, inhumane, or degrading treatment 

of detainees. Specifically, the question involves the 
733

Ethics and Military Medicine: Core Contemporary Questions 

concrete concern as to whether any harm—permanent 

or transient, physical or psychological—should be 

permitted at all. A starting point for addressing all 

these questions is to ask what approaches law enforcement personnel now take in the United States with US 

citizens when they suspect that these individuals have 

already committed or may commit heinous crimes. 

Some believe that what the general public currently 

permits in these situations goes too far. Still, assuming that what is now legally permitted is at least ethically acceptable, if not ideal, brings into focus the key 

questions that should now be asked regarding limits 

to interrogators’ actions: should interrogators be permitted to cause detainees greater harm than what is 

allowable with citizens, and, if so, how much greater, 

and why? 

The main argument in favor of allowing interrogators to inflict greater harm to detainees by using more 

harmful techniques is to further the possibility of saving more lives. As a starting point in this discussion, 

a suspected serial killer is a paradigmatic example of 

a US citizen wanting to kill others now or in the future. Such persons, if released, may continue to kill. A 

second paradigmatic example that can be used for the 

purpose of conducting this analysis is a person such 

as Timothy McVeigh, when it was suspected that he 

blew up the Murrah Federal Building in Oklahoma 

City in 1995.

In cases such as these, law enforcement personnel 

in the United States are limited in spite of the fact that 

if they used more harmful techniques, they might 

potentially save greater numbers of lives in future 

terrorism cases. Detainees may differ in several ways 

from “ordinary” criminals. Chief among these are 

three: First, they may have information that could 

save many more lives, even more than individuals like 

McVeigh. The number of lives saved could be in the 

tens, hundreds, thousands, or even more. If a terrorist 

planned to release a lethal biological agent in New York 

City and a detainee could identify a plot and potential 

perpetrators before this took place, it could save the 

lives of perhaps millions. 

The likelihood of this occurring may be remote. It 

may, also, be uncertain whether a detainee has this 

information and if so, whether duress during an interrogation will elicit the information in time for it to be 

of value. Research indicates that most information obtained by coercive measures is unreliable13; still, some 

of this information may be of value. The ethical conflict 

then is between respecting detainees optimally, such 

as treating them as one would US citizens suspected 

of being serial killers or mass murderers, like McVeigh, 

versus possibly gaining information through severe 

treatment that could save countless lives.

Second, the present threat is different from what it 

was during even World War II when the Nazis committed genocide. Now, terrorists can live alone, out of 

communication with each other for years or decades, 

only then to emerge and possibly endanger an entire 

city. The only means of finding these terrorists and 

preventing such harm may be to learn their identities 

from detainees. 

Third, many contemporary terrorists may be motivated to kill others for a variety of reasons, including religious ones. Terrorists motivated by religious 

reasons, however, may not care whether they live or 

die in the course of killing others. Indeed, they may 

actively seek to die as they carry out their attacks. This 

“new” motivation may escalate the means they are 

willing to take, such as killing themselves or even their 

children, thus adding another reason that interrogators 

might be more ethically justified in using interrogation 

techniques harsher than US civilian law enforcement 

personnel use.

The indignity and harm that using more “vigorous” techniques would cause detainees are the main 

ethical arguments against using these techniques. 

What should be further said regarding these arguments? First, even if tens of thousands of persons 

could be saved as a result of detainees having specific 

and valuable information, it doesn’t follow that any 

and all means possible to produce this outcome are 

ethically justifiable. Interrogation approaches, at the 

extreme, include torture, threats of torture, and torture 

or threats of torture to detainees’ families. At some 

point, especially in ancient times, these approaches 

were used, in large part for their deterrent effect. Now, 

these approaches are generally deemed unconscionable choices that might destroy the values initially 

worth fighting for.

Second, in other contexts in the United States, absolute priority is given to respecting all persons’ dignity 

regardless of the numbers of lives that could be saved 

by not doing this. The best example and paradigm 

here is the present practice in the conduct of research. 

Regardless of the possible gain, no participants can be 

used against their will.

Some, such as Michael Gross, the author of the previously mentioned military medical ethics text, question 

whether traditional value priorities should continue to 

prevail at this time.4

 Gross cites the question of what to 

do if terrorists infiltrate themselves among civilians so 

that they will not be caught. He argues that there are only 

two options: (1) doing nothing and becoming defenseless, or (2) departing from previous values and accepting 

a greater loss of “innocent” civilian lives in the effort to 

rout out the terrorists who have infiltrated them. 

Should limits be proscribed and, if so, should these 
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Combat and Operational Behavioral Health

be explicitly and specifically publicized? The first question to be answered here is where the line should be 

drawn between permissible and impermissible interrogation approaches. The second question that must 

be answered is the extent to which this line should be 

established by enunciating and publishing concrete, 

specific limits. If these limits are too vague, interrogators may more easily stretch them. Interrogators may 

do this for a worthy reason—hoping to save the greatest number of lives. Thus, due to the merit underlying 

this aim, many interrogators may seek to do this to the 

extent that they legally can. 

Specific limits help prevent this stretching. An example is the abuses that occurred at the prison in Abu 

Ghraib, Iraq. All military service persons know that 

they are legally required to refuse unethical or illegal 

orders. If it is unclear whether an order is unethical 

or illegal, a service person given such an order may 

be less clear on what to do. The cost of disobeying 

is potentially a court-martial. Thus, this is a strong, 

prima facie argument for establishing prior, specific, 

and concrete limits.

Too much specificity, however, that is too well 

publicized also carries a price when persons such 

as detainees may have information that could save 

lives. If limits are spelled out in too much detail and 

detainees come to know what these specific limits are, 

they may find it easier to “steel themselves” during 

interrogations so that they do not give information 

before these limits are reached. Consequently, they 

may give out less information and as a result fewer 

lives may be saved.

Should Detainees’ Conditions Be Improved Over 

Time? 

A similar price potentially exists in regard to giving detainees greatly improved conditions over time, 

such as to be able to communicate again with their 

families. Knowing that they can look forward to such 

privileges also may help them “hold out.” On the 

other hand, it is most humane to improve detainees’ 

conditions and give them the fullest access to their 

families after they have been interrogated and after 

the predominant likelihood of their giving information has passed. 

Once interrogation efforts have most likely exhausted the degree to which interrogators can “succeed,” 

logically the argument for giving detainees greater 

privileges, such as regaining contact with their families, should be greater. From this perspective, detainees 

should be regarded more and more over time as persons warranting greater respect and care, as opposed 

to their continuing to be regarded more as potential 

sources of life-saving information. If detainees know 

that in time this opportunity will occur, it may likewise 

make it easier for them to steel themselves during 

interrogations so that they don’t give out information 

that they otherwise would. Some might suggest that 

seeing their families could be used as a “carrot,” or 

incentive to give information. This approach would 

more extensively exploit detainees’ vulnerability and 

may be more ethically problematic and, in the view of 

some, even unconscionable for this reason.

As a possible alternative and a moral compromise 

between these conflicting values, greater opportunities 

could be given to some detainees but not all. Then, all 

wouldn’t know with certainty that they would ever 

gain these opportunities. It may be that, empirically, 

detainees’ knowledge of better futures will have no 

effect on their capacity or decision to withhold information during interrogations. Their knowing that 

they could see their families could, on the other hand, 

possibly increase their positive regard for the United 

States, and thus their willingness to give out more 

information. 

In general, detainees who are treated humanely may 

become more willing to give information over time. 

Even this possibility is ethically problematic, however, because it involves viewing detainees primarily 

not as ends in themselves, because they are humans, 

but as means to an end. Alternatively, it may be that 

detainees should only be ultimately regarded as ends 

in themselves. In this case, their captors should treat 

them humanely even at the expense of other losses, 

even including loss of other lives.

Remaining questions to be answered are whether, 

in extreme cases, there should be exceptions and a 

mechanism to implement the exceptions. Exceptional 

interrogation techniques might be permissible, in rare 

circumstances, when extremely extenuating criteria 

exist. These criteria might include many lives being 

endangered, the danger being imminent, and it being highly likely that a detainee has information that 

could save lives. In these situations there could also 

be a mechanism for outside review before exceptional 

interrogation approaches are used, as well as observation during the interrogation. The major argument in 

favor of permitting such a mechanism for exceptions 

is that it could save more lives. 

There are two ethical questions involved in interrogating detainees and having mechanisms for making 

exceptions to limits. First, what is the highest moral 

road? And second, what, if any, criteria would justify 

the United States not taking this usual “highest” moral 

road? In making these decisions, it may that a high 

price would be paid to maintain moral standards that 

most people can accept. This price would involve al-
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Ethics and Military Medicine: Core Contemporary Questions 

lowing persons’ lives to be lost and accepting this loss 

in advance.

Who Should Decide These Questions?

Who should decide what the limits for interrogators 

should be, notwithstanding the potential loss of lives? 

If established, should these limits then be made public 

and explicit?14(pp89–90) International codes may be one 

source of answers. Yet, ethically, using international 

codes alone to determine policy is problematic for 

many reasons. First, if the codes were enacted before 

the terrorist attacks of September 11, 2001, they could 

not have taken into consideration newer circumstances 

and possibly greater risks terrorists now pose. Codes 

enacted since this time, on the other hand, could. Second, codes by their nature are limited. Likewise, the 

ethical soundness of the tenets in all codes may be less 

sound in exceptional circumstances, such as when a 

detainee has information that could save thousands 

of lives.

These limitations inherent in codes may justifiably 

result in supporting interrogations that are harsh, or in 

allowing military medical personnel to treat POWs in 

ways that are unequal, as delineated in the discussion 

above. Military medical personnel may, consistently 

with international requirements, categorize all service 

persons and all POWs with abdominal wounds in the 

same group, notwithstanding these wounds’ seriousness and urgency. The code says that care providers 

must treat service persons and POWs equally. However, because it doesn’t specify whether both groups 

of patients must be treated alternately or on a random 

basis, military care providers could treat all their own 

soldiers in the same category of medical illness first, 

followed by treatment of POWs.2

Analogously, if a code prohibits interrogators from 

using cruel or inhumane approaches, it could, by its obverse implication, condone interrogators using harsh 

approaches that don’t quite meet the standard of cruel 

or inhuman, but nonetheless go beyond those permitted to US law enforcement personnel interrogating US 

citizens. It may be that these standards should be the 

same or, perhaps, that even the present policies for US 

citizens go too far—or not far enough—in allowing the 

use of harsh interrogation techniques.

Third, the risk of codes not being specific enough 

and not going far enough is especially possible because codes often represent a compromise. They may 

reflect political pressures and may, like laws, express 

the least demanding, but still permissible ethical action that persons should take, rather than expressing 

the highest ethical standards to which they can and 

should adhere. Because international codes represent 

a compromise that requires finding areas in which all 

can agree, codes may represent a “bottom line” acceptable to all participants. 

This situation currently poses a problem for the 

United States. Codes may proscribe certain practices 

with detainees, such as forced-feeding if the detainee 

is on a hunger strike. What may be optimal for countries in general may not be optimal or even acceptable 

for specific countries, such as those most targeted by 

terrorists for attack. Thus, the losses to these latter 

countries—such as the United States—for following 

the code may be greater and the benefits less than for 

other countries. Ethical analysis often can’t provide the 

right answers to these questions, any more than it can 

give an answer that is self-evidently valid. 

Achieving the best ethical outcome may be attempted by submitting what is at question to the 

optimal process of consideration. In the United States, 

this may mean submitting ethical questions such as 

these to legislators, who are the persons the greater 

society chooses to decide these questions, checked and 

countered, from time to time, by the courts. The decisions made at any one time may be overturned. Still, 

allowing legislation to determine ethical codes may be 

the best process possible.15,16(pp37–40) The “best antidote 

to bounded rationality—as manifested by cognitive 

biases and resulting errors in judgment—may be to 

deploy the law as a debiasing tool.”16(p37)

How Should Military Medical Care Providers Be 

Involved With Detainees, If At All?

The military’s general policies in regard to detainees, as just considered, are critical to the contingent 

question of how military care providers should interact 

with detainees.17 A first, core ethical issue in regard 

to military medical care providers’ involvement with 

detainees is the extent, if any, to which military care 

providers should isolate themselves from other military endeavors on the basis that they, as care providers, 

have a medical, profession-based, patient-oriented 

ethical standard to uphold, as opposed to a missionoriented moral standard. Key subquestions include the 

following: (a) how much should providers be involved 

in nonmedical actions, such as interrogations, and (b) 

what should providers do when they give detainees 

medical care. Should they, for instance, participate in 

force-feeding them?

In What Ways, If Any, Should Care Providers Be 

Involved in Nonmedical Acts?

There are many ways in which military care providers could be nonmedically involved with detainees.18
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Combat and Operational Behavioral Health

Psychiatrists and psychologists could work with 

interrogators during interrogations to try to find and 

probe areas in which detainees are most vulnerable 

in the hope of obtaining more information that could 

ultimately save lives. During interrogations, military 

care providers could also serve an opposite function: 

they could watch interrogations through a one-way 

mirror to attempt to ensure that the techniques interrogators use stay within their permissible limits and 

thus better protect detainees from harm.

What some view as the most overriding ethical 

concern here is that care providers have separate duties as care providers to detainees that may interfere or 

conflict with their obligations as military personnel or 

clash with military goals. The classical example in principle here is physicians’ obligation as physicians to do 

no harm, as proscribed under their Hippocratic Oath. 

Some view such care providers as having a higher 

moral standard regarding detainees’ well-being than 

interrogators, who are expected to at least be coercive if 

not harmful to detainees in seeking information. Thus, 

questions have been raised as to whether physicians 

should provide a safeguarding function for detainees 

by viewing them during interrogations through oneway mirrors.

Ethically, the assumption that military care providers have, or should have, a higher standard, as 

characterized above, may be more problematic than 

some have assumed. Persons in the military knowingly 

and willingly risk and often give their lives for their 

country. This is especially true when there is no draft. 

If there is a highest road in terms of behavior, it may be 

soldiers’ being willing to give their lives and carrying 

out other behaviors that also further the highest moral 

standards possible. Military noncare providers, such as 

interrogators, may be viewed as within this group in 

that they, like those willing to die during combat, give 

ultimate priority to trying to save others’ lives. 

However, it is not self-evident that care providers 

should serve some oversight function of interrogators merely because they and many others believe 

that they uphold a higher moral standard. What this 

suggests is that there may be, and perhaps should be, 

ethical conduct that both care providers and noncare 

providers would support equally. The military could 

adopt practices for interrogating detainees that most 

physicians, military or not, and most soldiers and most 

citizens would agree with. The military could decide 

also what actions, if any, it would need to take to enforce these standards. It would make sense, were this 

to occur, to view military personnel and military care 

providers as having moral values of equal status and 

to not see care providers as being the right group to 

serve an oversight function, practically or theoretically, 

because they serve higher moral values.4 

A second, related area of current controversy is 

whether physicians and particularly psychiatrists 

should not participate in the same ways as other care 

providers, specifically psychologists. The American 

Psychiatric Association (APA) has passed guidelines 

that forbid psychiatrists from being directly involved 

in interrogations, whereas the American Psychological 

Association has allowed participation to a greater extent. Inasmuch as both psychiatrists and psychologists 

may have clinical training, some psychologists question the basis on which psychiatrists—or physicians—

should be excluded from participating in military 

actions carried out to further the needs of the greater 

society, when psychologists aren’t, and possibly should 

not be, excluded.19–21 Nurses have raised this same 

question; however, their situation remains theoretical 

because nurses haven’t been asked to assist in interrogations. The same concern also applies to other mental 

healthcare providers, such as social workers. A possible 

overarching ethical question underlying these debates 

is whether it is possible for all military personnel, including interrogators and various care providers, to 

see themselves as pursuing the same ethical standards 

in serving the needs of the greater society. 

A further source of values that warrant moral 

weight and may conflict with those of care providers 

or those of the military is the greater society. A primary 

ground for society’s views warranting moral weight in 

regard to what physicians should do is that the public 

makes certain sacrifices so that medical students can 

learn to be physicians. Society funds medical schools 

and, more importantly, allows these students special 

privileges, such as to “practice” on bodies, whether 

cadavers or live patients, so they can learn the skills 

they will need later to be able to “cure.” This is also 

true in regard to other professionals such as nurses, 

clinical psychologists, and social workers.

Physicians, in return, at least implicitly promise to 

use their skills for good. This “good” may include conducting practices that society by inaction has implicitly 

condoned. Thus, in that society has allowed exceptions 

on this basis, exceptions justifiably exist. Physicians 

serve in some roles that serve society’s needs more 

than patients’ needs. An example is forensic psychiatry. 

Society, presumably, wants and accepts this.

One core ethical question regarding military care 

providers being involved in interrogations and other 

nonmedical military actions is whether society expects 

and accepts this, because if not, care providers may 

be violating their implicit promise to society to not 

harm but to “cure.” This question may be uniquely 

complicated, because the greater society might want 

physicians—psychiatrists in particular—to participate 
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Ethics and Military Medicine: Core Contemporary Questions 

in interrogations so that society may have greater protection. What the greater society wants and expects is, 

in theory, an empirical question. Society’s view may be 

expressed over time in how persons vote. The question remains, regardless of legislative outcomes, what 

moral weight should society’s view of the appropriate 

roles of care providers in the military have? Society 

may, on one hand, not want care providers to violate 

their implicit promise to cure, but on the other hand, 

society may want psychiatrists and other care providers to help protect society as much as possible.

The above question is of added importance because 

professional organizations may believe they, too, have 

a stake that warrants significant or even overriding 

weight in deciding what those within their profession should do. They may believe that their view 

should be decisive. Physicians have been told by the 

American Medical Association that they should not 

take on certain roles during criminal executions and 

psychiatrists, by the APA, that they shouldn’t evaluate criminal offenders and deem them sane to meet 

legislative criteria for execution. Organizations may 

take this same view in regard to psychiatrists or other 

care providers participating directly or indirectly in 

interrogations.

Thus, care providers within the military may fear 

that if the military asks them to serve in certain roles 

that depart from what their professional organizations have proscribed, they may jeopardize their good 

standing within these organizations or even lose their 

licenses to practice. This is again an instance in which, 

if possible, the military and these organizations becoming united and working toward adopting a shared, 

highest ethical value would be ideal.

Both the military and the APA may have grounds 

on which they could agree. Psychiatrists could, for 

instance, participate in formulating policy. Their 

agreeing on the level of participation in interrogations 

might make sense to both groups because behavioral 

healthcare providers offering suggestions in this capacity may help both the military and detainees. They 

may be able to suggest interrogation approaches that 

(a) are as effective but pose less of a risk of potential 

harm and (b) pose no more risk of potential harm but 

are more effective in eliciting information. These two 

possibilities illustrate an important general consideration regarding ethics that should always apply in 

cases such as this. That is, it is generally not difficult to 

recognize negative ethical aspects of a situation. What 

is more difficult ethically is to go one step beyond this 

and then find a better solution.

An important question regarding whether psychiatrists and other care providers should participate either 

indirectly or directly in interrogations is, therefore, 

what the relative gains and losses of each approach 

would be. One core consideration here is what would 

occur if psychiatrists, and other care providers, were 

not included in interrogations. The focus of controversy in regard to interrogations is, however, on 

military care providers being involved directly. Many 

care providers wince in response to the idea that they, 

themselves, as well as others, could rightfully perceive 

them as caring for patients on one day and stopping 

just short of inhumane treatment when working with 

detainees on the next.

It is not ethically clear that the solution of having 

mixed roles from one day to the next, sometimes in 

a forensic setting, which is generally accepted by forensic psychiatrists and psychologists, is sufficiently 

analogous to the interrogation issue to allow the 

justifications for one to apply to the other. When care 

providers evaluate suspected criminal offenders for 

insanity, they inform them that anything they say 

may be used against them. This warning helps respect 

these interviewees’ autonomy and helps behavioral 

healthcare providers in this role avoid engaging in 

implicit deceit.

Some believe that if care providers do the same 

thing with detainees, this may suffice, or at least reduce 

the extent to which the role of care providers, such as 

psychiatrists, is objectionable, so that they can, from an 

ethical standpoint, be justifiably involved in interrogations. This argument, however, may miss this point. 

The ethical presupposition made when forensic psychiatrists give this warning is that their conducting the 

evaluation is ethically justifiable even if psychiatrists 

find the interviewees to be sane as opposed to insane—

though the judge or jury will ultimately make this 

determination. This is because if psychiatrists don’t 

interview defendants to try to discern whether or not 

they were severely emotionally impaired when they 

committed their crime, the judge or jury will then have 

to make this determination. Without the psychiatry 

opinion, the judge or jury may be much more likely 

to infer that the defendants were sane. This could in 

some instances result in execution. 

In the interrogation of detainees, these same presuppositions don’t exist. The detainee is being pressured, purposefully, in the hope of affecting him or 

her sufficiently adversely to give up information. If 

the psychiatrist adds to this pressure, the psychiatrist 

is also doing harm. The psychiatrist could, however, 

also serve only as an ally to the detainee. For example, 

US military physicians have helped detainees greatly, 

some military care providers report, by developing 

their trust. This will be discussed in greater detail 

in the next section, which deals with detainees who 

refuse to eat.
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Combat and Operational Behavioral Health

A final question that should be asked is how could 

psychiatrists and other care providers help interrogators? It may be that the experience of interrogating 

detainees has no harmful effect on interrogators. Alternatively, however, it may. This especially may be 

the case if detainees are from a different ethnic group. 

This also may be truer if the approaches interrogators 

can use are harsher. Military care providers being 

present can help confirm for interrogators that while 

in the process of the interrogation, detainees remain 

persons not inherently different from the interrogators. 

Psychiatrists and others participating in this way could 

then be allies who might benefit interrogators as well 

as detainees.

How Should Military Care Providers Treat 

Detainees?

Ethical treatment of detainees by military care providers is complex. A potential scenario could involve 

a detainee with diabetes. Here, clinicians informing 

interrogators of this condition may be essential so 

that interrogators respond in ways that will maximally meet detainees’ medical need for drugs such 

as insulin. Interrogators with this knowledge may 

require medical providers to monitor food intake so 

that the detainee is unlikely to become hypoglycemic. 

Yet, at the same time, if clinicians provide clinical information, interrogators could misuse it. Interrogators 

could threaten to allow detainees’ blood sugar level to 

dangerously fluctuate (whether or not they could or 

would, in actuality, do this) to try to get detainees to 

provide the information they want.

It may be wholly implausible that this would 

happen. Rather, if clear specific limits are in place, 

interrogators are obligated to stay within the rules 

previously proscribed by the DoD, even if these rules 

are to some extent vague and thus allow “loopholes.”22

Furthermore, the military could develop mechanisms 

to ensure that if care providers give interrogators information like this to help detainees, interrogators don’t 

misuse it. Such mechanisms could include outside 

review, ensuring greater transparency, as indicated 

above. In other contexts, care providers couldn’t be 

reasonably expected to be able to treat detainees optimally unless they could wholly respect detainees’ 

confidentiality. If detainees were depressed, they might 

share their feelings, honestly, only if they felt that they 

had trustworthy care providers.

Military physicians, in innumerable cases, have 

reportedly shown extraordinary compassion to detainees and, as a result, gained their trust. In these 

cases compassion was shown not to gain trust in 

hopes of improved information gathering, but to treat 

detainees with respect, simply as persons, regardless 

of whether it would affect provision of information 

or not. To attain and maintain this confidentially may 

require additional resources. An example here is the 

need for sufficient numbers of interpreters. If the interpreters for clinicians and interrogators are different, it 

could be expected, both theoretically and practically, 

that detainees would have greater trust in their care 

providers. Otherwise, they might fear that information interpreters hear during the “clinical hour” could 

then be passed on to interrogators, who could use the 

information against them.

More money spent by the military, and by extension 

the greater society, to provide the necessary conditions 

for optimal medical care should be a high priority. 

Treating detainees with optimal respect should, perhaps, generally take priority over other, competing 

ethical values. Plausibly, the military’s doing this 

would serve to enhance detainees’ trust. The military 

at Guantanamo now may provide first-class medical 

care to detainees. For example, medical care previously offered to detainees of a certain age includes 

evaluation of elevated prostate-specific antigen blood 

levels to possibly detect early prostate cancer and endoscopic examinations of their lower bowels to assess 

for possible early colon cancer. Does the military do 

everything for detainees that care providers would for 

prisoners in the United States or civilians in the best 

US hospitals? Should it? 

The answers to these questions are analogous to 

many others considered above. Some of these decisions may rightfully be those for the greater society. 

However, the greater society may be unjust. What is 

clear is that what should be done can be known with 

greater certainty only as what is being done now 

becomes increasingly transparent. Then, wherever 

the lines are drawn now can be subjected to greater 

scrutiny, and society, through legislation or the courts, 

can decide whether or not what is done now is what 

should be done. 

The main reason for the military’s acting on behalf 

of the greater society to maximize detainees’ trust may 

not be to “win them over” in the hope that they would 

then give information that could save lives. Rather, the 

reason may be to regard detainees as primarily ends 

in and of themselves. The idea that humans should 

never be used unduly as means to others’ ends, as 

opposed to ends in themselves, is a common principle 

accepted in ethics and put forth by Kant. It is based on 

what respect for humans and human dignity requires. 

If, for example, interrogators pretend they are friends 

of detainees to get information, these interrogators 

are deceiving detainees and using them as primarily 

means to US ends. Ethically this is problematic, though 
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Ethics and Military Medicine: Core Contemporary Questions 

it may be justifiable if one can argue for other reasons, 

such as saving millions of lives. 

Optimal care may then be warranted merely because detainees should, as fellow humans, have care 

providers they can trust regardless of what they have 

done or may have done. As persons and captives, they 

still warrant utmost respect. This value, and this value 

alone, generally is presumed to be overriding unless a 

compelling case against it can be made. Similarly, this 

principle should be adhered to in all instances in which 

detainees are involved unless some other, convincing 

case can be made. Thus, providing detainees with the 

utmost respect can be a core, initial ethical position 

on which all persons—interrogators and physicians 

alike—could agree, at least initially. 

In regard to specific approaches permitted during 

interrogations, it may be that a resolution acceptable 

to most concerned parties is achievable. All parties 

should seek ethical unity, if possible. A next strategy 

to resolving the many potential conflicts between care 

providers and other military personnel is to seek out 

and find value priorities on which most parties, both 

military and civilian, can agree. 

The value in regard to which pursuing this stragey 

may be most plausible may occur after detainees have 

been incarcerated and later, during every moment 

of their interrogations. This value is that detainees 

should be respected as persons. This fundamental 

concept is paramount not only in this country’s ethics, 

but also internationally. Thus, it may be that greater 

ethical agreement both nationally and internationally 

may be possible. With this agreement it may be that 

applications shared to a greater extent by all can be 

brought about.

How Should Military Care Providers Respond 

When Detainees Refuse To Eat?

Substantial numbers of detainees may refuse to eat. 

The core ethical conflict this brings about is whether 

military care providers should force-feed detainees 

against their protests and thus maintain their lives, or 

if providers should respect detainees’ autonomy by going along with what they request.23,24 The key question 

here is what care providers should do and why.

Should Care Providers Force-Feed Detainees or 

Respect Their Autonomy?

In this situation, the context is most important ethically. Generally it is considered a first ethical priority 

to respect persons by allowing them autonomy. The 

one value that may most reasonably override this 

is another deontological value—that is, respecting 

detainees in another way by maintaining their lives. 

Detainees may have uncertain futures and be denied 

physical contact with their families. Thus, respecting 

their autonomy by allowing them to choose to die is 

especially problematic. This is because showing respect 

for detainees as persons may better be accomplished 

by improving the conditions under which they live. 

Respecting their autonomy warrants more moral 

weight if the context in which they live maximizes 

their welfare and if, as a result of this, their capacity 

to make choices is unfettered by pressing personal or 

emotional needs.

If the detainees’ situations are improved as much as 

possible, it may be that it is justifiable to still force-feed 

them against their will because this maintains their 

lives. Thus, it may be more effectively determined at a 

later time whether this same refusal to eat, if they still 

are refusing food, should be respected. This rationale 

may lose moral weight over time because it will be 

increasingly implausible to believe that detainees will 

decide they really want to live at some point if they 

have continued to refuse to eat.

This principle, attending to persons’ greater context 

as opposed to their most immediate needs, is exemplified most notoriously by an example involving 

research in Willowbrook, New York. Here, several 

thousand children who were “retarded” were institutionalized and lived in poor hygienic conditions. 

Many, if not most, of the children contracted hepatitis. 

Researchers wanted to study hepatitis by intentionally giving the disease to a group of these children. 

They justified this because the children participating 

in this research would be better off in two ways: (1) 

they would live under better conditions, and (2) the 

hepatitis they acquired would be less severe in the 

research setting than if naturally acquired from the 

general population at the institution. 

The study began in the 1950s and continued into the 

1960s. After the study was completed, it was criticized 

on the basis that it had exploited the children’s poor 

condition and in doing so treated them primarily as 

means to others’ ends. To treat them as ends in themselves would have meant to change their surroundings and make their surroundings better. Since then, 

this has been done. These children, now adults, were 

placed in small group homes; Willowbrook Institution 

no longer exists.

The analogy here is that respecting detainees’ 

autonomy by allowing them to die in their present 

context may be problematic because efforts could be 

taken to improve their situation. Respecting them more 

may require establishing rigorous criteria to determine 

when detainees are much more likely to give useful 

information, and once this “window” had passed, 
740

Combat and Operational Behavioral Health

creating for them better living conditions (according 

to their views of what these should be). Otherwise, 

care providers granting detainees autonomy under 

conditions that offer them little to no present source 

of meaningfulness in their lives would respect their 

autonomy literally and, in this one sense, also further 

the likelihood of their wanting to die.

Ethically, the practice of allowing detainees who 

wanted to starve to death to do so could risk military 

care providers meeting the requirement of international law but violating its spirit, just as they could 

when treating US soldiers and POWs “equally,” as 

described earlier in this chapter.2 Care providers could 

literally respect detainees’ autonomy while knowing 

that their environment is impoverished and intentionally leaving it that way. Thus, detainees could live and 

be allowed to remain in an environment unnecessarily 

conducive to increasing the likelihood that they would 

want to die.

In the case of care providers granting detainees 

autonomy to starve themselves to death, a similar 

question of intent may be involved. Suppose that detainees remain living under conditions in which they 

can find little or no meaning and that the likelihood 

of them providing useful information has become 

remote. If they are then allowed to die, allegedly to 

respect their autonomy, this could be done due to an 

underlying intent to further the likelihood that they 

would choose to die, as opposed to an overt intent 

to respect their autonomy. It would be unclear what 

the genuine underlying intent of those allowing the 

detainees to die really is. 

In like manner, care providers respecting detainees’ autonomy in a context that they find meaningless, when this context could be changed, may not be 

ethically justifiable. Care providers may be implicitly 

accepting and supporting the circumstances that 

may contribute to these detainees’ deaths. It may be, 

on the other hand, that improvements in detainees’ 

lives aren’t possible for reasons related to security. If 

so, significant harms that could result from making 

these changes might preclude these changes from 

being made.

Military care providers, even knowing all this, may 

have limited choices. Regardless, if they act in ways 

that accept and support a suboptimal environment, 

they may be ethically guilty of moral complicity. Still, 

if they do respect the prisoners’ autonomy by allowing 

them to not eat—whether this is the providers’ choice 

or that of others higher in their chain of command—

they may then have an ethical duty to offer detainees 

sedation so that as they starve to death, they don’t suffer. By giving this sedation, these care providers would 

be facilitating these detainees’ deaths, because sedation would most likely shorten their lives. Providing 

sedation might be viewed for this reason as ethically 

unjustifiable. Yet, the military care providers’ intent 

would be to relieve the suffering of the detainees. Giving sedation might ethically be not only justifiable but 

also mandatory because it is more humane.

A second choice of military care providers under 

these conditions would be to refuse to participate, 

even in giving sedation. Care providers are outside 

the combat setting and thus they should have greater 

opportunity to express and adhere to personal values 

that they hold within their moral conscience. Their 

refusing to participate could violate the principle of 

military necessity if detainees’ starving was viewed as 

likely to rally persons throughout the globe to carry 

on their fight. Then, and only then, might military care 

providers have a higher, overriding ethical military 

duty to do what they must to further the military mission of protecting society. 

The possibility of rallying other countries or organizations against the United States could be the 

ethical justifification to require physicians to forcefeed detainees. If important military needs are not at 

stake, however, military care providers should be able 

to adhere to their own moral values and views to the 

same extent as their civilian colleagues.

What this should require in practice is itself an 

ethical question. Assuming military necessity isn’t 

present, should a recruiter of physicians who will 

care for detainees on a hospital ward only ask them 

whether they have moral scruples or, if they say that 

they do have moral scruples, then ask them further 

what these are? Asking them only whether they have 

scruples most respects physicians as persons by not 

requiring them to come up with “valid” reasons. Asking them the specifics of their scruples, in comparison, 

in effect disrespects them, because their moral values 

are respected to a lesser extent. In other words, in the 

latter case, their values and moral conscience would be 

respected only if they give “acceptable” reasons.

Furthermore, recruiters’ asking military care 

providers for the reasons for their scruples presupposes that logical reasons underlie all valid emotional 

“qualms.” However, this isn’t the case. Many times, 

what persons experience as a violation of their moral 

conscience is a felt emotion, and persons may or may 

not be able to articulate why they feel this way. Likewise, in its effect, this question also would discriminate 

between those physicians who report “good reasons” 

and those who do not. This may violate a morally 

important aspect of care providers being treated with 

equality and, as an unwanted consequence, it might 

divide them as a group.

The highest road for physicians to take with most 
741

Ethics and Military Medicine: Core Contemporary Questions 

patients who want to refuse treatment and die by this 

means may be for these care providers to take measures to try to ensure that dying is what these patients 

really most want. Then, if and when providers have 

taken these measures, their highest moral road may be 

to accept the detainees’ wishes. For example, if patients 

have just undergone trauma and acquired quadriplegia, hours later they may request that their respirator 

be shut off. These patients’ care providers might well 

ask them whether they might be willing to take a bit 

more time because there are many persons in this situation who respond like the late Christopher Reeve, who 

lived for 9 years after suffering a catastrophic cervical 

vertebrae fracture in 1995. They may in time also find 

meaning in this wholly altered state. Military physicians may see their optimal ethical task as to take an 

analogous route with detainees.

The ethical idea at stake here is to try to enable 

such patients to be more truly autonomous and not 

unduly driven by overriding needs when these needs 

can be better met. This is especially important when 

one choice patients can make, namely death by starvation, is irreversible. The longer these patients persist in 

making this same request, the stronger the argument 

becomes for granting it, despite the fact that these 

patients may seem, from an objective perspective, to 

have unchanged needs. Subjectively, of course, even 

though their external environment hasn’t changed, 

detainees may be quite different “inside.”

Applying these ethical guidelines to detainees 

would suggest that an optimal ethical course might be 

to maximize the immediate benefits detainees could 

enjoy once reasonable time had been given to attempt 

to obtain information from them. After giving them 

maximal possible benefits, time should be allowed to 

help ensure that not eating was what a detainee really 

wanted to do. Detainees might change their minds 

over time and subsequently want to live without being 

aware beforehand that this might occur. Many patients 

with terminal illness want to die at one time only to 

feel later that they want to live on as long as they can. 

For this reason, even in the two states in the United 

States in which patients can have assistance in dying, 

their request generally must be repeated and sustained 

over a significant intervening period of time before care 

providers can go along with their request.

It might be claimed that because detainees’ external conditions are in so many respects impoverished, 

such as their not being able to have physical contact 

with their families, it is likely that many are genuinely 

depressed and thus their depression could deprive 

them of sufficient mental capacity to be competent 

to then choose to die. This concern, though ethically 

reasonable, would in principle be inconsistent with 

the possibility in civilian contexts in the United States 

that persons depressed or significantly emotionally 

impaired can still determine their outcomes. Thus, in 

this country, even if patients are severely depressed, 

this generally does not preclude them from making 

even life-ending decisions regarding themselves.

A question implicit throughout the above discussion 

is, however, whether patients who are ill or even have 

a terminal illness are the most appropriate subjects to 

use as an ethical analogy. It may be that no group will 

suffice as an analogy. Other analogies, such as prisoners incarcerated with life sentences, may be as, or more, 

valid, although not sufficient. This prisoner analogy 

could be cut in different ways. It might suggest that 

detainees should have much greater rights, such as to 

be able to meet physically with their families. But it 

might also imply (unlike the use of the medical analogy) that they should not have the option of choosing 

to die by starvation. The present policy of not allowing 

detainees to refuse to eat and thus to die by this means 

is based on US law regarding prisoners. 

The prisoner analogy may be flawed, depending on 

whether allowing prisoners to refuse to eat, even when 

they will be executed, is or isn’t ethically justifiable. 

The underlying rationale for not allowing the refusal 

to eat may be one of punishment. If so, the rationale 

of punishing detainees by this same means wouldn’t 

suffice. A second possible rationale some might offer 

for not allowing persons on death row to refuse to eat 

is that persons on death row may be depressed and 

for this reason incompetent to choose whether they 

want to die by starvation. This, too, wouldn’t suffice 

because even if patients are depressed, they still may 

be deemed sufficiently competent to refuse life-saving 

treatment.

In this instance there may be no adequately analogous situations. Military care providers not participating directly in interrogations may not be sufficiently 

like forensic psychiatrists, nor like physicians giving 

lethal injections to effect criminals’ deaths, nor like 

psychiatrists determining that persons are incurable 

sociopaths such that death should or should not be 

imposed. Likewise, a detainee wanting to starve to 

death may not be sufficiently like a patient with terminal illness wanting to refuse a respirator (or food 

and water) so that death is hastened. 

None of these examples may be a close enough 

replica of the detainee situation to serve as an ethically 

adequate model. If these analogies are insufficient, 

the answers to the above questions may thus be more 

difficult. Ethics may at best only shed light on the key 

factors to be considered. This analysis has considered 

both the importance and the limitations of codes. 

These codes emphasize the importance of respecting 
742

Combat and Operational Behavioral Health

prisoners’ autonomy. Allowing detainees to die under 

suboptimal conditions may, however, be qualitatively 

different from what those enacting these codes, which 

require respect for autonomy, had in mind. Thus, this 

different context should be considered.

The sanctity of persons’ lives is an important deontological value, as is respecting persons’ dignity 

in other ways, such as respecting their autonomy. In 

some situations it is considered ethically justifiable 

for physicians to override patients’ autonomy and to 

exercise therapeutic privilege. This is allowed by law 

in all states and recently has been reaffirmed by the 

Council on Ethical and Judicial Affairs, a body within 

the AMA.25 Physicians can exercise this privilege only 

when not doing so would, in their view, harm patients 

unduly. Whether overriding detainees’ refusals to eat 

would meet these same criteria is open to challenge. 

However, furthering detainees’ interests, such as in 

the use of therapeutic privilege, may be the only basis 

on which overriding detainees’ autonomy could be 

justifiable.

Soldiers’ Opportunity to “Speak Up”

Military care providers may have markedly different, even heart-felt, views on whether or not detainees 

should be force-fed. This raises a question in regard 

to not only this situation, but to all areas concerning 

the extent to which soldiers should be free to express 

their views and more specifically whether or not 

they should have more freedom than they have now. 

During combat operations, it is imperative that every 

soldier follows orders and works together with other 

soldiers to accomplish the mission, as directed. There 

is little room to question commands, unless the orders 

are in violation of the Uniform Code of Military Justice 

or the rules of engagement. Soldiers having a dissenting opinion may be vulnerable to highly significant 

sanctions if they speak out. 

There are also clear guidelines that limit a soldier’s 

first amendment right to free speech. But are the present limitations ethically optimal, or could the creation 

of an environment with more free flow of communication serve both soldiers and their commands better? 

Might the military be stronger if soldiers are allowed 

to verbally dissent? 

If soldiers could do this, they would need to 

be aware of the appropriate method to make their 

disagreements known, and a more “liberal” process 

would need to be set in place. This change might create a better system by instilling a pressure valve to 

allow soldiers an outlet for expressing themselves. 

This might work to increase morale by allowing even 

the lowest ranking individual an avenue to be heard. 

Many improvements may even be identified by this 

same method. 

Three recently occurring postdeployment problems 

particularly warrant ethical discussion. These are (1) 

whether soldiers with posttraumatic stress disorder 

(PTSD) should be redeployed, (2) what should be done 

when soldiers have or may have head injuries due to 

blasts, and (3) when, if ever, military physicians should 

make decisions on behalf of their soldiers’ interests and 

“against” rules and regulations, and “outside the box.” 

The appropriate role for military behavioral healthcare 

providers in these ethical issues is particularly evident. 

PTSD is among the most important of the disorders 

they must treat.

Posttraumatic Stress Disorder

The first of these problems focuses on whether soldiers who have deployed, and then been diagnosed 

with an acute stress disorder or PTSD, should be deployed again into a combat environment. This ethical 

dilemma revolves around the competing needs of the 

individual and the needs of the military. The needs of 

the individual may be best served by allowing them 

to delay deployment to allow treatment and healing 

or by avoiding another deployment altogether. 

This could, however, have a negative effect on 

soldiers by decreasing their expectancy that they will 

improve and may lead to a fixation of their symptoms 

and subsequent disability. This may also cause soldiers 

to experience increased guilt over not being with their 

buddies and unit during future operations. Some 

soldiers, especially those suffering from more mild 

degrees of PTSD, might not only want to return to the 

theater, but may do better if they do. 

Allowing these individuals to avoid a deployment can also have a significant effect on their unit’s 

readiness. Many individuals may begin to mimic 

these illnesses intentionally to avoid deployment. This 

“copycat” scenario is seen throughout military units. 

This phenomenon isn’t exclusive to deployments. 

There have been many accounts of one individual in a 

unit being administratively separated, or avoiding an 

agreed-upon military service commitment, and then 

this being followed by several other unit members 

claiming the same level of distress. Suicidality is an 

example, as well as soldiers alleging that continued 

military service would keep them at risk. They may 

POSTDEPLOYMENT PROBLEMS
743

Ethics and Military Medicine: Core Contemporary Questions 

then request to be administratively separated. This 

can affect a unit’s readiness and decrease the available 

number of trained troops. A competing concern is the 

potential negative consequences for units that may 

have these individuals with them in theater. These 

individuals, in addition, may be more vulnerable to 

recurrent or progressive impairments, can consume 

a disproportionate amount of human resources, and 

may compromise security.

Allowing this means of exclusion, especially for 

those more mildly affected, may also have effects on 

recruiting. Indicating to potential recruits that soldiers 

in distress will be taken care of, even to the extent that 

continued deployments may not be required, may 

facilitate recruiting. The extent of this effect, if any, is 

open to speculation. In the present state of uncertainty, 

three key variables should be weighed and considered. 

Two are in favor of deploying these soldiers, and one 

opposes deployment. Suppose that deploying the soldiers, overall, does help their healing process. This may 

benefit these individuals and their families. Military 

units may also benefit by allowing them to maintain 

their needed unit strengths, and therefore having the 

needed numbers of trained soldiers to complete their 

missions. 

Recruiting, which currently faces many challenges, 

may be enhanced by going the “other” way, namely, 

by allowing affected individuals to delay deployment 

to receive treatment, or to avoid another deployment 

altogether. Empirical data will indicate more clearly 

over time how soldiers with PTSD respond overall 

to being redeployed. Until this information is better 

known, the best ethical solution to this question may 

remain more open to debate. 

Head Injuries

The second postdeployment ethical issue involves 

soldiers who return with head injuries caused by blast 

injuries, primarily in Iraq. Here what has been found 

is that these soldiers’ impairment may differ from that 

caused by other head injuries, such as those sustained 

in a car accident.26,27 These soldiers may remain literally competent or able to acknowledge accurately the 

pluses and minuses of accepting or declining treatment 

or of participating in research, but, at the same time, 

they may still have extensive underlying difficulties. 

These difficulties may become apparent only through 

formal cognitive testing. Most importantly, these difficulties may profoundly affect their judgment. The 

question has arisen whether the usual methods of 

assessing competency prior to allowing these soldiers 

to consent to treatment or to participate in research 

should suffice, or whether a special new category 

should be established in both treatment and research 

contexts to better take into account the recently discovered, unique cognitive impairments and needs of 

soldiers with head injuries.

Respect for these persons might require that a 

higher, stricter standard for determining competency 

be established. This would be, however, the first time 

that a special category of this type has been developed 

for such a specific group. Establishing such a standard 

could have the adverse effect of stigmatizing these 

individuals. It could also result in some soldiers becoming fearful or angry by limiting their autonomy 

or by alerting them for the first time that they had 

deficiencies of which they were unaware. This abrupt 

overwhelming of their denial could do exceptional 

harm.

The best approach in both these instances—

treatment and research—might be to provide greater 

procedural safeguards, individualized according to the 

harms potentially at stake. Depending on these harms, 

review of each soldier’s competency could be evaluated in detail by a specially constituted board with 

varied and exceptional expertise. This board could apply a graded standard, which would require a higher 

threshold for competency only when the treatment or 

research proposed posed a significantly greater risk. 

This approach might be roughly analogous to the 

greater protections provided now in regard to both 

treatment and research involving children. Requirements are established concerning children in research 

that don’t exist for adults and that vary according to 

the extent of children’s personal risks. DoD research 

regulations provide exceptional requirements for doing research that involves children, especially when 

the research involves more than minimal risk.

These additional innovative measures might be 

required on the basis of compensatory justice. Because 

these soldiers have taken extra risks on behalf of their 

country, safeguards that would help ensure that they 

make the best choices, even when they don’t know 

that they can’t make them, may be not only ethically 

optimal, but from the perspective of compensatory 

justice, may be ethically mandatory.

Decisions “Outside the Box”

The third postdeployment ethical issue to be discussed here involves whether it is ever justifiable 

for military physicians to make treatment decisions 

that are inconsistent with official policy. Should the 

military behavioral healthcare provider, for instance, 

always make decisions that are consistent with official 

policy, even if that policy may have a negative impact 

on patients’ treatment?
744

Combat and Operational Behavioral Health

Official policy dictates that those active duty service members not physically or mentally capable of 

deploying should be placed on limited duty. Limited 

duty status is temporary, often removes the member 

from the current job, and serves several purposes. It 

allows the service member’s parent command the opportunity to obtain a deployable replacement. It also 

allows the nondeployable service member’s condition to improve so that return to full duty can occur. 

Without this limited duty option, this return may not 

be possible. Limited duty can, however, negatively 

impact treatment by reinforcing the patient role and 

delaying recovery. 

There may be instances, however, when a patient 

who is not mentally capable of deployment should 

not be placed on limited duty. For example, patients 

recently returned from war and diagnosed with PTSD 

from trauma that occurred during the war may not 

be mentally fit just yet to return to the war. It is often 

possible to continue to treat such patients clinically 

but not to place them on a limited duty status because 

they would not be deployed for some time. This can 

be highly advantageous and desired by such soldiers 

because it may prevent unwanted consequences from 

being placed for any length of time on limited duty 

status.

Is it ethical for the military behavioral healthcare 

provider in such a case to not follow official policy 

and to not place the patient on limited duty in order 

to provide or facilitate additional treatment? What 

is the best ethical choice in these instances? All rules 

tend by their nature to create some “bad results.” 

Military physicians making off-the-record exceptions 

may prevent some bad results. If, on the other hand, 

all such physicians commonly use their individual 

discretion, this would undermine the rules and possibly cause greater harm. In this case, it may be that 

military physicians would be ethically justified in 

making exceptions if the cases in which they would 

do so occur but rarely. In such instances, they should 

also establish and specify criteria that should be met. 

One such criterion might be that both the spirit and 

purpose for which the rule was made in the first place 

are not fundamentally violated.

What the relevant criteria warranting moral weight 

should be may vary depending on the type of case. 

Military physicians may vary on the criteria they 

choose and the moral weight they place on each if 

they use their discretion. Still, using discretion, and the 

foreseeable harms this may bring about, may ethically 

outweigh the harms that will occur if they followed the 

rules so absolutely that no exceptions would occur.

This last example of military physicians making exceptions is, perhaps, paradigmatic of all the problems 

examined in this chapter and thus an ideal one with 

which to end this discussion. Most ethical questions 

involve a determination not so much of what the decision or decisions should be “across the board,” but 

rather where along the spectrum of real and imagined 

circumstances one should “draw the line,” why, and 

who should draw it.

In this chapter, the authors have attempted to highlight many of the existing ethical questions as well as 

new and emerging ones that have arisen. There generally are no self-evident answers to these questions that 

all reasonable persons will agree on. Still, the principles 

and most relevant facts should always be considered 

by those having the responsibility to make these decisions. This is what, more than anything else, ethics 

and ethical analysis has to offer. This analysis may 

enable decision makers to more maximally consider 

“both sides.” 

In some cases, “ethics” can clearly show something 

is wrong. The rationales for genocide used by the Nazis 

during World War II are an obvious and unequivocal 

example. In most, more difficult ethical problems, 

however, the questions that arise are and must remain 

open to debate. In these situations, the debate is not, 

however, so much over what is right and what is 

wrong, but as just discussed, what should be the general rule; when, if ever, one should make exceptions; 

and who should decide.

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10. Bloche MG, Marks JH. Doctors and interrogators at Guantanamo Bay. N Engl J Med. 2005;353(1):6–8.

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Combat and Operational Behavioral Health: Final Thoughts and Next Steps

Chapter 47

COMBAT AND OPERATIONAL 

BEHAVIORAL HEALTH: FINAL 

THOUGHTS AND NEXT STEPS

ELSPETH CAMERON RITCHIE, MD, MPH,* and MICHAEL DOYLE, MD†

INTRODUCTION

RECENT BEHAVIORAL HEALTH INITIATIVES

Behavioral Health Proponency

Defense Centers of Excellence

Comprehensive Soldier Fitness

Behavioral and Social Outcomes Health Program

Behavioral Health Providers

Other Initiatives

SUMMARY

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

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

NE, 4th Floor, Washington, DC 20002

†

Colonel, Medical Corps, US Army; Deputy Chief of Clinical Services, US Army Medical Activity, US Military Academy, 900 Washington Road, West 

Point, New York 10996; formerly, Commander, US Army Health Clinic, Wiesbaden, Germany
748

Combat and Operational Behavioral Health

INTRODUCTION

While this book has been in production, Department of Defense (DoD) behavioral healthcare delivery 

has improved dramatically. From the beginning of the 

conflicts in Afghanistan and Iraq, a robust combat stress 

control presence has been operating in theater. Much 

of the initial improvement was in the management of 

patients in theater and as they redeploy (return home) to 

the United States. Many chapters, such as those focused 

on patient care at Landstuhl Regional Medical Center 

in Germany and Walter Reed Army Medical Center in 

Washington, DC, have highlighted these improvements. 

Back in the United States, improving the reintegration 

of soldiers and their families is a continuous priority for 

leaders at all levels and for the nation.

RECENT BEHAVIORAL HEALTH INITIATIVES

Multiple new organizations and initiatives emerged 

in the last few years, such as: (a) the Behavioral Health 

Proponency; (b) the Defense Center of Excellence; (c) 

the Comprehensive Soldier Fitness Program; and (d) 

the Behavioral and Social Health Outcomes Program 

at the former Center for Health Promotion and Preventive Medicine (CHPPM), now the Public Health 

Command (Provisional). The Army Campaign Plan 

for Health Promotion, Risk Reduction, and Suicide 

Prevention was formed in the spring of 2009. In 2010, 

the Army’s Comprehensive Behavioral Health System 

of Care was implemented. The November 5, 2009, 

shootings at Fort Hood, Texas, spurred numerous 

recommendations for both the DoD and the military 

services. Finally, there is a new DoD–Department of 

Veterans Affairs Integrated Mental Health Strategy. All 

of these new programs and organizations have sought 

improved approaches to the emerging challenges facing military behavioral health. 

Behavioral Health Proponency

The Army Medical Department (AMEDD) Behavioral Health Proponency, the first of these new initiatives, was established in 2007 to coordinate all the 

different behavioral health functions in the AMEDD. 

Modeled after AMEDD’s Proponency of Preventive 

Medicine, this organization is a multidisciplinary 

group, with its director located at the Office of The 

Surgeon General (this volume’s senior editor was the 

first director of the Behavioral Health Proponency). 

A Suicide Prevention Program Office was also established in 2007 to help centralize the diverse AMEDD 

elements that assist with education, training, and 

tracking of suicide prevention efforts. However, this 

latter office became redundant with the Behavioral 

Health and Social Outcomes Program and the Army 

Campaign Plan for Health Promotion, Risk Reduction, 

and Suicide Prevention and is not currently active. 

Defense Centers of Excellence 

The congressionally mandated Defense Centers of 

Excellence (DCoE) also started in 2007 and grew with 

congressional support due to a recommendation from 

the DoD Mental Health Task Force. The Department 

of Veterans Affairs and all of the military services are 

represented at DCoE, including the Public Health 

Service. The mission statement of the DCoE (available 

at: http://www.dcoe.health.mil/) is: 

Mission: The DCoE assesses, validates, oversees and 

facilitates prevention, resilience, identification, treatment, outreach, rehabilitation, and reintegration programs for psychological health (PH) and traumatic 

brain injury (TBI) to ensure the Department of Defense meets the needs of the nation’s military communities, warriors and families.

Comprehensive Soldier Fitness

The Army’s chief of staff, General George W Casey, 

Jr, requested the establishment of the Comprehensive 

Soldier Fitness (CSF) program, which was begun in 

2008. Under the umbrella of the G-3 (ie, the training 

directorate), the Army developed a comprehensive 

behavioral health strategy—“whole-life fitness”—that 

includes multiple categories of wellness (physical, 

emotional, social, family, and spiritual). This strategy 

recognizes the need to incorporate enhancement of 

current health (of the soldier and family), prevention of 

future problems, and treatment when problems arise. 

The strategy also emphasizes the use of standardized 

metrics to determine success, standardized screening 

and treatment modalities, and the use of evidencebased clinical guidelines. Ultimately the strategy 

recognizes that the Army team is successful when 

leadership and behavioral health professionals partner 

to remove any stigma associated with identifying the 

need for help and receiving behavioral health intervention. This strategy encompasses a holistic approach to 

behavioral health issues.

The “Army Strong” campaign has been a success. 

But mental, emotional, and spiritual strength, like 

physical strength, do not just “happen”—these attributes can and must be taught, practiced, and perfected. 

As with physical capability, everyone enters the Army 
749

Combat and Operational Behavioral Health: Final Thoughts and Next Steps

with a variable amount of strength in each of these 

domains, everyone has the potential to improve, and 

both the rate of improvement and ultimate achievement will be different for every soldier and family. At 9 

years into the global war on terror, with its unrelenting 

operational tempo, a focus on comprehensive fitness 

has become an operational mandate. 

The vision and mission statements of whole-life 

fitness (available online at: http://www.army.mil/

csf/about.html) are:

Vision: An Army of balanced, healthy, self-confident 

Soldiers, families and Army civilians whose resilience 

and total fitness enables them to thrive in an era of 

high operational tempo and persistent conflict.

Mission: Develop and institute a holistic fitness program for Soldiers, families, and Army civilians in order to enhance performance and build resilience. 

The CSF program ensures that all soldiers undergo 

appropriate assessment of their total fitness, encompassing all the “Army Strong” components. The 

results of the assessment will direct further training, 

intervention, or treatment as needed. This begins at 

accession and, like physical fitness, includes reassessment at appropriate intervals. Furthermore, the CSF 

office makes certain that all training, interventions, and 

treatments utilized have demonstrated effectiveness, 

applying accepted methodology and scientific rigor. 

They are also chartered to ensure timely reassessment, 

to demonstrate value added to both the soldier and 

the leadership. 

The CSF office also ensures that the training programs, services, and interventions offered complement 

one another, are not duplicative, are resourced based 

on objective outcomes, and are standardized across the 

Army, including the Reserve components. Lastly, CSF 

is dedicated to making sure that all stakeholders, both 

internal (soldiers, families, leaders, and Army commands) and external (members of Congress and staff, 

media, and veterans’ groups) understand the absolute 

necessity of a comprehensive, coordinated effort to 

enhance the fitness and resiliency of the Army, which 

is particularly important during this era of persistent 

conflict and for the foreseeable future. 

Behavioral and Social Health Outcomes Program

A new focus on surveillance of behavioral health 

emerged at the former CHPPM, now the Public Health 

Command (Provisional). Great demand exists for such 

capacity, as evidenced by increasing requests from 

Army leadership for actionable data from population 

health indicators in this area. Recent Mental Health 

Advisory Team surveys and epidemiological consultation investigations have clearly demonstrated that 

no single data source is sufficient for acquiring the 

information necessary to perform analysis of individual, community, or military health system factors 

that are associated with suicides and related adverse 

behavioral outcomes. Timely and effective intervention 

requires data to be collected and reviewed in a way 

that allows a comprehensive understanding of both 

individual suicide cases and the broader community 

context (psychological and physical health, installation 

and unit factors, social ties, and other applicable factors). The former CHPPM received funding from the 

US Army Medical Command for the establishment 

of this capability, as well as funding from the Army 

G-1 to establish a separate “strategic analysis cell” 

to collect and follow data for the specific purpose of 

generating actionable data in the effort to mitigate 

suicides in the Army. 

CHPPM’s Behavioral and Social Health Outcomes 

Program (BSHOP) is a comprehensive behavioral 

health epidemiology and surveillance program formed 

to evaluate the full spectrum of psychological health 

and social wellness in Army communities. BSHOP’s 

mission is to establish and operate a central behavioral 

health and social health outcomes epidemiologic resource for the Army and to bolster ongoing behavioral 

health program development and evaluation capability at CHPPM. The program is structured to analyze, 

interpret, and disseminate information on the status, 

trends, and determinants of the behavioral health 

and fitness of America’s Army. The end objective is to 

provide a ready means to identify and evaluate impediments to medical readiness and establish a basis 

for preventive action. 

In the spring of 2009, the Army’s vice chief of staff 

established the Army Suicide Prevention Task Force 

(ASPTF) in response to the Army’s increasing suicide 

rate. The ASPTF’s effort has resulted in roughly 250 

initiatives throughout the Army that are currently 

being executed, in addition to the development of 

the Army Campaign Plan for Health Promotion, Risk 

Reduction, and Suicide Prevention.

Efforts to mitigate the psychological effects of war 

continue. The shootings at Fort Hood led to both DoD 

and service-specific recommendations. The recommendations relevant to behavioral health, published in 

“Protecting the Force” (available at: http://www.army.

mil/-news/2010/01/15/33006-protecting-the-forcelessons-learned-from-fort-hood/), emphasized caring 

for medical personnel and screening for violence. It is 

unclear at this point how well these recommendations 

will be implemented. 

The Army’s Comprehensive Behavioral Health 

System of Care, begun in 2010, seeks to implement 

best practices in optimal integration across the Army. 
750

Combat and Operational Behavioral Health

Begun in the Western and Pacific regions, under the 

leadership of Brigadier General Patricia Horoho and 

Brigadier General Steve Jones, it seeks to improve the 

reintegration process using lessons learned throughout 

the Army. The new DoD–Veterans Affairs Integrated 

Mental Health Strategy incorporates 28 strategic actions aimed at aligning the two healthcare systems. 

Although many of the recommendations are similar 

to others already made, the new program focuses on 

transitions from military to civilian life. 

The shootings at Fort Hood have led to three major 

health-related efforts for the Army and DoD: (1) to 

seek to uncover violent tendencies in individuals; 

(2) to build upon the comprehensive behavioral response to the shooting; and (3) to expand provider 

resiliency training. There have also been concerted 

efforts to improve access to care by increasing the 

number and availability of providers and decreasing stigma. In the Army, the number of behavioral 

healthcare providers has increased almost 70% between 2007 and 2010.

When this chapter was written, the Army had 2,579 

behavioral health providers available, with a conservative need estimate of 3,072 military, civilian, and 

contract behavioral healthcare providers. This represented an 84% fill, or a shortage of 493 providers. The 

Army is currently attempting to hire or contract the 

additional providers (87 psychiatrists, 146 psychologists, 222 social workers, and 38 psychiatric nurses). 

However, these numbers continually change, as providers are hired or leave and as new requirements are 

developed. 

Provider hiring difficulties are not due to lack of 

funding; rather, the difficulties stem from a lack of 

civilian providers willing to practice in remote locations, compensation limitations inherent to government employment, and a national shortage of qualified 

providers. To address these limitations, the Army has 

employed selected behavioral health recruitment and 

retention incentives. These include

• implementing a critical skills retention bonus 

for master’s level clinical psychologists;

• including social work officers (captains) in 

the critical skills retention bonus program 

instituted by the Army;

• establishing incentive special pay for psychiatric nurse practitioners;

• providing increases in multiyear special pay 

for psychiatrists

• utilizing the active duty health professions 

loan repayment program for both accession 

and retention of behavioral healthcare providers;

• making health professions scholarship program allocations available as a tool for the 

US Army Recruiting Command to recruit 

psychiatric nurse practitioners; and

• increasing the number of health professions 

scholarship allocations dedicated to clinical 

psychology and increased the seats available in 

the clinical psychology internship program.

SUMMARY

This volume began with a brief look at the history of 

behavioral healthcare in the US military, especially the 

genesis of the two volumes on military psychiatry in 

the Textbooks of Military Medicine series that were published over 15 years ago. Many of the “lessons learned” 

described in those two volumes were based on military 

experiences during Vietnam. Both the military and civilian society have dramatically changed since Vietnam, 

but one point that remains constant is that the human 

ability to adapt to the horrors of combat is finite. It is 

through the evolution of both proactive measures to 

help soldiers “steel” themselves against their experiences and therapeutic interventions by the behavioral 

healthcare system that the best possible outcomes can be 

achieved for military personnel. This project has summarized the experiences of more than 150 behavioral 

healthcare providers, in all fields and specialties, who 

have given their time and words to capture these latest 

battlefield conditions and lessons learned. 

The system of behavioral healthcare in the US 

military is always in flux, with numerous individuals and organizations attempting to improve it via 

various innovative programs. One constant theme, as 

demonstrated in the discussion in this chapter, is that 

the many attempts at both quick and comprehensive 

solutions only demonstrate the complexity and difficulties of the mission. Clearly the effects of the conflicts 

in Operation Enduring Freedom and Operation Iraqi 

Freedom, as well as tsunamis and other natural and 

manmade disasters, will continue to take their toll 

on US military members, their families, and the nation. It is thus a national duty to continue providing 

our service members the best behavioral healthcare 

available.
751

Provision of Behavioral Health Services During Operation Iraqi Freedom One

Appendix 1

PROVISION OF BEHAVIORAL HEALTH 

SERVICES DURING OPERATION IRAQI 

FREEDOM ONE

ROBERT D. FORSTEN, DO*; BRETT J. SCHNEIDER, MD†; SHARETTE KIRSTEN GRAY, MD‡; COLIN 

DANIELS, MD§; and GARY J. DROUILLARD, MD¥

INTRODUCTION

ECHELONS OF TREATMENT IN THE COMBAT THEATER

ARRIVING IN KUWAIT

COMBAT SUPPORT HOSPITALS

COMBAT STRESS CONTROL UNITS

DIVISION MENTAL HEALTH SECTIONS

SUMMARY

*Lieutenant Colonel (P), Medical Corps, US Army; Command Psychiatrist, US Army Special Operations Command (AOMD), 2929 Desert Storm 

Drive (Stop A), Fort Bragg, North Carolina 28310-9110; formerly, Staff Psychiatrist, Department of Psychiatry, Walter Reed Army Medical Center, 

Washington, DC

†

Lieutenant Colonel, Medical Corps, US Army; Deputy Chief, Department of Psychiatry, Building 61, Child and Adolescent Psychiatry Clinic, Walter 

Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307

‡

Lieutenant Colonel, Medical Corps, US Army; Chief, Hospital and Administrative Psychiatry Services, Department of Behavioral Health, Building 

36000, Darnall Loop, Carl R. Darnall Army Medical Center, Fort Hood, Texas 76544; formerly, Division Psychiatrist, 4th Infantry Division, Fort 

Hood, Texas 

§

Lieutenant Colonel, Medical Corps, US Army; Psychiatrist, Department of Psychiatry, Madigan Army Medical Center, 9040 Fitzsimmons Drive, 7BLM, 

Tacoma, Washington 98431; formerly, Chief, Behavioral Health Services, 28th Combat Support Hospital, Operation Iraqi Freedom 2003

¥

Lieutenant Colonel, Medical Corps, US Army; Chief, Chemical Addiction Treatment Service, Department of Psychiatry, 1 Jarrett White Road, Tripler 

Army Medical Center, Honolulu, Hawaii 96859; formerly, Chief, Consultation Liaison Psychiatry, Tripler Army Medical Center, Honolulu, Hawaii
752

Combat and Operational Behavioral Health

INTRODUCTION

In 2003, the US Army deployed four different 

medical units with behavioral health assets during 

Operation Iraqi Freedom One (OIF I). Each of these 

units provided varying levels or echelons of healthcare 

throughout the war zone. A review of care echelons 

and each behavioral health unit is discussed later in 

this appendix. The primary mission of these behavioral 

health units was to provide evaluation and treatment 

for all behavioral health disorders and operational 

stress issues, in addition to administrative psychiatric 

support services. The structure of each unit and how 

it delivered its services varied markedly, depending 

on numerous factors, including the unit supported, 

location, command, logistic support, and assigned 

personnel. Behavioral health assets were located 

throughout Iraq at the combat stress control (CSC) 

detachment or company, division mental health section (DMHS), combat support hospital (CSH), and area 

support medical battalion/company. Of these different 

types of behavioral health assets, two are medical units 

(CSH and area support medical battalion), and two 

are assigned directly to the combat units (DMHS and 

CSC). The area support medical battalion/company’s 

behavioral health capability was phased out in 2007 

and will not be discussed in this appendix; also, the 

forward support medical company (FSMC), as part of 

the forward support medical battalion (FSMB), may 

have had behavioral health assets assigned to it but 

this organizational structure will be phased out. Only 

the CSC company and detachment, DMHS, and CSH 

will be discussed. 

Although many other resources on medical topics 

and military operations exist, this appendix focuses 

on helping behavioral health providers understand 

the challenges identified during the conventional 

ground phase of OIF I (2003), amid highly uncertain 

conditions characteristic of the early stages of combat 

operations, as well as potential differences between 

behavioral health operations during future deployments or campaigns.

During peacetime, US Army physicians, nurses, 

medical administrators, and enlisted medical personnel primarily work in post hospitals and clinics. The 

aforementioned behavioral health units have key personnel assigned to them at all times to operate the unit 

in garrison. During war or contingency operations, 

these personnel may receive activation orders to augment medical units through the Army’s Professional 

Officer Filler Information System (PROFIS). PROFIS 

assigns personnel working in hospitals and clinics to 

deploying Forces Command (FORSCOM) units. 

The Army attempts to assign behavioral health 

officers (psychiatrists, psychologists, social workers, psychiatric nurses, occupational therapists, 

and behavioral health specialists [formerly military 

occupational specialty 91X, now 68X]) who are geographically located close to their PROFIS unit (in many 

cases the personnel are located on the same base as 

the unit), so these personnel can train or coordinate 

with the unit in garrison. However, some personnel 

assigned to units as PROFIS providers have duty 

stations hundreds (and in some cases thousands) of 

miles away from their FORSCOM unit’s home station 

or garrison. In addition, Reserve component medical 

and behavioral health units also participated in OIF I, 

with some active duty PROFIS personnel augmentees 

filling Reserve vacancies. 

Most PROFIS personnel who met the deployment 

challenge—coming together to comprise the treatment 

aspect of the medical and behavioral health units—

had never met prior to deployment, in contrast to 

FORSCOM units (combat arms, combat support, and 

combat service support branches) that train for wartime missions continuously in garrison, and US Army 

medical branches that perform “real life” missions on 

a daily basis. However, moving into a battlefield setting to treat medical and behavioral health casualties 

presents different challenges, such as the logistics of 

patient care in the austere or hazardous environment, 

compared to the more complex and heavier case loads 

typically managed in garrison medical organizations. 

Despite the challenges, most professional personnel 

adapted to their new environment and completed the 

medical mission admirably. 

ECHELONS OF TREATMENT IN THE COMBAT THEATER

Every behavioral health unit in a theater of combat operations provides different treatment options, 

increasing with the treatment echelon (level) of care. 

There are five echelons of care, with echelon 5 possessing the most comprehensive or definitive options 

(similar to a medical center in the continental United 

States [CONUS]) and echelon 1 composed of self-aid, 

aid from other unit members (buddy aid), and care 

from combat medics. As the echelon increases, so does 

the evaluation capability and medical care provided. 

In terms of behavioral health assets, each unit at the 

battalion level—echelon 1—was assigned an enlisted 

behavioral health specialist whose activities were 

coordinated by the DMHS. 
753

Provision of Behavioral Health Services During Operation Iraqi Freedom One

Each behavioral health specialist is an enlisted soldier or noncommissioned officer (NCO) with varying 

degrees of experience in the diagnosis, treatment, and 

management of behavioral disorders. Starting at the 

brigade level—echelon 2—a CSC detachment (also 

assigned at corps or echelons-above-brigade [EAB] 

level) focuses on interventions to prevent combat 

operational stress response casualties through critical incident debriefings, stress management classes, 

“walk-about” marketing contacts, and some restoration/fitness programs resembling brief day-treatment 

programs, as well as providing conventional clinicbased behavioral health evaluation and treatment. 

Each brigade also has an organically assigned 

behavioral health officer—usually a psychologist 

or social worker—who may conduct evaluations of 

brigade soldiers or facilitate command liaisons with 

area CSC/CSH elements. Echelon 3 consists of CSC 

companies providing fitness or restoration units, the 

CSH (which is typically assigned at corps-level EAB), 

and the DMHS, if the theater organization utilizes 

conventional division structure instead of modular 

independent brigades. On a linear battlefield, echelons 

of care also show predictable positions relative to the 

forward line of troops, but a nonlinear battlefield obscures this relationship, with many behavioral health 

resources (units or detached slices/elements) located 

across large areas, such as a forward operating bases 

(FOBs) or logistic support areas (LSAs). However, 

some behavioral health resources may support small 

camps or outposts with small elements positioned 

locally or rotating out from FOBs, depending on local 

needs, resources, distances, transportation/logistics, 

and expected travel-related hazards. 

Prior to wartime deployment, all units (augmented 

with their PROFIS personnel) complete tasks such 

as medical screening; legal documents (wills, powers of attorney); weapons qualification; training in 

unexploded ordinance; CBRNE (chemical, biological, 

radiological, nuclear, and explosive) hazards; and 

all other training required by unit readiness training 

matrices. PROFIS personnel join the unit for this specified “train-up” period to ensure they are familiar with 

the standard operating procedures, mission essential 

task list, and internal workings of the host unit. Many 

PROFIS personnel may lack prior experience with the 

specific unit or its chain of command and may never 

have met face-to-face with any of the unit’s members. 

The exception is DMHS, which operates in garrison 

with most of the personnel required during deployment, but may be augmented with PROFIS personnel 

depending on wartime mission requirements. 

Garrison division mental health personnel will 

need to train all the personnel within the behavioral 

health section with whom they will be deploying. At 

a minimum, this training should consist of setting up 

standard operating procedures related to evaluation, 

diagnosis, treatment, clinic management, and prevention techniques. The training also gives the unit leaders 

an assessment of each team member’s technical proficiency and experience, and the extent to which that 

provider is able to function independently. Supervision 

may be required depending on training, licensure, and 

credentialing levels.

ARRIVING IN KUWAIT

Prior to entering Iraq, most units from OIF I 

landed in Kuwait at the SPOD/APOD (sea [for equipment]/aerial [for personnel] point of embarkation/

debarkation). Many units had expected to arrive at 

another SPOD/APOD in Turkey and approach from 

the north but received last-minute redirection to the 

overcrowded Kuwait staging area due to diplomatic 

issues. From the APOD, most units moved to a “cabal,” 

or tactical assembly area, where they reassembled 

their operating capability and prepositioned while 

awaiting movement north into Iraq. These cabals were 

small base camps with minimal infrastructure located 

in the remote Kuwaiti desert. The majority of OIF I 

soldiers then convoyed into Iraq from Kuwait, loaded 

into high mobility multipurpose wheeled vehicles 

(HMMWVs or Humvees), family of medium tactical 

vehicles (FMTVs) or the older M939 series 2.5 (“deuceand-a-half”) vehicles, and 5-ton trucks. These convoys 

often took up to 3 days to complete because anytime a 

vehicle broke down, the entire convoy waited until the 

vehicle was remobilized or recovered. Furthermore, 

early-phase convoys also contended with nearby combat or threatened engagement by Iraqi Army forces. 

Additionally, the early unit convoys faced challenges 

related to unlabeled and undeveloped routes through 

an unmapped country with minimal signage and 

many roads that were inadequate for large and heavy 

military vehicles. While some units possessed globalpositioning-satellite capability, many navigated with 

uncertain means in a landscape with few reliable visual 

landmarks during a season where large dust storms 

could completely obstruct visibility and stifle breathing 

for extended periods (soldiers deploying to OIF now 

fly directly into Iraq via the nearest air strip to where 

they will assume mission responsibility). 

Units typically resided in tents, although some 

moved into dirty, decrepit, abandoned masonry structures. Tent space became very limited in both Kuwait 
754

Combat and Operational Behavioral Health

and Iraq during OIF I; many personnel were fortunate 

to have 2 linear feet of space on either side of the cot on 

which they slept and stored all their gear. Many lessfortunate soldiers, especially in combat arms units, did 

not have either a cot or a tent and slept on the ground 

or on their vehicles, in extremely variable stifling heat 

or bitter cold. Overcrowded tents, stress, and close living proximity accelerated viral spread and increased 

the frequency of infectious illnesses. Anecdotally, the 

average weight loss per soldier during the first month 

was 5 to 10 lb; many infantry soldiers lost 20 to 40 lb 

during the conventional ground combat phase due to 

limited food consumption, along with irregular and 

continuous combat operations. However, most soldiers 

within these units adjusted physically and behaviorally, bonding into a cohesive team and unit. During this 

period, officers had to avoid complaining, especially 

around the enlisted soldiers, who tended to lose respect 

for officers they heard complaining. However, among 

some officers, complaining, mostly through humor, 

was a helpful way to vent frustration, improving 

overall officer morale, mood, and bonding. 

The largest stressor in Kuwait was not the Scud 

missile alerts and subsequent donning of the missionoriented protective posture (MOPP) 4 suits (thick, 

carbon-based chemical weapons protection suits), or 

joint-service lightweight integrated suit technology 

(JSLIST) equipment, but boredom coupled with overcrowding and the austere environment, which tended 

to fuel gossip behaviors and interpersonal conflicts. 

Additionally, soldiers experienced emotional stress 

from a perceived conspicuous absence of information 

on each unit’s specific mission, leading to speculation 

on justifications for deployment, chain-of-command 

motives, and when each unit would actually move 

forward to begin operations in Iraq. In most cases, unit 

equipment arrived in port (SPOD) after unit personnel 

had been flown into the APOD, causing personnel to 

wait in the cabals for their equipment while residing 

in overcrowded tents with minimal infrastructure or 

recreational opportunities. 

Units with responsive and competent commanders 

who fostered group cohesiveness and subordinate 

communication, keeping their soldiers busy with mission-focused operational training, appeared to have 

less disruptive drama and stress-related behavioral 

health issues or conduct problems. These leaders effectively implemented the primary preventive actions 

to control and reduce the stressors known to increase 

combat and operational stress reactions, validating 

the basic precepts of combat psychiatry, as per Field 

Manual (FM) 4-02.51 (formerly FM 8-51), Combat and 

Operational Stress Control.

Most soldiers seen by medical personnel on the cabals 

were not “emergent,” but rather had interpersonal problems with supervisors, were homesick or had home-front 

problems, or did not adjust well to the high operation 

tempo the deployment could demand. The first two 

stressors (unit/command problems and home-front 

worries) emerged as the top two most common stressors of deployed service members, as shown in the first 

and subsequent Mental Health Advisory Team (MHAT) 

reports. Each cabal had a small clinic set up for seeing 

medical emergencies and sick call, but these battalion 

aid station equivalents did not have behavioral health 

assets unless augmented individually by providers in 

units temporarily assembling at a particular base. 

Privacy became an issue while evaluating patients 

on the cabals because no structures approximating 

“clinical space” had been set up, nor was there a 

mechanism for medical recordkeeping. Despite this, 

commanders knew where the medical units were located on the cabals and sent their personnel to “walk 

in” for evaluations. Soldiers were often evaluated by 

medical personnel who sat down with them on the 

sand, in the shade of a vehicle or tent. Documentation 

remained an unresolved issue without any means of 

copying files, and no soldier had a medical record 

to review or document care. Most of the medical 

notes completed during OIF I were handwritten on 

SF600 forms, and soldiers typically lost these notes. 

Records kept at facilities would not follow soldiers 

through their care at different locations. The Armed 

Forces Health Longitudinal Technology Application 

(AHLTA) or the Composite Healthcare System (CHCS)

electronic medical records did not become operational 

until later rotations (approximately 2006–2007). The 

role of the behavioral health professional on the cabal 

during OIF I was primarily evaluation to determine 

which soldiers were safe and could move north to 

Iraq and which soldiers needed to be evacuated from 

theater for further evaluation, treatment, or administrative separation. Some soldiers had unexpected 

panic responses to the MOPP-4 protective mask. This 

required either prompt successful desensitization 

(sometimes with benzodiazepine-induced relaxation) 

to learn to tolerate the mask or evacuation from theater. Behavioral health emergency patients had to join 

a convoy to the hospital in Kuwait, which was staffed 

by one psychiatrist.

COMBAT SUPPORT HOSPITALS

Two combat support hospitals—the 21st and 28th 

CSHs—were at cabals in Kuwait by March 2003, preparing to deploy their hospitals north to Iraq after 

initiation of the ground invasion. Because the 21st CSH 
755

Provision of Behavioral Health Services During Operation Iraqi Freedom One

was an early Medical Reengineering Initiative (MRI) 

CSH, it did not have a neuropsychiatric group as the 

28th CSH had. The primary mission of the new MRI 

CSH was to perform split operations in two locations, 

separating into two smaller hospitals, both capable of 

operating independently but with the same chain of 

command. Campaign evolution soon demonstrated 

the need for smaller hospital organizations that maintained similar capability levels but provided more 

geographically dispersed support, prompting the 28th 

CSH to perform a split operation as well, as did all 

subsequent CSH units. The lack of a neuropsychiatric 

group meant that the behavioral health section of the 

21st CSH brought no equipment such as bedding, tentage, or cots, and only a limited number of behavioral 

health personnel: a psychiatrist, a psychiatric nurse, 

and two behavioral health specialists. In contrast, the 

28th CSH had a psychiatrist, a social work officer, three 

psychiatric nurses, and approximately six enlisted 

behavioral health specialists. The 28th CSH did not 

operate a separate neuropsychiatric ward and planned 

to use only one or two beds from the medical–surgical 

ward to house psychiatric patients. They also did not 

plan to operate an outpatient clinic or behavioral health 

holding capability (resembling a fitness program at a 

CSC). 

Once operations commenced, the number of psychiatrically hospitalized patients exceeded the number 

of medical patients on the ward. Additionally, units 

often packed a ground evacuation vehicle with soldiers requiring behavioral health evaluations. These 

convoys would go directly to the CSH, bypassing 

other echelons and flooding the CSH with outpatient 

evaluations. Some units also sought to “medicalize” 

the behavioral problems within their unit and send 

misconduct cases to the CSH for presumed evacuation instead of administering disciplinary action and 

initiating administrative returns. These numerous outpatient evaluations resulted in many soldiers who did 

not require hospitalization or evacuation but needed 

several days of observation before returning to duty. 

Furthermore, delays in transportation also increased 

needs for a holding requirement and some supervision 

by behavioral health staff.

Once the 21st CSH split, a professional provider and 

a behavioral health specialist went with each hospital 

slice. As an MRI CSH, the 21st was composed of three 

companies: A Company (CO), B CO, and Headquarters 

CO. As stated above, the primary mission of the new 

MRI CSH was to perform split operations so that one 

slice could set up and operate independently of the 

other. B CO left approximately 5 days before A CO in 

mid-April and was located in Mosul, Iraq, approximately 160 miles north of A CO, which was located on 

a large airfield in Balad, Iraq, about 40 miles north of 

Baghdad. The 28th CSH set up its main unit initially 

in Camp Dogwood, a patch of desert near Baghdad, 

and subsequently packed up the tent hospital to move 

into a fixed facility (Ibn Sina) in Baghdad, maintaining 

a smaller slice in Tikrit.

One of the earliest goals of the CSH was to set up 

the emergency room (ER) and operating rooms (ORs) 

within 48 hours or less to be ready to accept patients. 

Once this “main line” is set up, the remainder of the 

CSH is then built adjoining it. There is no set procedure 

on how or where to put clinics, wards, and so forth, 

so the hospital is usually arranged by the experience 

within the command. For example, the 21st CSH in 

Balad had a section of tents between the ER and the 

OR that acted as an “exchange,” so patients could 

overflow if needed into this area. The exchange made 

coordination of patients easier for mass casualty 

events, air evacuation, and movement to and from 

the ER, OR, and radiology. The 21st CSH set up an 

outpatient clinic in addition to inpatient services. In 

this case, the psychiatrist worked in both settings seeing routine outpatients as well as inpatients usually 

admitted through the emergency room. The outpatient 

service was located in the “specialty clinic” area of the 

hospital in an “office” consisting of half of one of the 

sections in the eight-section tent, with a field desk and 

two chairs. The 28th CSH had a similar arrangement, 

except that the behavioral health “clinic” was located at 

the other end of the hospital tent complex, away from 

any other clinics and next to the chaplain’s “office.” 

The clinic space also consisted of a small tent section, 

with patient interviews often conducted in hallways 

during busy periods.

As soon as the 21st CSH arrived at Balad, behavioral health consultations began. Because the 21st was 

the first medical treatment facility on the base, the 

psychiatrist and behavioral health specialist quickly 

started seeing patients. Initially, behavioral health 

patients were seen on an outpatient basis because the 

hospital ran sick call for the base from the specialty 

clinic. Three fourths of the behavioral health referrals at sick call were sent by the chain of command to 

rule out danger to self or others. These were soldiers 

who had threatened to hurt themselves or others. The 

other 25% needed medication refills because they did 

not deploy with enough medication or were close to 

running out after being in Kuwait for several months 

before moving forward into Iraq. The 28th CSH saw 

a similar preponderance of danger evaluations and 

medication refills. Units also sent numerous evaluations for chapter separation, conscientious objection, 

or other administrative issues. Army Reserve and 

Army National Guard units seemed to have a disproportionate number of chapter evaluations, as the 

active duty deployment gave these Reserve units an 
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Combat and Operational Behavioral Health

unanticipated opportunity to evaluate actual duty 

performance and separate those incapable of meeting 

mission requirements. However, the main active duty 

unit supported by the 28th CSH, the 3rd Infantry Division (ID), appeared to supply most of the malingering 

and misconduct cases seen at this CSH.

The 21st CSH pharmacy section deployed with a 

small supply of paroxetine and fluoxetine, but these 

drugs were quickly depleted within the first week after 

the hospital was set up. However, the CSH was collocated next to a medical logistics battalion that was able 

to coordinate future medication supplies. After 6 to 8 

weeks, the pharmacy stocked up on oral medications, 

including several selective serotonin reuptake inhibitors, second-generation antidepressants, stimulants, 

atypical antipsychotics, benzodiazapines, and sleep 

medications. The 28th CSH pharmacy also deployed 

with a minimal supply of medications, forcing providers to dispense medications in 1-week increments to 

delay or minimize stock-outs, which still occurred. In 

contrast to the 21st CSH, the 28th CSH did not have 

logistics support and sustained operations with the 

limited drug supplies the psychiatrists personally 

carried into theater. In addition, behavioral health 

specialists from the 28th CSH who went to Landstuhl Regional Medical Center (LRMC) in Germany 

on medevac escort missions requested and obtained 

medication resupply from the psychiatrists there to 

bring back into theater. For future reference, any psychiatrist deploying to an immature theater should have 

a lockbox (or several) of medications and coordinate 

as soon as possible with the medical logistics battalion 

and pharmacist for resupply. 

The dynamics of a deployed CSH were such that it 

took a physician with a great deal of military experience as well as an approachable, healthy personality to 

function as the deputy commander for clinical services 

(DCCS). The DCCS is particularly helpful in organizing the physicians into a tight-knit team. The DCCS 

acts as a buffer between providers and along the chain 

of command, engaging in the medical administrative 

battles to allow other physicians to focus on their 

medical mission, and to ensure that their junior rank 

did not result in others ignoring or overruling their 

expert recommendations based on rank alone. The 

DCCS also mentors junior medical officers by arranging training—military and nonmilitary—as well as 

normalizing the deployment experience.

Many referrals to the CSHs were soldiers requiring 

dispositions from outlying behavioral health units. 

Early in OIF I, if a soldier was evacuated to a hospital 

remote from the referring unit, that soldier usually 

ended up being evacuated out of theater to Kuwait and 

then to Germany. Discussing cases with commanders 

and behavioral health teams during the early phases 

of OIF I was often difficult due to limitations in communication lines, which were down at least half the 

time. It was also not uncommon for all convoys to be 

halted for several days at a time secondary to increased 

fighting. This frequent lack of any communication 

abilities with commands, via either telephone line 

or in person, discouraged providers, overburdened 

holding capabilities, and led to medical evacuation of 

soldiers who might otherwise have returned to duty. 

The division psychiatrist had multiple examples of 

soldiers being dropped off at the DMHS clinic for an 

evaluation, and the unit then convoyed for hours back 

to their assigned FOB prior to contacting the DMHS. 

Although most of these soldiers received fit-for-duty 

dispositions, they remained at the DMHS for several 

weeks because no one could contact their command, 

and it could take 2 weeks or so for the referring unit to 

convoy back and pick up the soldier. At the 21st CSH, 

providers usually admitted soldiers for observation 

and safety to the medical–surgical intermediate care 

ward (and later, the five-bed neuropsychiatric unit 

of the 28th CSH). However, a theater policy to admit 

patients to a CSH for no more than 7 days resulted in 

evacuations to a higher level of care where return to 

duty (RTD) became even more difficult and improbable. Most unit commanders supported providers 

who recommended patient evacuation, but on some 

occasions they objected to evacuation and wanted 

their soldiers returned to them. A chain-of-command 

representative (the commander, first sergeant, or senior 

NCO) then came to the CSH or CSC to pick up the 

soldier in person.

The 21st CSH did not have neuropsychiatry assets 

to establish an inpatient milieu; behavioral health patients admitted to this CSH did not have the benefit of 

a psychiatric ward setting with groups, confidentiality, 

or a multidisciplinary approach to treatment. However, the milieu remained very limited and public at 

the 28th CSH as well. Patients had a few groups run 

by psychiatric nurses but shared the ward with medical and surgical patients. Nursing care was generally 

delivered to these patients by a psychiatric nurse; 

however, medical and surgical nurses also contributed 

to nursing care of psychiatric patients due to staffing 

necessities. While some staff sought to increase privacy 

by hanging blankets as dividers around a psychiatric 

patient’s bed, this effectively identified them as a psychiatric patients and increased interest in them when 

they stepped out from behind the hanging blanket. 

Open space anonymity provided better confidentiality 

because other patients would not know why another 

patient had been hospitalized. 

Very few psychiatric cases evacuated from Iraq 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

returned to Iraq. Once soldiers were evacuated to the 

47th CSH in Kuwait, the psychiatrist assigned to the 

47th noted that:

most soldiers sent to Kuwait markedly improve as 

they “move Westward” and most of what is sent here 

for air evacuation to Germany (Landstuhl Regional 

Medical Center) is not battle fatigue and not severe 

behavioral illness but rather a failure to adapt to the 

deployment due to occupational stress and problems 

back home. Because of this, more soldiers were sent 

back to their commands with recommendations for 

administrative separation. However, many were 

transported out of the theater on a medical evacuation because they were “conditionally suicidal” but 

we still recommend for a chapter separation. 

Some behavioral health providers were unwilling 

to make the recommendation for a chapter separation. 

One of the psychologists in a reserve CSC unit stated, 

“I’m just not comfortable making a decision like that 

that will have such an impact on someone’s life,” 

meaning that this provider thought a separation would 

affect a soldier’s career in civilian life. However, these 

administrative duties remain an integral part of the 

job for military behavioral health providers, either in 

garrison or on deployment. During OIF I, the chief of 

psychiatry at LRMC stated that, “it helps Landstuhl 

tremendously to have recommendations like these 

because these soldiers look fine when they get there 

and we don’t get to see them when they are in Iraq, 

when they have mentally decompensated.” Such was 

the case in the CSHs in Iraq when soldiers were sent 

for evaluation from smaller behavioral health units 

(DMHS, CSC, chaplain, behavioral health technicians) 

or battalion surgeons embedded within combat units. 

These soldiers usually improved quickly but also 

decompensated quickly when told they were being 

sent back to their unit. Providers at the CSH would 

then spend extensive time trying to reach the unit at 

a distant location for collateral information via primitive telephonic infrastructure to make the necessary 

determinations. Without collateral information providers would often not know the relevant conditions 

and observed behaviors of the soldier. However, some 

units became more available for discussion when they 

received notification from the patient administrative 

section or the CSH patient administrative section that 

their soldier was in RTD status and needed pick-up 

for transportation back to the unit.

As stated, the policy of the CSH was to evacuate 

any soldier admitted for more than 7 days. Usually, 

units off the base could not be reached in this period 

of time and these soldiers were sent to Germany via 

the 47th CSH in Kuwait. However, the 28th CSH accumulated a large holding population awaiting RTD, 

sometimes exceeding the 7-day hospitalization policy 

if RTD appeared probable. Extensive holding populations entailed some risk and caused some concern to 

the hospital command, but the command then used 

its resources and influence to achieve contact with 

the original unit and arrange transportation. Some of 

the psychiatric patients at 28th CSH needed evacuation and went to LRMC, which facilitated pharmacy 

resupply, as already discussed. However, these evacuations presented another issue as it typically took 2 to 

3 weeks for a behavioral health specialist who escorted 

the patient to return to the CSH for routine duties. 

Sometimes the CSH sent other nursing personnel on 

these missions, but that depleted other sections of their 

nursing or enlisted medical personnel. The poor lines 

of communication to units and limited treatment options presented challenges that the CSH units handled 

differently; the 21st CSH usually evacuated these soldiers from theater, whereas the 28th CSH held them for 

RTD to prevent personnel depletion (at the CSH and 

sending unit). Early in OIF I, when commanders were 

able to locate their soldiers and call or visit the CSH 

to see how they were doing, the commanders were 

occasionally angry that they had “lost” their soldiers 

to the medical evacuation system. Getting soldiers to 

agree to commit themselves to maintaining personal 

safety and return to their units was sometimes very 

difficult with only supportive therapy and “three hots 

and a cot,” especially if the soldier had the expectation 

of release from theater.

Soldiers’ mood and affect usually brightened when 

they were away from the stress of their unit; had some 

rest, a shower, and three meals; and were in an airconditioned hospital. Many soldiers evaluated in this 

setting stated they had joined the Army for “college 

money” and “never thought [they] would deploy”; 

they often acted out when told they were going back 

to their units. This situation became an ethical dilemma 

for psychiatrists sending soldiers back to combat 

knowing they might be killed, injured, or deteriorate 

behaviorally, but these issues applied to any soldier 

ordered into a combat environment.

After the end of the major combat offensive, roughly 

the end of April 2003, it was not considered very 

dangerous for units to convoy to hospitals or clinics, although sporadic attacks with small arms and 

rocket-propelled grenades continued. However, after 

the insurgency became more organized, these ground 

convoys decreased in frequency as improvised explosive devices (IEDs) hidden around roadways became 

the primary weapon against coalition forces. Camps 

received regular mortar (indirect) fire after early July 

2003, and the roadside IEDs and rocket indirect fire 
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Combat and Operational Behavioral Health

attacks also increased dramatically. For example, the 

Balad (Arabic for “in the country or countryside”) 

airfield (aka Camp Anaconda), a huge, sprawling airbase of many square miles, received multiple mortar 

attacks from July 3 to September 26, 2003. Most of 

these mortar attacks occurred in the quadrant of the 

base containing the CSH. 

Commanders reported difficulty in referring soldiers to DMHS or CSC units where they would normally have been seen for evaluation and treatment. Because CSHs were located on large LSAs, units brought 

their soldiers to the CSHs when they convoyed to the 

LSA to pick up supplies. A very small percentage of 

cases seen involved florid psychosis or mania; most 

referrals were lower-ranking enlisted personnel with 

adjustment disorders. However, the behavioral, logistical, and combat stressors of OIF I affected all ranks 

and branches. For example the psychiatrist of the 21st 

CSH evacuated two aviators due to panic attacks and 

anxiety that affected their flying, caused in each case 

by “brown out” situations (caused by sand and dust 

from the rotor wash during landings). This resulted 

in such significant anxiety about future recurrences 

that it impaired overall mission capability. Other cases 

were more serious and involved stress confronted by 

higher level commanders. 

Case Study A1-1: A 40-year-old combat arms battalion 

commander with 19 years active duty presented as a selfreferral for worsening depressed mood with suicidal thoughts 

to shoot himself in the head with his 9-mm pistol. His brigade 

commander described him as “the strongest and most reliable 

battalion commander in the brigade.” His depression centered 

on the lack of control he felt over the lives of his troopers 

and the lack of training his men had been given for “extra 

duties” such as security and patrols. While on a patrol two of 

his soldiers had been killed by insurgents. After admission 

to the hospital for 5 days followed by 3 weeks of outpatient 

treatment consisting of counseling and medication, his mood 

and suicidal thoughts continued to worsen. He was evacuated 

from theater for more intensive treatment. In follow-up, he was 

noted to be doing well and still on active duty.

Another factor that led to referrals to behavioral 

health was the guilt associated with killing enemy 

combatants or the sheer terror of seeing friends killed 

by insurgent attacks. Many soldiers did not confront 

these stressors until seen by a behavioral health provider. Many would break into tears when asked the 

simple question of whether or not they had killed anyone in combat. Another common source of guilt came 

(correctly or incorrectly) from whether one’s actions 

or inactions led to a negative outcome for a friend, 

civilian noncombatant, or fellow soldier. 

Case Study A1-2: A 22-year-old enlisted soldier presented to the CSH, referred by his unit for depressed and 

psychotic symptoms. He blamed himself for the death of his 

commander. His commander had reached up to catch a line 

that was falling on top of the Bradley fighting vehicle that the 

commander was on top of. It electrocuted the commander. 

The presenting soldier had been the gunner but was inside 

the vehicle at the time of the electrocution. He felt guilty and 

demonstrated severe depression with psychotic features, 

hearing voices telling him he was a “poor soldier” and that he 

“should have done something to help his commander,” with 

whom he had a good working relationship. In reality, there 

was nothing he could have done to save his commander, yet 

he believed it was his fault that his commander died. Traumatic event management with the soldier and unit proved 

helpful in this case, and his psychotic symptoms improved 

significantly with an antidepressant and low-dose atypical 

antipsychotic medication, allowing him to return to duty.

One behavioral health unit referred a soldier to the 

CSH for medevac to LRMC for a “sleep study to rule 

out sleepwalking.” While conceptually it was easy 

to send this soldier back to the unit for observation, 

the increase in mortar and rocket attacks made his 

return more complicated and potentially hazardous. 

The provider admitted this soldier instead, observing 

him at the CSH before sending him back to his unit. 

In most cases, sleepwalking referrals were returned 

to the unit after brief medical work-up to avoid an 

epidemic of sleepwalking “evacuation syndrome” in 

these units.

During the period in late 2003 when insurgent attacks increased, word began to spread that most units 

would remain deployed for a year rather than the 6 

months many had expected. From May to June 2003, 

there were six suspected cases of self-inflicted gunshot 

wounds to the foot seen at the 21st CSH in Balad and 

several at the 28th CSH at Camp Dogwood. The psychiatrist at the 21st consulted for the surgical team to 

evaluate one of these cases that appeared suspicious. 

Case Study A1-3: An orthopaedic surgeon consulted 

psychiatry to evaluate an enlisted soldier in his mid-20s to 

determine whether the soldier’s injury was accidental or 

self-inflicted, and to assess the soldier’s risk of self-harm. 

The soldier stated that he shot his foot by accident. During 

the initial evaluation he reported depressed mood “ever 

since I’ve been deployed,” and noted that he wanted to go 

home. He also complained of having interpersonal problems 

with his chain of command. He reported poor sleep, guilt 

about the deployment, anergia, and poor concentration 

since being deployed. He denied having these symptoms 

prior to deployment and felt they would “go away if he were 

home.” He expressed surprise that the orthopaedic surgeon 

would send him back to duty, even though his foot had a 

clean injury without any fractures. He commented that, “I 

might as well shoot myself intentionally in order to leave if 

I have go back there.” The provider also noted that during 

the initial evaluation the soldier stated that his first concern 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

was where he would be “sent from here,” expecting “that it 

would be Germany.” 

Initial psychiatric evaluation recommended that after 

sufficient orthopaedic recovery, he follow up with a CSC 

unit near his unit duty location with a stress management 

group. In the following days, his unit started a line-of-duty 

investigation, which contributed to his stress. The hospital 

chaplain then consulted psychiatry 3 days later when the 

soldier hinted that he would display violent behavior if he 

returned to the unit. When questioned about suicide or homicide, he stated, “I don’t know what will happen if I go back 

to my unit.” He still insisted that the initial incident was an 

accident. He denied pulling the trigger and could not come 

up with a reason for the weapon discharging. Ten days after 

the second evaluation, his chain of command contacted the 

hospital and informed the medical team that they wanted to 

court-martial the soldier. However, the line-of-duty investigation remained incomplete and would take 2 to 3 more weeks 

to complete. The CSH informed the unit that the soldier’s 

foot had healed sufficiently for discharge from the hospital, 

but because of the unit’s remote location and lack of medical facilities to change his foot dressings, he would need air 

evacuation to LRMC in Germany. When the soldier learned 

of this decision, his affect and mood brightened to euthymic 

and he reported, “I expected that.” He appeared happy that 

he would be getting out of the Army, stating, “Any way is 

good.” He reported feeling “glad that I’m not going back to 

my unit with a loaded weapon.” 

After the soldier had been at the CSH for approximately 

6 weeks, due to the nature of his injury, the line-of-duty 

investigation, and the poor communication with his unit, he 

was sent to Kuwait for evacuation to Germany. However, his 

unit intercepted him in Kuwait and told him he was returning 

to Iraq for a court-martial, at which point it required several 

personnel to restrain him. He was nonetheless eventually 

evacuated from Kuwait to an Army hospital in Germany due 

to his combative behavior. 

From June to July 2003, a suicide cluster occurred, 

with each case likely having had multiple contributing factors, but ultimately leading each individual to 

feel hopelessness and intolerable depression. These 

soldiers may have felt trapped in a situation with no 

clear departure or end date (unprecedented in this 

generation of deployed soldiers). Additionally, all 

soldiers carried their weapons and ammunition at all 

times. Added deployment stressors were the following: separation from family and loved ones; receiving 

“dear John/Jane” letters ending relationships; no lines 

of communication home; threat of being killed or injured; high temperatures; perceived harassment from 

chain of command; and poor sleep, latrines, hygiene, 

and food. Behavioral health planners and commanders discussed relocating the 113th CSC fitness teams 

from Mosul and Baghdad to the 21st CSH in Balad 

to start a neuropsychiatric unit after these suicides. 

This collocation never occurred, but a CSC fitness or 

restoration unit should collocate with an MRI CSH to 

share resources, treatment, and evaluation of soldiers, 

since the post-MRI CSH has limited behavioral health 

assets. (This arrangement worked very well during 

subsequent deployment rotations observed in the authors’ subsequent deployments, including the 1908th 

CSC and 10th CSH in 2006 in Baghdad, and the 47th 

CSH and the 528th CSC at COB Speicher, in 2009.) 

Such collocation could improve RTD rates, as well as 

reduce evacuations from theater. At the 21st CSH in 

Mosul, the 98th CSC ran an outpatient clinic next to 

the hospital with two CSC psychiatrists (who admitted 

patients to the hospital if needed), a social worker, and 

five behavioral health specialists.

COMBAT STRESS CONTROL UNITS

The US Army’s behavioral health community has 

long recognized the impact of acute and chronic stressors, as well as traumatic events, on the functioning 

of individual soldiers and military units. The Army 

currently maintains two types of CSC units: (1) CSC 

companies and (2) CSC detachments. The former are 

primarily staffed by reservists and contain 80 personnel of various disciplines, including psychiatrists, 

psychologists, psychiatric social workers, psychiatric 

advanced practice nurses, general psychiatric nurses, 

a medical-surgical nurse, numerous psychiatric technicians, and administrative support staff (eg, a cook, 

mechanics, and so forth), so they can function as selfsustaining units in a deployed environment. The active 

duty component CSC detachments grew 50% larger 

after the introduction of MRI units and are approximately half the size of a CSC company, but with fewer 

psychiatrists. Also, they do not contain the same mix 

of personnel as pre-MRI units or CSC companies.

CSC units are designated primarily as units tasked 

to perform preventative activities. As such, personnel 

in a CSC usually are configured into teams, known as 

prevention teams, consisting of one professional and 

two paraprofessionals (behavioral health specialists). 

These teams are usually assigned to specific units for 

which they provide primary and secondary prevention for combat-stress–related issues. Specifically, these 

teams present psychoeducational briefings focusing 

on suicide prevention, stress management, identification of combat fatigue or depression, and briefings 

preparing soldiers to reconnect with their families 

near the end of their deployment. At the beginning 

of OIF, military doctrine recommended critical event 

debriefing as the preferred intervention for traumatic 

events experienced by groups of soldiers. However, 

concurrent studies, both in the military and in civilian 
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Combat and Operational Behavioral Health

settings, questioned the efficacy of these critical event 

debriefings. 

Even more important to the practitioner, some 

studies reported that critical event debriefings had the 

potential to actually harm some participants, possibly 

through reexperiencing the trauma or by overwhelming the psychological defense mechanisms that had 

otherwise been allowing the soldier to manage the 

trauma without intervention. Furthermore, many providers had not attended courses certifying proficiency 

in conducting critical event debriefings. These factors 

contributed to a wide variation in the utilization of 

the debriefings and the consistency of responses to 

potentially traumatizing events. The military behavioral health community had previously promoted the 

utility of critical event debriefing to Army leaders 

during the years leading up to OIF, which resulted in 

commanders requesting a debriefing for their soldiers 

anytime any adverse event happened. The following 

case study describes some of the issues involved in 

this process.

Case Study A1-4: A military chaplain phoned a local 

CSC unit after a fire had broken out in a hangar that served 

as the “barracks” for a military unit. The chaplain said that 

the unit’s commander had requested a critical event debriefing. The chaplain asked for the assistance of the CSC unit 

inasmuch as the chaplain was inexperienced in performing 

such a debriefing and because the large unit would require 

multiple group debriefings (debriefings are usually limited 

to 20 people). 

The consulted behavioral health officer evaluated the 

situation and determined that no one’s life had been threatened by the fire, only property was lost, and that finding 

new housing was the unit’s most immediate concern. The 

CSC staff discussed the situation with the chain of command and decided that instead of critical event debriefings 

(where everyone participated in groups discussing their 

experience, both factual and emotional), they would take a 

different approach with this particular event. This approach 

consisted of a meeting with the whole unit at once. The unit’s 

commander spoke first to reassure his unit that new housing 

was in process and expected imminently. Furthermore, the 

Army would help the soldiers replace items lost in the fire. 

The behavioral health staff then gave an educational briefing 

about stress management and coping skills to the assembled 

soldiers along with specific contact information if any soldier 

wanted individual meetings. 

Adaptive doctrine allows these CSC teams more 

flexibility to evaluate and treat soldiers with combat 

fatigue and behavioral health disorders. The teams also 

engage in traumatic event management and critical 

event debriefings, providing evaluation and appropriate intervention for involved units. The teams provide 

consultation to military commanders, both in ways to 

help the whole unit prevent combat-stress–related dysfunction and also by performing command-directed 

behavioral health evaluations on individuals when 

commanders are concerned about their safety and 

reliability. Finally, the teams provide assessment and 

treatment for soldiers who self-refer for evaluation of 

their own distress. 

These functions require that the prevention teams 

live with units and travel within the operational area 

of the units for which they provide support services. 

Due to the travel hazards in the evolving Iraqi theater 

and in any nonlinear battlefield, routine travel plans 

decreased somewhat during OIF I. These prevention 

teams are “assigned” to cover the unit, but are not 

actually organic to the unit, so living and integrating 

with the host unit becomes imperative to develop 

trust from the unit’s leaders and soldiers. Without 

developing these strong relationships, including being 

perceived as available and “useful” to the commander 

and soldiers, a prevention team would not accomplish 

its defined mission; not due to lack of skill or personnel, but due to an inability to earn credibility and trust 

with their customers. Without the credibility, barriers 

inevitably arise and limit the prevention team’s access 

to the soldiers who need their care. 

Despite the task of prevention and the doctrinal 

mission of psychoeducation classes, this pivotal underlying mission of relationship-building conveys a 

similarity with marketing functions. Although philosophically debatable, a unit’s referral rate from the first 

sergeant or sergeant major provides a useful practical 

indirect metric of a prevention team’s effectiveness, 

as these NCO leaders keep their fingers on the metaphorical pulse of the unit and will only refer when their 

skeptical trust has been earned. Some CSC units sought 

to justify their existence by optimistically counting social and coincidental contacts as “prevention” (marketing) contacts to report as statistics, but these contacts 

provide minimal actual care. Genuine individual or 

small-group sessions, usually with credentialed providers, not initiated by CSC staff, constitute substantive 

care and adverse outcome prevention. 

In contrast to the established doctrine promoting 

team travel, some observations provide insights requiring diligent consideration to optimally balance benefits 

with costs. Travel tended to increase breadth of contact, but greatly decreased the depth of intervention. 

Soldiers needing behavioral health services tend to get 

directed to nearby behavioral health components perceived as helpful and competent, and whose personnel 

accumulate into provider panels. These panels quickly 

evaporate when disrupted by travel, as soldiers move 

on instead of establishing a perceived new relationship 

with another provider. Command elements directing 

behavioral health activities often do not appreciate the 
761

Provision of Behavioral Health Services During Operation Iraqi Freedom One

differences inherent in behavioral health relationships 

and expect a comparable portability from behavioral 

health as they might expect from other medical providers, such as sick call or dental or surgical services. 

New locations established after travel rarely yield a 

client/patient panel to match the size of the panel at 

the previous location. 

Professional providers practicing in the best interest 

of beneficiaries maintain some degree of skepticism 

towards disruptive relocations that do not appear 

warranted or logical on clinical grounds. Directed activities may serve as perceived requirements or even 

a beneficial bullet in someone’s reports or evaluations 

that actually detracts from collective soldier care. For 

example, an author questioned an ill-advised tasking 

that appeared more politically motivated than caredriven because the decision makers did not permit 

any merit discussion or consult actual subject matter 

experts. This particular tasking decimated a robust 

panel at a large base with ten to twelve substantive 

appointments per day while yielding two to three 

appointments per day after relocation. After returning in 8 weeks, the panel required another 8 to 12 

weeks of rebuilding before approaching its previous 

productivity level.

CSC units also had a second type of function—

restoration—with the restoration (formerly known as 

fitness) team. This team had more personnel assigned 

and usually operated from a stationary location, unlike 

the prevention teams. In addition to providing marketing activities similar to those provided by prevention 

teams, the restoration team also served as a treatment 

alternative for the prevention teams, commanders, or 

other nonbehavioral health providers, for soldiers who 

needed an evaluation and may have benefited from 

a spectrum of intervention activities ranging from 

prescriptions with interval aftercare to an intensive 

outpatient/partial hospitalization program equivalent 

to daytime groups and self-care quarters. By doctrine 

(specifically FM 4-02.51), restoration teams were meant 

to provide a stable place, somewhat removed from the 

front lines, where a soldier could be “restored” through 

the basic principles of the acronym BICEPS (brevity, 

immediacy, contact, expectancy, proximity, and simplicity). (PIES—proximity, immediacy, expectancy, and 

simplicity—was the previous acronym, used in FM 

8-51.) Nonetheless, these treatment concepts led to the 

practice of “three hots and a cot,” with the belief that 

the majority of combat stress casualties could be reconstituted in a short time, usually 1 to 3 days with close 

attention, to avoid accumulating large numbers or 

permitting extended care (> 3–4 day), which decreased 

the soldier’s expectation of RTD, possibly prompting 

symptom sustainment to delay RTD and maximize 

reprieve at the relatively comfortable CSC. In concept, referrals managed with BICEPS would adapt 

better in the long run if returned to their units than if 

“medicalized” and evacuated. Doctrine also discourages labeling these soldiers as “patients,” since labels 

also shape expectations (this appendix uses the term 

“patient” in the CSC context for consistency to denote 

a beneficiary receiving services, without intending to 

imply any particular treatment/intervention model or 

outcome expectation). In practical settings, care often 

transitioned fluidly across environments dictated by 

external circumstances (eg, care could occur at the 

CSC for one encounter, then a dining facility table, and 

then a CSH clinic office, with various combinations 

of pharmacological, psychological, educational, and 

behavioral interventions). 

During OIF I, most restoration teams were based in 

camps that also housed a soldier’s unit headquarters 

and that sometimes took frequent indirect fire. Thus, 

providers observed little difference between, or benefit 

from, quartering soldiers in the CSC versus leaving 

them with their host unit. While providing a respite 

from the immediate unit environment and command 

interactions may provide some benefit for certain cases, 

it may also adversely affect soldiers’ perceived proximity to their unit and expectation for prompt RTD. 

Typically, documentation given to unit commanders 

recommended environmental and behavioral modifications as part of the treatment/restoration program, 

including the expected CSC aftercare. Anecdotally, 

by not keeping soldiers separated from their peers, 

commanders reduced the general unit perception that 

the soldier was “mental” or “crazy,” thus reducing the 

stigma of care within these units. As discussed, restoration teams often functioned like community behavioral 

health clinics, providing psychiatric evaluation and 

treatment of ambulatory patients. This function also 

provided a referral resource for nonpsychiatric clinicians and the prevention teams. 

The most common complaint from soldiers presenting to the CSC, consistent with the CSH, was for 

evaluation of “home-front issues,” such as difficulties 

with significant others or family members at the home 

station or elsewhere in the United States or Germany. 

Depressed mood, insomnia, and anxiety, most commonly in the form of panic attacks, hypervigilance, 

or “jumpiness,” remained prevalent symptom complaints, but frank posttraumatic stress disorder (PTSD) 

was very rarely diagnosed among soldiers during their 

deployment. 

With the chief complaints listed above, most practicing psychiatrists would recognize that targeted 

psychopharmacologic interventions would have an important role in helping to alleviate symptoms. As previ-
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Combat and Operational Behavioral Health

ously mentioned, military doctrine for CSC was written 

to support a linear Cold-War–style combat campaign. 

Linear battlefields with conventional mobility warfare 

feature a rapidly moving, fluid battlefield requiring 

more prevention and triage than formal diagnoses, treatment, and aftercare plans. Doctrine writers appeared to 

conceive definitive psychiatric care (permitting RTD) 

as a separate activity to occur in rear areas after CSC 

doctrinal interventions failed to achieve prompt RTD, 

or after the rapidly moving campaign concluded. Thus, 

no provisions in FM 8-51, the doctrine at the beginning 

of OIF I, detailed how a CSC should obtain or store 

medications or a recommended formulary. Since the 

beginning of OIF I, the Army recognized this change 

in underlying assumptions and the consequent need 

to revise CSC doctrine in OIF II (2004). Of note, treatments with potentially sedating medications, especially 

atypical antipsychotics for insomnia or anxiety and benzodiazepines for anxiety, received increasing scrutiny. 

Media coverage of the issue and command concern understandably arose about ensuring that soldiers remain 

alert during missions. Providers must use these options 

responsibly to alleviate symptoms while recognizing 

that soldiers may display less optimal performance or 

alertness if their symptoms remain unaddressed. Benzodiazepines demonstrated good efficacy in overcoming 

or desensitizing acute stressors, but these drugs require 

vigilance, responsible prescribing, and commensurate 

psychological interventions. Without this attention, 

escalating use occurred frequently, leading to habituation and perpetuation of anxiety symptoms after return 

to CONUS.

DIVISION MENTAL HEALTH SECTIONS

During OIF I, combat forces deployed as entire 

divisions, under the organizational structure of the 

“Operational Force” (all divisions except the 4th and 

25th IDs) or “Force XXI” (the 4th and 25th IDs had 

changed to Force XXI by the beginning of OIF I). This 

organization differed from the new “modular” organizational structure now in place due to the Army’s 

transformation after OIF I. This appendix relates 

specifically to the DMHS assets during OIF I, prior 

to the Army’s transformation to the current modular 

organizational structure and operation.

The organically assigned DMHS assets belong 

specifically to the division, as permanent and integral parts of the division in peacetime and wartime. 

During a deployment, the DMHS can occasionally 

receive supplemental behavioral health PROFIS personnel if there is a shortage of assigned but needed 

personnel. In contrast to the DMHS, CSH and CSCtype units have few organic medical assets and receive most of their medical personnel from PROFIS. 

DMHS personnel operate within the division, both 

in garrison and in a deployed environment, as the 

primary behavioral health resources for the division. 

They evaluate and treat division soldiers, liaison 

with chain of command, and provide command 

consultation services for the various units within 

the division.

In garrison, the DMHS usually operates from one 

location as a full behavioral health section, generally 

located near other division medical assets. If division brigades are located in different geographical 

areas, such as Germany or Korea, then the DMHS 

will have more than one operating clinic. DMHS staff 

provide the full range of behavioral health services, 

including

	 •	 evaluation for all behavioral health disorders

(whether self-referrals, command referrals, or 

medical referrals);

	 •	 treatment, including individual therapy,

group therapy, and medication management; 

and

	 •	 prevention services (usually via command

consultation and liaison).

In divisions structured in either the Operational 

or Force XXI structure, the DMHS generally has one 

division psychiatrist, one division psychologist, one 

division social worker, and six to eight behavioral 

health specialists (military occupational specialty 68Xs, 

previously designated as 91Xs). Depending on the 

organizational structure of the division (ie, Operational vs Force XXI), DMHS personnel were either all 

assigned to the main support battalion (as part of the 

division support command brigade) or to a specific 

support battalion within the division. 

In an Operational structured division (eg, the 101st 

Airborne [Air Assault] Division), all DMHS personnel 

were assigned to the main support battalion. However, 

in a Force XXI structured division (eg, the 4th ID), the 

DMHS operated together in garrison but were actually 

assigned to the various support battalions. In these 

divisions, the division psychiatrist and noncommissioned officer-in-charge (NCOIC) were assigned to the 

division support battalion. The other DMHS personnel were assigned to the FSMCs, part of the forward 

support battalions, designated to support a specific 

brigade combat team during deployment. Under this 

structure, usually one behavioral health officer (either 

the division social worker or division psychologist) 

along with one or two behavioral health specialists 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

were assigned to each of the FSMCs. However, with 

three FSMCs but only two available behavioral health 

officers (ie, a social worker and a psychologist), one 

FSMC would have a team of only behavioral health 

specialists assigned to it, with no assigned officer.

According to linear battlefield doctrine, the division psychiatrist provided behavioral health service 

support to division personnel evacuated from the 

maneuver brigades, as well as to personnel assigned or 

attached to units collocated with the division support 

units and division headquarters. However, as stated 

previously in this appendix, OIF I did not develop 

according to a “linear” battlefield model, particularly 

with the various maneuver brigades and brigade combat teams located on different FOBs throughout Iraq, 

with nonlinear patterns of enemy engagements or orientation of combat forces. Therefore, patients from the 

various maneuver brigades could be routed directly 

to the division or main support battalion according to 

doctrine, or directly to a nearby higher echelon of care 

(eg, CSC or CSH). Proximity became more important 

as travel hazards increased and soldiers understandably presented to the closest asset with the capability 

to adequately evaluate the problem and minimize 

overall risk. 

Once receiving deployment orders, the DMHS 

shifted operations from the garrison mission to the 

deployment or operational mission. This included 

screening for and identifying division soldiers whose 

behavioral health conditions made them unsuitable 

for deployment, transferring their care to the garrison 

hospital behavioral health assets, and processing recommendations for medical separations (via Medical 

Evaluation Board) or administrative separations (ie, 

AR 635-200, Chapter 5-13/5-17), as indicated. Reserve 

component units frequently referred soldiers for 

evaluation prior to deploying, but sometimes these 

referrals occurred after arrival in theater when medical 

screening revealed that the soldier was taking mood 

stabilizers or antipsychotic medications for the treatment of bipolar disorder or psychotic disorders that 

the Reserve unit did not fully recognize. Subsequent 

screening processes became more comprehensive and 

prevented deployment of these vulnerable soldiers in 

later rotations. As expected, other routine referrals to 

behavioral health included cases of existing depression, anxiety disorders, or substance-use disorders. 

Case Study A1-5: A 44-year-old E-8 reservist with over 

25 years in service was referred for anxiety and alcohol 

dependence. He had been drinking one half of a fifth of 

whiskey in Kuwait every other day. Prior to deployment he 

drank a case of beer from Friday night to Sunday night, with 

an occasional beer on the weekdays. The soldier initially 

presented prior to deployment, secondary to increasing 

anxiety and depression related to recent activation to active 

duty and occupational difficulties. He minimized his alcohol 

use at this time. He was assigned as his unit’s first sergeant 

but did not feel he could handle the position’s responsibility. 

In addition to symptoms of anxiety, he also reported uncontrollable crying spells, poor concentration, fatigue, and 

decreased appetite. The initial CONUS provider diagnosed 

him with an adjustment disorder with anxious and depressed 

mood, starting him on citalopram, clonazepam, and zolpidem. 

He was found fit to deploy but directed to seek behavioral 

health services once he arrived in theater. He returned for 

aftercare 2 weeks later while still in CONUS and reported 

that his symptoms had improved and that he had stopped 

the prescribed medications. 

After deploying to theater, his symptoms of anxiety returned and he sought help at the CSH in Kuwait. His provider 

restarted him on his previous medications but he stopped 

these again after 4 weeks. He subsequently presented 

again in relation to pending Uniform Code of Military Justice 

charges due to his alcohol consumption while deployed, a 

violation of General Order Number 1. He did not feel that he 

could go on with his job and was evacuated from theater for 

treatment of his alcohol dependence and anxiety. 

As preparations for deployment continued, all 

garrison DMHS operations were shut down and 

the care of soldiers remaining behind transferred 

to the garrison hospital behavioral health assets, 

while the DMHS focused on equipment readiness, 

packing, and training for the upcoming deployment 

missions. Packing followed existing up-to-date load 

plans and focused on identifying what supplies and 

equipment would be needed in theater. Packing 

included inventory, assessment, and loading the 

equipment already “owned” by the DMHS, per the 

Table of Organization and Equipment (tents, light 

sets, field desks, chairs, cots, and vehicles). It also 

included assessing the need for and acquiring other 

anticipated useful supplies necessary to conduct 

the mission (eg, supplies for writing patient notes, 

maintaining charts, performing command referrals, 

writing mental status evaluations, useful templates, 

prescription pads, and any important resources such 

as textbooks or field manuals). 

Of note, supplies of psychotropic medications were 

not obtained prior to leaving the garrison environment. Once deployed and OIF I began, the absence 

of pharmaceutical supplies quickly became apparent, 

with poor availability in theater and lengthy delays to 

establish dependable supply chains. By approximately 

midsummer 2003, a dependable supply chain had 

developed and medications became readily accessible 

through the division’s own supply chains or at the 

various CSH units.

Maneuver brigades and their supporting units 

convoyed from Kuwait into Iraq during the initial 
764

Combat and Operational Behavioral Health

assault that began OIF I. Some combat units, such as 

the 101st Airborne (Air Assault) Division, that were 

directly involved in the initial assault “jumped” 

from one location to the next. This occurred from 

the beginning of formal combat operations until approximately May 2003, as units repositioned with 

a northerly movement direction and support units 

completed their convoys afterwards. As the mission 

evolved, permanent FOBs became established, with 

designated units operating out of a given location. 

During the previous “jumping” phase, conducting 

behavioral health and support operations had the 

unique challenge of operating in temporary environments without the stability, infrastructure, or luxuries 

of an established base. Prior to arriving and setting 

up at their permanent FOBs, the various maneuver 

brigades and supporting units (main and forward 

support battalions) remained in one location for only 

a few days to weeks, conducting operations from 

tents and makeshift buildings. Conditions remained 

austere for all units during this time, and did not 

provide ideal conditions for conducting sustainable 

operations. Fortunately the behavioral health mission 

did not have significant equipment requirements, 

and the DMHS teams experienced limited adverse 

effects because they required only a pen and paper to 

document encounters and a location to see patients. 

Providers could see patients in any safe, convenient, 

and relatively comfortable place. Providers utilized 

their ingenuity to create clinical spaces, for instance, 

in the small DMHS tent, in the back of a HMMWV, or 

in any “field-expedient” location providing a minimal 

amount of privacy for soldiers. Once established in 

the permanent FOBs, units dedicated more time and 

resources to setting up tents for permanent operations 

or occupying and improving old, abandoned Iraqi 

buildings on the FOB premises, converting them for 

living and working accommodations.

As previously mentioned, in a deployed environment, the DMHS section was divided into small 

two- to three-person teams (usually composed of a 

behavioral health officer—psychiatrist, psychologist, 

or social worker—and one or two behavioral health 

specialists) integrally located with the support battalion. Therefore, these were small operations, usually 

working out of a small tent or other accommodations, 

available 24 hours a day to accommodate soldiers who 

could present at any time (because soldiers presented 

unexpectedly day or night after convoying several 

hours from another FOB that lacked behavioral health 

assets). These DMHS teams were able to provide a 

range of behavioral health services and support to 

all the soldiers in the supported brigade and in their 

vicinity or catchment area. They were responsible for 

direct behavioral health patient care, as in garrison, 

with services that included

	 •	 evaluation of acute behavioral health issues

whether presented via self-referral or command referral;

	 •	 command consultation; and

	 •	 treatment, including brief supportive therapy

and medication management, if required. 

In terms of the types of cases presenting for treatment to DMHS, the whole spectrum of behavioral 

health concerns was represented, from significant Axis 

I disorders to subthreshold symptoms consistent with 

adjustment disorders related to situational stressors 

(occupational, home-front, or other operational stressors, classified, per Army doctrine, as “combat and 

operational stress reactions”) to misconduct stress 

behaviors. The most common cases presenting were 

those not meeting the threshold for actual significant 

Axis I disorders but rather were more consistent with 

misconduct stress behaviors (eg, substance abuse, 

fighting) or combat and operational stress reactions—

problems that might formerly have been diagnosed, 

per the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, terminology, as occupational problems, adjustment disorders, or even partner-relational 

problems. Soldiers were presenting with symptoms of 

stress related to the “operational” stress of functioning 

in an austere environment with extreme temperatures, 

extended separation from home and family, lack of privacy, and increased behavioral and physical demands. 

There was significant occupational stress from difficulties with peers or superiors; home-front stress from 

family, partner-relational, or financial concerns; or just 

frustration with the environment and the cumulative 

effect of the various stressors. 

Soldiers also presented with symptoms of actual 

Axis I depressive disorders, anxiety disorders, bipolar 

illness, psychosis, and attention deficit hyperactivity 

disorder (ADHD), either newly presenting or with 

diagnoses present prior to deployment (the latter cases 

needing continued treatment and routine medication 

management, particularly for depression, ADHD, or 

anxiety). A significant number of soldiers also presented with substance use issues, usually related to 

alcohol or other drugs (such as “Iraqi valium,” which 

they acquired illegally from Iraqis). The presentation of 

soldiers with acute stress disorder (ASD) or PTSD-type 

symptoms related to traumatic combat experiences 

was rarer at the beginning of OIF I prior to the maturation of the insurgency. However, by approximately 

August 2003, after the increase in insurgent attacks 

(eg, IEDs, rocket-propelled grenades, mortar attacks), 
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Provision of Behavioral Health Services During Operation Iraqi Freedom One

the number of soldiers presenting with ASD/PTSD 

symptoms notably increased. Overall, the ratio was 

approximately 6 to 4 for soldiers presenting with 

either “misconduct stress behaviors” (eg, substance 

abuse, assault on other soldiers) or subthreshold 

symptoms classified in Army parlance as “combat 

and operational stress reactions” to those presenting 

with significant Axis I disorders.

The number of patients presenting to DMHS usually ranged from eight to twelve soldiers per day. 

Soldiers generally presented as walk-ins (either as 

self-referrals or as command referrals). Most presentations were patients with an acute crisis; those who 

presented for routine treatment (ie, medication refills 

or follow-up) usually came whenever their operational 

mission would allow or, if located on another base, 

whenever they could “hop” a ride on a convoy that 

was traveling to the FOB where DMHS was located. 

Command referrals were usually acute (ie, for soldiers 

with imminent risk issues) but were also occasionally 

for routine, nonacute concerns.

In addition to evaluation and treatment of both 

acute and routine issues, DMHS teams accomplished 

other associated behavioral health activities, similar to 

those in a garrison-type environment. These included 

behavioral health evaluations, as required, for administrative separations (Chapters 13 and 14 separations) 

and recommendations to command for Chapter 5-13 

or 5-17 administrative separation for soldiers whose 

conditions clearly indicated unsuitability for continued 

service. Sanity boards were also conducted for soldiers 

undergoing court-martial. In addition, evaluations 

were done occasionally for soldiers planning to attend 

drill sergeant or recruiting school upon redeployment. 

The DMHS staff also provided consultation on a regular basis to commanders, first sergeants, chaplains, 

other medical personnel, and Judge Advocate General 

personnel, to ensure the safest, most appropriate, and 

most efficient dispositions for soldiers.

Examples of cases that presented to DMHS included 

the following: 

	 •	 soldiers who “locked and loaded” their weapon against their unit members; there were 

several cases a month of significant soldier 

versus soldier violence.

	 •	 soldiers in acute suicidal crises, including soldiers of all ranks, who had locked and loaded 

their weapon and held it to their head; 

	 •	 a soldier with a past history of clinical depression who had been barred from convoys/

patrols by his unit because he had been taking 

“pot shots” at local Iraqis;

	 •	 a soldier involved in “horseplay” with two

other soldiers that “got out of hand” when the 

soldier pulled out his bayonet, which caused 

the threatened soldier to pull out his 9-mm 

pistol;

	 •	 single or married soldiers presenting in recurrent suicidal crises after learning that soldiers 

with whom they were sexually involved were, 

simultaneously, sexually involved with other 

soldiers in the unit; 

	 •	 cases of soldiers who consumed alcohol and

became belligerent, suicidal, and/or homicidal, and occasionally assaulted other soldiers, 

or held their squad at gunpoint while intoxicated (two cases occurred on one FOB); 

	 •	 soldiers who made suicide attempts by overdose or who had unintentionally overdosed 

on “Iraqi valium” obtained from local Iraqis 

(with prolonged sedated, amnestic periods);

	 •	 multiple soldiers who “head-butted” brick

or concrete walls (or fractured hands from 

punching walls) due to anger involving 

NCOs, coworkers, or home-front issues;

	 •	 a sergeant major with anxiety, panic attacks,

and nightmares of death after being accidentally electrocuted by another soldier; 

	 •	 soldiers with acute manic or psychotic presentations (although rarer); and

	 •	 soldiers with notable ASD- and PTSD-type

anxiety symptoms resulting from involvement 

in combat operations. 

The 4th ID DMHS psychiatrist/NCOIC team was 

collocated with a CSC restoration team on the same 

FOB, which was very helpful for soldiers who presented acutely and who could benefit from a brief 

period of restoration away from their acute stressors. 

Soldiers who required evacuation to higher echelons 

of care, including out of theater, were evacuated to 

the closest CSH.

From April 2003 to November 2003, the 4th ID 

psychiatrist and DMHS NCOIC at the 4th ID DSB, 

located at FOB Speicher in Tikrit, Iraq, evaluated over 

600 soldiers. Of this number, 22 were referred to the 

CSC restoration program (due to operational stress 

reactions that made them temporarily nonmission 

capable), and 12 were evacuated to higher echelons 

of medical care (including some out of theater), resulting in an RTD rate of a minimum of 94.4%. This 

rate improved later in the year when the same team 

(although with a new division psychiatrist) saw an 

additional 480 soldiers from mid-November 2003 

until March 2004, when the 4th ID redeployed stateside, with only three soldiers requiring evacuation 

out of theater.
766

Combat and Operational Behavioral Health

SUMMARY

Over the past 8 years, behavioral health issues 

in the Army and the Department of Defense have 

changed greatly and continue to do so. This appendix is historical in nature. It may be used as a 

training tool for military residents and fellows (for 

example, in a military psychiatry seminar) or to 

assist in preparation of future providers deploying 

to an immature theater. The case studies may be 

used for discussions about varying stressors and 

other conditions that might be encountered during 

deployments. Regardless of the use of this material, 

the discussion of each major unit during OIF I and 

the challenges faced should be considered in future 

operations.

REcommended READING

 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM 

IV-TR). Arlington, Va: APA; 2008. 

 US Department of the Army. Mental Health Advisory Team (MHAT) Reports I-VI. Available at: http://www.behavioralhealth.army.mil/research/index.html. Accessed November 23, 2010.

 US Department of the Army. Combat Stress Control in a Theater of Operations. Washington, DC: DA; 29 September 1994. 

Field Manual 8-51.

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

4-02.51.

 US Department of the Army. Active Duty Enlisted Administrative Separations. Washington, DC: DA; April 27, 2010. AR 

635-200.

 Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, eds. War Psychiatry. In: Zajtchuk R, Bellamy RF, eds. 

Textbooks of Military Medicine. Washington, DC: DA, Office of The Surgeon General, Borden Institute; 1995.
767

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
768

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 
769

Operational Psychiatry in Operation Enduring Freedom 

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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Combat and Operational Behavioral Health

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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Combat and Operational Behavioral Health

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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Operational Psychiatry in Operation Enduring Freedom 

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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Combat and Operational Behavioral Health

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.
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Good or Bad News? Media Coverage of Soldiers: Focus on Behavioral Health in Iraq During OIF 05-07

Appendix 3

GOOD OR BAD NEWS? MEDIA COVERAGE OF SOLDIERS: FOCUS ON BEHAVIORAL HEALTH IN IRAQ DURING 

Operation Iraqi Freedom 05-07

JEFFREY S. YARVIS, PhD,* and ELSPETH CAMERON RITCHIE, MD, MPH†

INTRODUCTION

BASICS OF interactING WITH the MEDIA

ISSUES AND CONCERNS WITH BEHAVIORAL HEALTH REPORTING ON IRAQ

Suicide Rates in the Army

Baghdad ER

Haditha

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington, DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland

†

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

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

NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

The mental health of soldiers during the wars in Iraq 

and Afghanistan has generated ongoing media interest, focusing on major issues such as suicide, administrative discharges, psychiatric medications, fitness to 

deploy, care of wounded soldiers, and traumatic brain 

injury. This appendix provides some basic guidance for 

interacting with the media, followed by a discussion 

of media coverage during a specific period of time. 

Questions raised include: Does the media’s portrayal 

of soldiers with mental illnesses present the public 

with an accurate picture? How does the representation 

of the behavioral health of soldiers affect behavioral 

health operations? 

This appendix explores the possible operational 

impact of negative portrayals of soldiers with mental 

illnesses, using examples from Operation Iraqi Freedom (OIF) 05-07, through discussions of sensitive 

behavioral health issues such as suicide, portrayals of 

the combat environment to the public via documentaries such as Baghdad ER, and controversial events 

such as the killings in Haditha. In some cases media 

reporting can magnify the stigma experienced by 

soldiers with behavioral health problems, in addition to affecting the practices of military behavioral 

health. In other cases, the media can shed light on 

problems that need to be, and indeed are, addressed 

by military behavioral healthcare providers and 

policy makers.

BASICS OF INTERATING WITH THE MEDIA

Members of the media often approach military 

behavioral healthcare providers. If approached by a 

journalist, the first rule for the provider is to contact 

the public affairs office (PAO). PAO staff will handle 

negotiations with the media, and decide if it is an appropriate interaction. If an interview is approved, the 

interviewee should be prepared for surprise questions 

and always remember that quotations can be taken out 

of context. If giving a lecture, the speaker should keep in 

mind that media are often in the audience. Again, PAO 

staff should provide guidance for any public speaking 

or media interactions by military practitioners.

ISSUES AND CONCERNS WITH BEHAVIORAL HEALTH REPORTING ON IRAQ

During OIF 05-07, the war in Iraq entered its fourth 

year. Like all wars, the Iraq War is an extremely complex set of ever-changing dynamics. The battlefield has 

evolved considerably since US forces first invaded Iraq 

in 2003, changing from largely combat operations during the first months into civil-military endeavors since 

then. During this time the enemy had also evolved 

from organized Iraqi forces into varying militias, including some foreign fighters. Over 1,100 tribes live 

in the country; tribal territories often extend beyond 

Iraq’s national boundaries. Other nation states also put 

external pressure on Iraq. Various religious and ethnic 

groups compete for scarce resources in the Bedouin 

cultural tradition. Privateers and black-marketers 

make a living in chaotic social and economic circumstances. Iraqi politicians maintain different views about 

the best way to govern. Despite this complex and 

evolving environment, media reports have sometimes 

given a simplified impression that the ongoing conflict 

results from sectarian violence between the Sunni, 

Shia, and Kurdish groups. 

Combat stress or behavioral health assets were positioned throughout Iraq to help soldiers negotiate their 

way through these complex operational and emotional 

terrains. During OIF 05-07, the ongoing war in Iraq 

affected behavioral healthcare in two important ways. 

First, enough time had elapsed by then for military 

leaders to be aware of outcomes and problems that 

had arisen from OIF I (the first rotation) and OIF II (the 

second rotation). Consequently, new policies involving 

the behavioral health community were initiated (ie, 

suicide prevention, use of psychiatric medications; 

see Chapter 25, Suicide Prevention, and Chapter 

10, Psychiatric Medications in Military Operations, 

respectively, for further discussion of these topics). 

Secondly, the length of the conflict and the number of 

casualties had generated increasing media interest in 

the war and in behavioral health services available to 

soldiers. Although it is impossible to determine to what 

extent the media influenced the day-to-day operations 

of behavioral health providers, the increased scrutiny 

did concern military leadership. This translated into 

greater cognizance of behavioral health activities. 

The media has covered wars since the advent of 

print journalism. With the introduction of motion 

pictures, war coverage reached larger audiences 

throughout World War II. During this period, as well 

as during the Korean War, most of the video reporting of the war was seen in movie theaters. It was not 

until Vietnam that images of war were televised into 

the homes of the US populace. This footage, however, 

was generally edited at a network before it was aired 
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Good or Bad News? Media Coverage of Soldiers: Focus on Behavioral Health in Iraq During OIF 05-07

because the media lacked the capability of a live feed 

from the battlefield. Beginning with the Persian Gulf 

War (1990–1991), however, journalists were able to 

send live feeds from their embedded positions directly 

to television broadcasts. Commanders and politicians 

had virtually no time to review what might be broadcast, and in many cases heard of issues raised by the 

media only after they had been aired. 

The following three issues—suicide, Baghdad ER, 

and Haditha—all of which involved situations during 

OIF 05-07, will be examined as they were reported by 

the media and acted upon by the military. Neither the 

nature of recent advances in media technology nor the 

media’s effect on public opinion has been fully measured. However, it is not difficult to imagine that media 

coverage of behavioral health could have operational 

impacts and affect the behavior of soldiers. Mention 

Abu Ghraib or Haditha and one will elicit a wide range 

of reactions, from well informed to hearsay, from those 

responding. It is then that one can sense the true power 

and influence the media can have. The positive impact 

of this phenomenon is that the military often gains the 

attention and the political support it needs to address 

important psychological health needs of soldiers, for 

example, suicides in the Army.

Suicide Rates in the Army

Various media sources began reporting in 2003 that 

Army suicide rates were on the rise and that those 

soldiers deployed to Iraq and Kuwait experienced the 

greatest increase.1

 Although Army suicide statistics 

remained lower than for comparable age groups in the 

civilian population, the Army surgeon general, Lieutenant General James Peake, said that “any suicide is 

something we worry about and want to stop.”2 Despite 

the trend data being consistent with the civilian sector, 

recommendations were immediately implemented, 

including augmenting the Army’s suicide prevention 

program and making behavioral healthcare more accessible to soldiers in combat and other high-stress 

environments. However, media reports, such as the 

articles on suicide, may alter mission focus and influence military behavioral health resources by diverting 

limited assets to respond to the reporting. 

The Army’s first mental health survey ever conducted in a combat zone took place in 2003 (see 

Chapter 5, Walter Reed Army Institute of Research 

Contributions During Operations Iraqi Freedom and 

Enduring Freedom, in this volume, for a more detailed 

discussion of the survey process). At the request of the 

commanding general, Combined Joint Task Force-7 of 

the US Central Command established and dispatched 

the first Mental Health Advisory Team (MHAT) to 

survey and provide recommendations on OIF-related 

behavioral health services. A team of 12 military and 

civilian psychiatrists, psychologists, social workers, 

and combat-stress experts surveyed 756 soldiers in Iraq 

between late August and early October 2003. They also 

surveyed behavioral health and medical care providers, unit leaders, and unit ministry staffs. The survey 

was conducted when conditions were at a low point: 

at the end of a very hot summer, before much of the 

infrastructure that created more comfortable living 

conditions had been put in place, and before most soldiers knew when they would redeploy to their home 

stations. The team leader of this first MHAT, Colonel 

Virgil Patterson, said one in four soldiers surveyed 

reported moderate or severe emotional, alcohol, or 

family problems. More than half reported low or very 

low morale. 

After media reports on suicide began appearing, 

military behavioral health experts found themselves 

adding one additional task to their already significant duties: to maintain current and accurate data on 

suicide in theater and remain prepared to respond to 

media reports. For example, in 2003 the Baltimore Sun

ran an article with the title “Army’s Suicide Rate Has 

Outside Experts Alarmed,” and the follow-on subtitle of “Most died serving in Iraq after major combat 

phase.”3

 Similar reports were carried by most of the 

major news networks and papers. Later articles used 

language similar to that used by the Baltimore Sun in 

2003. For example, the Hartford Current noted in 2007 

that the “Army continues to struggle with suicides,” 

and the “2006 Rate Of Self-Inflicted Deaths In Iraq 

Could Exceed Record Set In 2005.”4 Since OIF 05-07, 

an upward trend in suicide rates in active duty military has occurred, as discussed further in Chapter 25, 

Suicide Prevention, in this volume.

Baghdad ER

The 2006 HBO (Home Box Office) documentary 

Baghdad ER was a graphic and emotional account 

of the realities of war through the emergency room 

experiences of a combat support hospital. At the very 

outset of Baghdad ER, the producers pointed out that 

90% of soldiers wounded in Iraq survive—the highest 

survival rate in American military history. (During OIF 

05-07, survival rates exceeded 96%.5

)

Visual documentaries can serve as powerful reminders or “triggers” for soldiers who have been 

exposed to the sights, sounds, and smells of combat 

injuries; Baghdad ER was such a harsh reminder of the 

brutal realities of war. Military officials were allowed 

to preview the documentary and proactively prepare 

for its impact. The Army surgeon general at the time, 
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Combat and Operational Behavioral Health

Lieutenant General Kevin Kiley, recommended that 

Army medicine plan for the effect that Baghdad ER 

might have on those who saw it. Said Kiley, “This film 

will have a strong impact on viewers and may cause 

anxiety for some soldiers and family members.”6 He 

noted that, “some may have strong reactions to the 

medical [surgical] procedures such as the amputation of a limb.”6

 Kiley said military medical treatment 

facilities should be ready to assist troops and family 

members who might be upset after watching the film. 

He suggested that behavioral health facilities should 

extend their treatment hours and reach out to the 

troops proactively.6 Kiley recognized that families and 

soldiers with ongoing psychological difficulties might 

have additional behavioral healthcare needs after the 

program aired. There were no known negative effects 

from viewing the program, although this was not systematically studied. From conversations with viewers, 

one of the authors (ECR) reported positive response 

to the program.

Haditha

Additional media interest in the military in Iraq 

came in the wake of the killing of 23 Iraqis on November 19, 2005, in Haditha, a city in the western 

Iraq province of Al Anbar. It was alleged that the 

killings were retribution for the attack on a convoy 

of US Marines with an improvised explosive device 

that killed Lance Corporal Miguel Terrazas.7

 A Marine 

Corps communiqué initially reported that 15 civilians 

were killed by the bomb’s blast and 8 insurgents were 

subsequently killed when the Marines returned fire 

against those attacking the convoy. However, evidence 

provided by the media contradicted the Marines’ account.7

 According to these media reports, at least 15, 

and allegedly all, of those killed were noncombatant 

civilians and were killed by the Marines.

Discussing the events in Haditha, psychiatrist 

Robert Jay Lifton explains that, “atrocity is a group 

activity.”8

 Therefore, he wrote, “[t]o attribute the likely 

massacre at Haditha to ‘a few bad apples’ or to ‘individual failures’ is poor psychology and self-serving 

moralism.”8 Lifton says that the Haditha incident can 

be understood as what he calls “an atrocity-producing 

situation”—which he defines as 

one so structured, psychologically and militarily, that 

ordinary people, men or women no better or worse 

than you or I, can commit atrocities....Recognizing 

that atrocity is a group activity, one must ask how individual soldiers can so readily join in. I believe they 

undergo a type of dissociation that I call doubling—

the formation of a second self. The individual psyche 

can adapt to an atrocity-producing environment by 

means of a sub-self that behaves as if it is autonomous and thereby joins in activities that would otherwise seem repugnant.8

In environments where sanctioned brutality becomes the norm, homicidal ideation and homicidal 

impulses, dormant in most individuals, are likely 

to be expressed.9 The violent energy of the group 

becomes such that an individual soldier who questions it could by turned against by his or her peers. 

(For example, a Vietnam veteran who had been at My 

Lai told this author [JY] that he had refused to fire 

and pointedly lowered the barrel of his gun to the 

ground.) To resist intense group pressure requires a 

combination of conscience and moral courage, the 

very qualities that the military seeks to instill in soldiers as “core values.” 

Previously, Lifton explained his concept of atrocity-producing situations during a lecture about the 

possible torture of prisoners at Abu Ghraib.8

 In such 

situations, Lifton explained, although individuals 

are responsible for their own actions, when attempting to assign blame for atrocities it is perhaps more 

instructive to examine the conditions and examples 

set by higher commanders. When the rules of engagement do not appear to apply, or when ambiguities 

exist about what means may be used to achieve a 

“worthy” end, soldiers are less likely to adhere to the 

values that the military has sought to instill within 

them. Likewise, stress results from not knowing 

who the enemy is, not feeling safe, and witnessing 

evil. Cumulatively, these situations can contribute 

to behaviors that at times might exceed the rules of 

engagement. Additionally, the rules are sometimes 

difficult for a soldier to apply in the heat of battle or 

under circumstances outside normal soldier experiences or training. This explanation does not purport 

to dismiss the notion of accountability; however, it 

speaks to the process of “pathologizing” a new generation of soldiers. 

Politics, social control, and mental health have 

long been tied together. For instance, diagnostic terms 

can reflect the bias of people and the times, such as 

“hysteria”—a term inherently biased against women. 

“Mental health” has been used both to limit civil 

rights and to advocate for civil rights. The former was 

discussed in the writings of the psychiatrist Thomas 

Szasz,10 who suggested in 1961 that “mental illness” 

and the threat of being institutionalized were the 

means by which societies controlled those who strayed 

from the common morality. He advocated for the rights 

of those who had been institutionalized, setting in motion a movement that resulted in the release of many 

previously confined patients.10
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Good or Bad News? Media Coverage of Soldiers: Focus on Behavioral Health in Iraq During OIF 05-07

SUMMARY

Behavioral healthcare in the military differs from 

the civilian practice in one distinct way: military behavioral health providers are tasked to conserve the 

fighting strength of the military. Thus, although they 

treat individuals, their focus is on the overall institution. Military providers accomplish their mission 

by caring for both US military personnel and their 

families. These providers, however, can be distracted 

by the situations that inevitably arise when complex 

mental health issues are reported in a simplified manner. The media can bring attention to areas indeed 

needing corrective action; however, the media can 

also sensationalize stories, as evidenced by titles like 

“Potent Mixture: Zoloft & a Rifle.”11

The accurate presentation of behavioral health data 

is essential to combat and operational stress policy and 

doctrine; however, when data are misunderstood or 

reported out of context, they can undermine popular 

support for soldiers and potentially impact soldiers’ 

mental health. Possible areas of operational consequences due to media coverage include changing 

policies on evacuation of behavioral health casualties, 

limiting use of psychotropic medication in theater, 

and lessening the trust in clinician “instincts.” This 

operational impact has been termed the “CNN [Cable 

News Network] effect” and is seen as a double-edged 

sword—a “strategic enabler” and a potential operational risk.12

It is difficult to quantify the operational impact or 

strategic effect the media can have on behavioral health 

planning and execution. However, it is clear that the 

media are powerful forces shaping the environment 

in which behavioral health practitioners can work. 

Therefore, clinicians must be proactive as scientistpractitioners to demonstrate the efficacy of their 

practices, to plan effective battlefield interventions and 

operations for combat and operational stress control, 

and to assist with screening and surveillance of the 

service members within the scope of their responsibility. The media can also play a crucial role in drawing 

needed attention to situations in the military affecting 

soldiers in both garrison and operational settings. This 

unique convergence of two professional communities 

can contribute to conserving the fighting strength, 

which is, of course, the mission of all members of the 

military medical community.

REFERENCES

1. Miles D. 2003 Suicide rates elevated among [Operation] Iraqi Freedom troops; 2004 rates dip. American Forces Press 

Service. March 25, 2004. Available at: http://www.defenselink.mil/news/newsarticle.aspx?id=27000. Accessed August 

4, 2010.

2. Miles D. Army suicide rate in combat zones elevated. American Forces Press Service. March 26, 2004. Available at: http://

usmilitary.about.com/cs/terrorism/a/arsuicide.htm. Accessed August 4, 2010.

3. Martinez M. Army’s suicide rate has outside experts alarmed: most died serving in Iraq after major combat phase. 

Baltimore Sun. December 30, 2003. Available at: http://www.commondreams.org/headlines03/1230-01.htm. Accessed 

August 4, 2010.

4. Chedekel L, Kauffman M. Army’s suicide struggles continue: 2006 rate of self-inflicted deaths in Iraq could exceed 

record set in 2005. Hartford Courant. January 31, 2007. Available at: http://www.courant.com/news/specials/hc-unfitstrugglescont-jan31-2007,0,4648693.story. Accessed August 4, 2010.

5. Swann S, Berry T. Task Force 30th Medical Brigade Commander’s Overview: OIF 05-07. ERMC Medical Service Corps 

Conference, Grassau, Germany, November, 2006. 

6. Starr B. Army: HBO documentary could trigger stress disorder. CNN. May 15, 2006. Available at: http://www.cnn.

com/2006/SHOWBIZ/TV/05/15/baghdad.ER/index.html. Accessed August 4, 2010.

7. McGirk T. Collateral damage or civilian massacre in Haditha? Time. March 19, 2006. Available at: http://www.time.

com/time/world/article/0,8599,1174649,00.html. Accessed August 4, 2010. 

8. Lifton RJ. The psychology of atrocity. Editor and Publisher. 2006. Available at: www.editorandpublisher.com/.
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9. Kirkland FA. Honor, combat ethics, and military culture. In: Beam TE, Sparacino LR, eds. Military Medical Ethics. Vol 

1. In: Lounsburg DE, Bellamy RF, eds. Textbooks of Military Medicine. Washington, DC: Department of the Army, Office 

of The Surgeon General, Borden Institute; 2003: 157–198.

10. Szasz TS. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, NY: Hoeber-Harper; 1961.

11. Kauffman M, Chedekel L. Potent mixture: Zoloft & a Rifle. Hartford Courant. May 16, 2006. Available at: http://www.

courant.com/news/specials/hc-unfitzoloft0516.artmay16,0,3148380.story. Accessed August 4, 2010.

12. Belknap MH. The CNN Effect: Strategic Enabler or Operational Risk? Carlisle Barracks, Penn: US Army War College; 2001. 

Available at: www.au.af.mil/au/awc/awcgate/army-usawc/cnn-belknap.pdf. Accessed August 4, 2010.
xxxi

Index

Index 

A

AAS. See American Association of Suicidology

Abrams, Gen. Creighton, replacement of Gen. Westmoreland 

with, 18

ACGME. See American Council of Graduate Medical Education

Achilles in Vietnam (Shay), 130

ACS. See Army Community Service

Acute radiation sickness

atomic weapons dropped on Hiroshima and Nagasaki and, 

600

symptoms, 596

Three Mile Island, PA, nuclear accident and, 599

ADAPT. See Alcohol and other Drug Abuse Prevention Training

Adjustment disorder

brief psychotic disorder and, 442

fitness for duty and, 180

homicidal ideation and, 437

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 203, 212

Adler, Dr. Amy, Battlemind program and, 72

Adolescents

books recommended for dealing with trauma and grief, 

559–560

effects of deployment on, 494–495

grief responses, 547

response to a combat-injured parent, 515–516, 518

Aeromedical Evacuation Patient Considerations and Standards of Care

(Air Force Instruction 41-307), 197–198

Aeromedical Evacuation Patient Record (Air Force Form 3899), 198

Aeromedical evacuations

aeromedical evacuation patient classification codes (table), 198

aeromedical evacuation publications (table), 196–197

aeromedical staging facilities, 200–203

aircraft used for, 194–195

behavioral health consultation for medical patients and, 204

carrier psychology program and, 125–126

contingency aeromedical staging facilities, 192, 195, 200–201

Department of Defense Patient Movement System, 195–200

description, 192

historical background, 192–194

Operation Iraqi Freedom and Operation Enduring Freedom 

and, 192, 203–204

patient classification codes, 197–198

patient movement precedence, 195, 197

patient records and, 198, 200

patient-support pallet development, 195

psychiatric patients and, 197–198, 200, 445–446

sample patient movement request (exhibit), 199

survival rate improvement and, 192

by the United Kingdom armed forces for behavioral health 

reasons, 659–660

use of restraints and, 200, 446

Aeromedical staging facilities

contingency aeromedical staging facilities, 192, 200–201

typical mission description, 202–203

Affective disorders. See Mood disorders

Afghanistan. See also Operation Enduring Freedom

contingency aeromedical staging facilities and, 201

history of, 768

U.S. military involvement in, 768–769

Age factors

anorexia, 451

bipolar disorder, 443–444

bulimia, 451

coping with the stress of deployment, 536

divorce, 539

schizophrenia, 442, 707

spouse maltreatment, 537

AH-1W Cobra helicopters, aeromedical evacuations and, 195

AHECs. See Area Health Education Centers, description

Air Force Form 3899: Aeromedical Evacuation Patient Record, 198

Air Force Instruction 41-307: Aeromedical Evacuation Patient Considerations and Standards of Care, 197–198

Air Force Instruction 44-121, drug testing and, 481

al Qaeda, September 11, 2001, terrorist attacks and, 594

Alcohol abuse. See Alcohol use and abuse

Alcohol and other Drug Abuse Prevention Training, description, 

481

Alcohol use and abuse

abstract reasoning abilities and, 474

binge drinking definitions for women and men, 475

blackouts and, 475

bolus drinking, 475

brain volume decrease and, 475

CAGE questionnaire, 475–476

cognitive impairment and, 474

coping with stress and, 260

homicidal ideation and, 437

Land Combat Study and, 78

light, moderate, and heavy drinking amounts, 475

memory impairment and, 475

mild traumatic brain injury and, 233

pain management and, 349

posttraumatic stress disorder and, 305

prevalence of, 475

Quantity Frequency Questionnaire, 475

screening for, 475–476

sleep impairment and, 475

suicide and, 425, 429, 431

Vietnam War and, 17, 152

visual-spatial impairment and, 474

visual tracking of objects and, 474

withdrawal issues, 475

Alcoholics Anonymous, Operation Iraqi Freedom 05-07 and, 142

Alzheimer’s disease

genetic research and, 396

vitamin E and, 396

Ambien, insomnia treatment, 159, 160, 250

Ambiguous Loss: Learning to Live With Unresolved Grief (Boss), 560

AMEDD. See Army Medical Department

AMEDD C&S. See Army Medical Department Center & School

American Academy of Child and Adolescent Psychiatry, description and Web site, 556

American Academy of Pediatrics

description and Web site, 556

use of lithium during pregnancy, 709

American Articles of War, birth of American military law and, 694

American Association of Suicidology

Suicide Prevention: A Resource Manual for the United States Army,

405

suicide prevention efforts, 404, 405

American Board of Medical Specialties, core competencies program, 676

American Council of Graduate Medical Education

accreditation history of U.S. military psychiatry residencies 

(table), 671

accreditation role, 670, 671, 681, 688

competencies (exhibit), 675

core competencies, 675, 676
xxxii

Combat and Operational Behavioral Health 

fellowship programs and, 680

program leadership requirements, 673

Residency Review Committee requirements for psychiatry 

residents, as of 2007 (exhibit), 678

supervisor meetings, 678

time requirements for rotations, 678

American Medical Association, criminal execution role for physicians, 737

American Psychiatric Association. See also Diagnostic and Statistical 

Manual of Mental Disorders

anti-Vietnam War stance, 25

founding of, 671

guidelines that forbid psychiatrists from being directly involved in interrogations, 736, 737

American Psychological Association

anti-Vietnam War stance, 25

participation of providers in interrogations and, 736

resilience self-help Web site, 50

Task Force on Promoting Resilience in Response to Terrorism, 

45

American Red Cross. See also International Red Cross and Red 

Crescent Movement

occupational therapy and, 359

September 11, 2001, terrorist attack response, 583

American Revolutionary War, military medical evacuations and, 

192

American Society of Addiction Medicine, treatment decision making, 481

Amphetamines. See also Stimulants; specific drugs

World War II use of, 152

AN. See Anorexia nervosa

Anderson, A.E., eating disorder research, 454

Andrews Air Force Base, MD

aeromedical staging facility role, 201–203

Air Force Family Liaison Officer program and, 201

Annie Loses Her Leg But Finds Her Way (Philipson and Takatch), 

558

Anorexia nervosa

age of onset, 451

bingeing/purging type, 451

comorbid psychiatric disorders, 453, 455

course and prognosis, 455

deployment and, 463

differential diagnosis, 455

DSM-IV definition, 451

families characteristics and, 453

functional impairment and, 455

hospitalization and, 458, 459

indications for hospitalization in (exhibit), 459

laboratory findings, 455

medical assessment, 458

medical findings, 454

medications effective as mono-therapy in placebo-controlled 

trials for (exhibit), 460

medications for, 460–461

military population statistics, 456

mortality rates, 454, 455, 459

oral health effects, 263–264

outpatient treatment, 459

poor insight and, 458

prevalence of, 450

psychotherapy, 459

rapid refeeding and, 459

recovery rate, 455

restricting type, 451, 454

treatment, 458–459

vitamin supplementation and, 459

warning signs of (exhibit), 451

Anthrax attacks

delayed recognition of, 594

long-term effects, 601

media and, 598

physiological effects, 581

Anticonvulsants

binge eating disorder treatment, 462

obesity treatment, 462

pain management and, 344, 347

Antidepressants. See also Tricyclic antidepressants; specific drugs

anorexia nervosa treatment, 460

binge eating disorder treatment, 462

major depressive disorder treatment, 444, 445

obesity treatment, 462

pain management and, 246, 344, 347

posttraumatic stress disorder treatment, 303

Antipsychotic drugs. See also specific drugs

anorexia nervosa treatment, 460

availability in the field, 443

bipolar disorder treatment, 158

pain management and, 347

schizophrenia treatment, 443, 707

side effects, 443, 460

trauma patients and, 249

women and, 707

Antisocial personality disorder, suicide and, 426

Anxiety disorders

combat and operational stress continuum model red zone and, 

112

complex humanitarian emergency survivors and, 627

exercise and, 705

fitness for duty and, 180

in-theater treatment, 159

posttraumatic stress disorder and, 298, 305–306

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 203–204, 212

sleep disturbances and, 252

symptoms, 251

traumatic injuries and, 251–253

treatment, 304

uncontrolled pain and, 246

women and, 709–710

Anxiolytics. See also specific drugs

indications for use of, 153

Vietnam War use, 11–12, 34

Appenzeller, G.N., articles on the roles and responsibilities of 

division mental health units, 92

Applied Suicide Intervention Skills Training program, description, 406

Area Health Education Centers, description, 335

Aripiprazole, bipolar disorder treatment, 158

Arlington National Cemetery Commemorative Project, For Children of Valor: Arlington National Cemetery gift book, 554

Armed Forces Health Surveillance Center, EPICON responsibilities, 415

Armed Forces Mortuary, Dover Air Force Base, DE, behavioral 

health consultations for workers at, 204

Armed Service Vocational Aptitude Battery

job assignments and, 705

lowering scores on to meet recruitment goals, 728

Army Center for Substance Abuse Programs, information paper 

on challenges of substance abuse issues, 481

Army Central Registry, reports of family maltreatment, 536–537, 

538

Army Community Service

behavioral health liaison project and, 571, 572–574

deployment of the 25th ID and, 565

“Ready 4 Reunion” DVD, 574
Index

xxxiii

Army Health Promotion (Army Regulation 600-63), 397, 408

Army Medical Command

child maltreatment prevention program, 539

EPICON responsibilities, 415

Fatality Review Board findings on family maltreatment, 539

guidelines on screening for depression in spouses of service 

members, 538

suicide prevention and, 406–407

Suicide Risk Management and Surveillance Office, 407

Army Medical Department

Behavioral Health Proponency, 748

career course, 98, 103

general officers behavioral health summit, 81

psychiatrist training and preparation for the Vietnam War, 

14–15

Army Medical Department Center & School

Battlemind program and, 73, 74, 80

Professional Quality of Life Scale and, 382–384

Provider Resiliency Training and, 376

Army Medical Support in Vietnam (Neel), 16, 28

Army Medical Surveillance Activity, population-wide assessment 

of the Post-Deployment Health Assessment, 79

Army Military Family Research Institute, Web site, 501

Army Physical Disability Evaluation System, improvement initiative for, 328

Army Regulation 40-5: Preventive Medicine, 415

Army Regulation 40-216: Neuropsychiatry and Mental Health, 90, 91

Army Regulation 40-501: Standards of Medical Fitness, 180

Army Regulation 190-8: Enemy Prisoners of War, Retained Personnel, 

Civilian Internees, and Other Detainees, 101

Army Regulation 600-63: Army Health Promotion, 397, 408

Army Regulation 600-85, drug testing and, 479, 481

Army Regulation 608-18, Family Advocacy Program and, 536

Army Substance Abuse Program

Alcohol and other Drug Abuse Prevention Training and, 481

clinical role of providers, 481–482

employee assistance program model, 480–481

number of soldiers enrolled in, 480

treatment recommendations, 481

unit commanders and, 481–482

Army Suicide Event Reports

analysis of data, 145

command POCs and, 397–398

data collection (figure), 398

data collection process, 398

description, 397

improving accessibility of ASER data, 399, 400

replacement of “psychological autopsies” by, 404

required source information and, 399

source information required to complete (table), 399

variables, 398–399

Army Suicide Prevention Program

Applied Suicide Intervention Skills Training, 406

Army National Guard efforts, 408–409

Army Reserves efforts, 409

Army Suicide Prevention Task Force, 409

Behavioral and Social Health Outcomes Program, 409

Chief of Chaplains and, 405

community health promotion councils, 408

G-1 and, 405, 406, 409

gatekeepers and, 406

initiatives and efforts to minimize suicidal behavior, 406–409

Installation Management Command, 408

Medical Command and, 406–407

Office of The Surgeon General and, 405

Operation Iraqi Freedom theater suicide assessment, 409–412

psychiatric epidemiological consultations, 412–418

QPR Institute and, 406

Suicide Prevention and Psychological Autopsy (PAM 600-24) and, 

405

Suicide Prevention Campaign Plan, 405

Suicide Prevention Task Force, 405

Army Suicide Prevention Task Force, description, 409, 749

Army Surgeon General. See Office of The Surgeon General; specific 

Surgeons General

Army War College, Carlisle Barracks, PA, Spouses’ Project recommendation for a care team, 545

ARNG. See U.S. Army National Guard

Arnold, Caroline, What We Do When Someone Dies, 559

ARS. See Acute radiation sickness

Artiss, Lt. Col. Kenneth, textbook on military psychiatry and, 5, 6

ASAP. See Army Substance Abuse Program

Asaro, Regina, Military Widow: A Survival Guide, 551

ASERs. See Army Suicide Event Reports

ASFs. See Aeromedical staging facilities

ASIST program. See Applied Suicide Intervention Skills Training 

program

ASPP. See Army Suicide Prevention Program

ASPTF. See Army Suicide Prevention Task Force

Assisting Marsh Arabs and Refugees, medical civil-military operations in Operation Iraqi Freedom 05-07 and, 616

ASVAB. See Armed Service Vocational Aptitude Battery

Attention-deficit hyperactivity disorder, clearance for deployment 

and, 157

Atypical antipsychotic drugs. See also specific drugs

bipolar disorder treatment, 303–304

borderline personality disorder treatment, 303–304

pain management and, 347

posttraumatic stress disorder treatment, 303–304

trauma patients and, 249

Aum Shinrikyo cult’s sarin attack on the Tokyo subway system, 

594, 597, 598, 599, 601–602

AusAID. See Australian Agency for International Development

Australian Agency for International Development, Indian Ocean 

tsunami disaster relief and, 637–639

Australian Council for International Aid, complex humanitarian 

emergencies and, 621

Authentic Happiness: Using the New Positive Psychology to Realize 

Your Potential for Lasting Fulfillment (Seligman), 560

B

Bachman, J.G., draft issues during the Vietnam War, 23–24

Bacon, B.L.

guidelines for psychiatry residents on becoming a division 

psychiatrist, 92

use of psychotropic medications during the Persian Gulf War, 

153

Baghdad ER HBO program, 147–148, 777–778

Baker, Col. Stewart L., Jr., survey of illegal drug use in the Vietnam War, 11

Balkin, J.J., review of the demoralization of troops fighting in 

Vietnam, 26

Bamber, M., stressors for staff working with trauma victims, 255

Bandura, A., resilience research, 46

Barbiturates. See also specific drugs

World War II and use of, 152

Bascaglia, Leo, The Fall of Freddie the Leaf, 557

Battlemind training program

acronym explanation, 332

Army Medical Department Center & School and, 73, 74, 80

background of, 72

Basic Battlemind, 73

Battlemind First Aid, 73

Battlemind for Leaders, 73

Battlemind Warrior Resiliency Training, 73
xxxiv

Combat and Operational Behavioral Health 

command-requested mental health training, 72

components (exhibit), 283

continuum of care for veterans and their families and, 332

current status, 73–74

deployment-cycle training and, 65, 73, 80–81

description, 65, 72, 80, 332

dynamic nature of, 74

event-driven psychological debriefing and, 80

focus of, 80, 283

fundamental principles, 73, 332

life-cycle training and, 65

Mental Health Advisory Team IV report and, 73

modules under development, 73

objectives of, 65

postdeployment training, 72–73, 80

predeployment modules, 73, 80

resetting the force and, 283–284

soldier support training and, 65

state and community partnerships and, 336

“Steel Your Battlemind” video, 73

targets of, 65

time-driven psychological debriefing and, 80

training for spouses, 72, 80–81, 332

training videos, 72–73

use by other nations, 73

Walter Reed Army Institute of Research and, 72–74, 80–81

BCT BHOs. See Division psychiatrists and brigade behavioral 

health officers

Beardslee, W.R., Out of the Darkened Room: When a Parent is Depressed, 517

Becker, C.B., barriers to clinician use of exposure therapy for 

PTSD, 311

BED. See Binge eating disorder

Behavioral and Social Health Outcomes Program, description, 

409, 749

Behavioral health. See also Operational behavioral health; specific 

aspects of the topic

discussion about this text’s title, 6

recent initiatives, 748–750

stigma and barriers to care, 4, 78, 117, 126, 327, 425, 564

stigma associated with seeking behavioral healthcare (exhibit), 

411

Behavioral health consultations for medical patients, Operation 

Enduring Freedom and Operation Iraqi Freedom and, 204

Behavioral health issues for detained individuals. See also Hunger 

strikes

acting-out behavior and, 650, 651

Bureau of Prisons standard operating procedures and, 646

clinical process, 648–649

cognitive disorders, 653

common syndromes, 653

context of care and, 647

corrections staff and, 650–651

cultural factors, 647, 650, 654

distribution of medications, 652

emergence as a critical issue, 646

“equivalent care” mandate, 646, 647

functional impairment and, 650

hoarding medications and, 652

interacting with other sites, 652–653

medical record management and, 653

medication distribution process for detainees (exhibit), 652

medication management, 651–652

nongovernmental organizations and, 646, 649

observation and, 651

predeployment preparation, 646–648

primary care providers and, 649, 654–655

privacy and confidentiality and, 653, 654

review of the active caseload and, 648

screening for behavioral health risk factors, 648

secondary gain and, 650

security issues, 647–648, 649

self-injurious behavior, 647, 649, 651

Task Force Medical 115 and, 646–656

Task Force Medical 344 and, 646–656

therapeutic trust and, 648

training the team, 646–649

translators and, 649–650

treatment planning and, 650–653

24-hour nature of care, 648–649

unique nature of the setting, 651, 656

unit transition and, 649

Behavioral health liaison project

aim of, 571

Army Community Service and, 571, 572–574

Army Community Service support, 572

“communities of practice” concept and, 565, 574–575

community town hall meetings and, 573

deployment sustainment and, 573

emotional cycle of deployment briefing and, 572

family readiness group briefing topics (exhibit), 572

family readiness groups and, 572, 573

initial challenges, 571

job fairs for military spouses, 572–573

lessons learned, 574–575

predeployment support, 572–573

quality of welcome by unit in the behavioral health liaison 

project (figure), 572

redeployment and reintegration and, 573–574

team composition, 571

training and education opportunities, 573

Tropic Lighting University reunion program and, 574

unit welcome and, 571–572

video teleconferencing for soldiers and families, 573

Behavioral Health Proponency, description, 748

Behavioral Science Consultation teams

“behavioral drift” and, 699

description and role, 699

detainees and, 699

global war on terror and, 699

mission and objectives, 699–700

Belanger, H.G., traumatic brain injury research, 231

Belenky, G.L., use of tricyclic antidepressants by Israeli forces, 153

Bell, C.C., resilience program, 51

Benadryl, agitation treatment, 159

Benedek, D.M.

integrated use of combat stress detachments and division 

mental health assets during Operation Joint Endeavor, 153

rationale for using a formulary for military operations, 

153–154

Benight, C.C., resilience research, 46

Benzodiazepines. See also specific drugs

anxiety disorder treatment, 159, 304

indications for use of, 153

pain management and, 344, 347, 348

posttraumatic stress disorder and, 253, 304

potential for abuse of, 158, 159, 253, 304

Bereavement. See also Children and families of fallen service 

members

adult grief responses, 546–547

bereavement reaction to traumatic injury, 246

children’s grief responses, 547–549

88th Regional Readiness Command COSC program and, 

365–366

posttraumatic stress disorder and, 306

prolonged grief disorder and, 348
Index

xxxv

reaction to acute pain, 348

Bessler, M., overview of problems in civil-military cooperation, 

623

BHL. See Behavioral health liaison project

Bhopal, India, chemical accident, 620

BICEPS principles. See Brevity, immediacy, centrality, expectancy, 

proximity, and simplicity

Bill and Melinda Gates Foundation, humanitarian role, 622

Binge eating disorder

oral health effects, 264

prevalence of, 450

proposed DSM-IV category for, 452

treatment, 462

Biofeedback, occupational therapy and, 369

Biological and Toxin Weapon Convention, 594

Biological weapons. See Chemical, biological, radiological, nuclear 

and explosive weapons

Bipolar disorder

age of onset, 442, 443–444

bimodal onset, 443

evacuation from the combat zone and, 158

fitness for duty and, 180

in-theater treatment, 158

pharmacological treatment, 444

presentation of, 444

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 212

recurrent episodes and, 444

treatment, 303–304

type I, 444

type II, 444

women and, 709

Birgenheier, P.S., women in the military, 493

Birmingham, C.L., zinc deficiency in anorexia nervosa and, 460

Blank, Capt. A.S., Jr.

antiwar sentiment effect on soldiers, 18

posttraumatic stress disorder diagnosis and, 30

Bloch, Capt. H.S., antiwar sentiment effect on soldiers, 18

Blum, H.P., loss of self-identity in trauma victims, 246

BMI. See Body mass index

BN. See Bulimia nervosa

Boake, C., postconcussive disorder research, 232

Body mass index, eating disorders and, 452, 454, 458

Bolton, E.E., posttraumatic stress disorder program evaluation, 

310

Bombardier, C.H., posttraumatic stress disorder link with traumatic brain injury, 233

Bonn, R., How to Help Children Through a Parent’s Serious Illness,

517

Borderline personality disorder

bulimia nervosa and, 453

treatment, 304

Bosnia

gender-based violence and, 626

Operation Joint Endeavor and, 76, 79, 153

Boss, Pauline, Ambiguous Loss: Learning to Live With Unresolved 

Grief, 560

Boston Publishing Company, historical series on the Vietnam War, 

25–26

Bourne, Maj. Peter

“combat provincialism” of troops fighting in Vietnam, 17

comparison of U.S. Army psychiatric hospitalization rates in 

Vietnam with those of the Army of the Republic of Vietnam, 

16

incidence of combat psychiatric casualties, 18

marijuana use by troops in the Vietnam War, 17

one-year tours of duty in Vietnam, 17

study of physiological, psychological, and social correlates of 

stress, 11

BRAC. See U.S. Department of Defense Base Realignment and 

Closure Act

Bradley, Gen. Omar, division psychiatrist position and, 90

Bradley, J.C., rationale for using a formulary for military operations, 153–154

Bradley, R., PTSD treatment outcome studies, 308

Brain Injury Association, 88th Regional Readiness Command 

COSC program and, 365

Breslau, N., major depression in soldiers with PTSD, 305

Brevity, immediacy, centrality, expectancy, proximity, and simplicity

combat and operational stress control and, 66–68, 108

Operation Iraqi Freedom 05-07 and, 148

unit watch and, 424

Brief psychotic disorder

description and symptoms, 442

progression to schizophrenia, 443

Brief therapies, psychiatry residency programs and competency 

in, 677

Brigade behavioral health officers. See Division psychiatrists and 

brigade behavioral health officers

Brooke Army Medical Center, San Antonio, TX

merger with Wilford Hall Air Force Medical Center, 672

Parent Guidance Assessment--Combat Injury instrument and, 

513, 521–532

specialized burn care, 508

Brown, Marc, When Dinosaurs Die: A Guide to Understanding Death,

557

Brusher, Maj. Edward, Battlemind program and, 73

Bryan, C.J., suicide research, 395

Bryant, R., mild traumatic brain injury and posttraumatic stress 

disorder, 307

BSCs. See Behavioral Science Consultation teams

Buddy watch, unit watch component, 428–431, 432

Building Strong and Ready Families Program, description, 501

Buildup phase of the Vietnam War, 1965-1967

alcohol use and abuse, 17

combat exhaustion casualties and, 15–16

evacuations for psychiatric reasons, 17, 34

hospital psychiatrists, 15

morale during, 16–17

Neuropsychiatric Consultants and, 15, 35

organization and preparation of Army psychiatrists, 14–15

phasic nature of moods and attitudes affecting soldiers, 17–18

psychiatric overview, 17–18

psychiatrists reports, 18

transition from buildup to drawdown, 1968-1969, 18–21

U.S. Army medical and psychiatric support, 14

Bulimia nervosa

age of onset, 451

comorbid psychiatric disorders, 453, 455

compared with bingeing/purging type of anorexia nervosa, 

451

deployment and, 463

description, 450

differential diagnosis, 455

DSM-IV definition, 451

families characteristics and, 453

hospitalization and, 461

indications for hospitalization (exhibit), 460

laboratory findings, 455

medical findings, 454–455

medications effective in placebo-controlled trials for (exhibit), 

461

military population statistics, 456

mortality rate, 455

nonpurging type, 451
xxxvi

Combat and Operational Behavioral Health 

normal weight and, 454

oral health effects, 263, 264

prevalence of, 450

psychotherapy, 461

purging type, 451

recovery rate, 455

relapse and, 455, 462

Russell sign and, 455

treatment, 461–462

warning signs of (exhibit), 452

A Bunch of Balloons (Ferguson), 556

Bunting, Eve

Memory String, 558

The Wall, 557

Bupropion

bulimia nervosa treatment, 462

depressive disorder treatment, 158

posttraumatic stress disorder treatment, 303

safety of use during pregnancy, 709

side effects, 462

Bureau of Prisons, standard operating procedures and detained 

individuals, 646, 647

Burn casualties

Brooke Army Medical Center’s specialized care, 508

control of metabolic and stress responses and, 340

hyperalgesia and, 343

stress of treatment, 345

Burnout

definition, 377

synergistic effects of primary, secondary, and operational 

stress, combined with burnout symptoms, on providers 

(figure), 380

Bush, Pres. George W., importance of healthcare in medical civilmilitary operations, 610–611

Byrdy, Capt. H.S.R., rate of combat stress reactions in his unit, 16

C

C-17 Globemaster aircraft, aeromedical evacuations and, 195

C-130 Hercules aircraft, aeromedical evacuations and, 195

C-9 Nightingale aircraft, aeromedical evacuations and, 195

CAGE questionnaire, alcohol use and abuse and, 475–476

Campbell, S.J., article on division mental health units, 92

Canadian International Development Agency, complex humanitarian emergencies and, 621

Canadian Medical Education Directions for Specialists, 676

CAPS. See Child and Adolescent Psychiatry Service

Cardiac disorders, anorexia nervosa and, 454, 455

Caregivers. See also Provider fatigue

combat and operational first aid and, 132

deployment as individual augmentations, 131–132

mission and personnel, 131–132

OSCAR communication strategy, 132–133

self-help barriers, 132

trauma exposure and intervention strategies, 132

U.S. Navy support for, 131–133

Carlton, J.R., eating disorders in the U.S. Navy population, 458

Carrier psychology program

cost savings examples, 126

historical background, 125–126

prevented medevacs and, 125–126

prevention of chronic psychological problems, 126

stigma reduction and, 126

Casey, Gen. George W., Jr., Comprehensive Soldier Fitness program and, 748

CASFs. See Contingency aeromedical staging facilities

Caspi, A., role of serotonin metabolism in stress reactivity, 46

Castro, Maj. Carl, Battlemind program and, 72, 73

CBRNEs. See Chemical, biological, radiological, nuclear and 

explosive weapons

CBT. See Cognitive-behavioral therapy

CDC. See Centers for Disease Control and Prevention

Celecoxib, pain management and, 344

Celexa, depressive disorder treatment, 158

Center for Excellence in Disaster Management and Humanitarian 

Assistance, civil-military operations centers and, 624

Center for Health Promotion and Preventive Medicine. See U.S. 

Army Center for Health Promotion and Preventive Medicine

Center for Mental Health Services, Web site, 500

Center for the Intrepid rehabilitation facility, description, 328

Center for the Study of Traumatic Stress

dealing with the death of a service member, 555

Parent Guidance Assessment--Combat Injury, 513, 521–532

Web site, 555

Centers for Disease Control and Prevention

course on emergency risk communication training, 595

EPIAID and, 413

estimates of traumatic brain injury prevalence and mortality, 

226

Gulf War syndrome research, 600

Hurricanes Katrina and Rita health surveillance, 586–587

Injury Statistics Query and Reporting System, 399–400

obesity in the U.S. population, 452

PsySTART program, 636, 640

risk and protective factors for suicide, 411–412

Web site, 595

CH-47 Chinook helicopters, aeromedical evacuations and, 

194–195

CH-46 Sea Knight helicopters, aeromedical evacuations and, 

194–195

Chaplains. See also Religious and spiritual issues; U.S. Army 

Chaplain Corps

Army Suicide Prevention Program and, 405

Chaplain Annual Sustainment Training course, 408

children and families of fallen service members and, 549

Combat and Operational Stress/Staff Resiliency program and, 

219, 220, 221

88th Regional Readiness Command COSC program and, 365, 

366

Landstuhl Regional Medical Center role, 211

outreach to couples struggling in their marriages, 539

provider fatigue and, 380

public health model for deployment mental health and, 331

September 11, 2001, terrorist attack response, 583

state and community partnerships and, 336

“Strong Bonds” program, 407, 539

suicide awareness training kits, 406–407

suicide prevention, 407–408

Charney, D.S., neurobiological factors in resilience, 46–47

CHCS-ITT. See Composite Health Care System-Interactive Training Tool

Chemical, biological, radiological, nuclear and explosive weapons

acute effects, 597–600

acute radiation sickness and, 596

availability of, 594

biological agents, 598, 601, 602

catastrophe description, 595

chemical warfare agents, 598, 599, 600–602

disaster description, 595

disaster fatigue and, 594

emergencies description, 595

estimating psychological casualties, 597, 602–603

explosives, 599, 602

lack of provider preparedness for psychological symptoms, 

596–597

long-term effects, 600–602
Index

xxxvii

mass casualty events, 595

mass hysteria description, 594

mass panic and, 595, 597, 602

mass psychogenic illness description, 594

media and, 595, 596

mental disorders and, 599–600, 601–602

military experience, 600

nuclear weapons, 599–600, 601

outbreaks of multiple unexplained symptoms and, 594, 

597–599, 600–601

psychological effects, 596–597, 602–603

“radiation response syndrome” and, 600

radiological agents, 599, 601, 602

risk communication, 595

risk perception, 595–596, 603

terminology, 594–595

triage and issues of differential diagnosis, 596–597

“worried well” persons and, 594

Chernobyl nuclear accident

description, 599, 620

mental disorders and, 602

psychoneurological syndromes following, 601

CHEs. See Complex humanitarian emergencies

Child abuse and neglect. See Family maltreatment

Child and Adolescent Psychiatry Service

children of combat-injured service members and, 511

integrated behavioral health services at Schofield Barracks, HI, 

and, 565, 569

Solomon Wellness Educational Program and, 569, 570

Child maltreatment. See Family maltreatment

Children. See also Deployment impact on military families and 

children; Family maltreatment; specific age groups

COMFORT scale for pain assessment, 346–347

effect of the death of a child on a service member, 552

Faces Scale for assessing pain, 347

pain evaluation and management, 340, 346–347, 349

Poker Chip Tool for assessing pain, 347

posttraumatic stress disorder and, 345

Children and families of combat-injured service members

case studies, 508, 509

Child and Adolescent Psychiatry Service support, 511, 512–513

child response to events resulting from combat injury (figure), 

505

children in the hospital setting and, 510–512

children’s activity level and, 511

comorbid psychiatric symptoms and, 505

cultural factors, 510

developmental factors in children’s responses, 513–516

drawing by the 3-year-old son of severely injured service 

member (figure), 514

drawing by the 5-year-old son of severely injured service 

member (figure), 515

effect of the injury on the parent/service member, 516–518

family function effects, 504

Girls Time Out program, 510

goals for children of injured service member parents (exhibit), 

516

hospitalization phase of recovery, 508–512

lack of research on, 504–505

language barriers and, 510

level of parental disability and, 504

limiting and structuring hospital visits for children, 511–512

long-term rehabilitation and transitions, 517–518

monitoring children who are vulnerable, 516

moving from known communities and, 518

nontraditional families and, 508

notification of injury, 505–508

parent-child interaction and, 516–517

Parent Guidance Assessment--Combat Injury instrument, 513, 

521–532

percentage of service members with children, 504

presence of children as a complicating factor in care, 508

Preventive Medical Psychiatry role, 509–510

“Principles of Caring for Combat-Injured Families and Their 

Children,” 517, 533–534

principles of caring for families and children of the combat 

injured (exhibit), 517

resources (exhibit), 517

support to, 512–513

traumatic brain injury and, 504–505

treatment facilities’ support of families of the combat injured 

(exhibit), 512

vignettes, 507–508, 509, 510, 511–512

Children and families of fallen service members

adult grief responses, 546–547

adult grieving process timeline (table), 546

Casualty and Mortuary Affairs operation center and, 545

casualty assistance call officers and, 544

casualty assistance officers and, 544

children’s emotional and behavioral responses to death (exhibit), 548

children’s grief responses, 547–549

death, illness, or injury of a leader, 551

death of a spouse or child, 552

ensuring the accuracy of death notices, 545

Families First Casualty Call Center and, 545

grief responses, 546–551

grief symptoms, 546–547

health grieving, 546

literature on, 551, 556–562

mass casualties, 551

media and, 552

military care team, 545–546

military funerals, 549

military response to the death of a service member, 544–545

missing in action, 551

number of service members who have died in Iraq and Afghanistan as of October 2007, 544

percentage of service members who are parents, 544

prisoners of war, 551

protecting children from media exposure, 547

resources, 554–562

special circumstances, 551–552

suicide, 551

support services and organizations, 550–551, 554–556

survivor benefits changes, 545

traumatic death compared with anticipated death, 549

traumatic grief, 549–550

unique aspects of military family loss, 547

Chloral hydrate, World War I and use of, 152

Chlorine gas, attacks with during World War I, 597

CHPPM. See U.S. Army Center for Health Promotion and Preventive Medicine

Cigarette smoking. See Tobacco use

Cisapride, anorexia nervosa treatment, 460

Citalopram

anxiety disorder treatment, 253

bulimia nervosa treatment, 462

posttraumatic stress disorder treatment, 303

Civil-Military Relationship in Complex Emergencies, 620

Civil War, medical evacuations and, 192

Clark, D.M.

cognitive model of trauma, 45

Cognitive Theory of PTSD, 299–300

social support effect on posttraumatic stress disorder, 46

Clifton, Lucille, Everett Anderson’s Goodbye, 557
xxxviii

Combat and Operational Behavioral Health 

Clonazepam, insomnia treatment, 159–160

Clonidine, posttraumatic stress disorder treatment and, 304

Cocaine, patterns of use, 477

Cody, Col. Samuel F., use of aircraft for medical evacuations and, 

192

Cognitive-behavioral therapy

anorexia nervosa, 459

bulimia nervosa, 461, 462

panic disorder, 710

premenstrual dysphoric disorder treatment, 708

psychiatry residency programs and competency in, 677

Cognitive disorders

detained individuals and, 653

traumatic injuries and, 245–246, 253–254

Cognitive impairment

alcohol use and abuse and, 474

traumatic brain injury and, 231–235, 253

Cognitive processing therapy, posttraumatic stress disorder, 302, 

308, 309, 311

Cognitive therapy

pain management and, 246

posttraumatic stress disorder, 302, 304

traumatic injury patients and, 252

Cohen, Judith, Treating Trauma and Traumatic Grief in Children and 

Adolescents, 562

Cohn, Janice, I Had a Friend Named Peter: Talking to Children About 

the Death of a Friend, 556

Colbach, Col. Edward, overview of U.S. Army mental health 

activities in Vietnam, 16

Combat and operational stress behavior

adaptive stress reactions, 63

combat and operational stress reaction and, 63–64

description, 61, 62

impact of combat and operational experiences on all soldiers, 

62

misconduct behaviors, 64

overlap with combat and operational stress reaction, posttraumatic growth, and posttraumatic stress disorder, 64

physical and behavioral effects of stress, 61–62

postcombat and operational stress and, 62–63, 64

potentially traumatic events and, 62

Combat and operational stress continuum model

background and development, 108–110

chaplain’s role, 117

the combat and operational stress continuum model with its 

four color-coded stress zones (figure), 110

the combat and operational stress decision matrix flowchart 

(figure), 115, 123

core leader functions, 112–117, 122, 132

decision flowchart for, 114–116, 123

“demedicalized” model of combat stress reactions and, 108, 

109

description, 122

distinguishing between normative and abnormal stress reactions, 122–123

first aid for stress injuries, 116

green “ready” zone description and attributes, 110, 112, 114, 

117, 122

leadership and, 113

“leaky bucket” metaphor for stress (figure), 114

“operational stress injury” concept and, 109–110

orange “injured” zone description and attributes, 111–112, 115, 

117

psychological or medical treatment for stress injuries, 116–117

red “ill” zone description and attributes, 112, 115–116, 117

reintegration of stress casualties, 117

stigma and, 117

stress mitigation and, 113–114

training to strengthen service members, 113

unit cohesion and, 113

yellow “reacting” zone description and attributes, 110–111, 

112, 114–115, 117, 122

Combat and operational stress control

adaptive stress reactions, 63

assessments for, 66

Battlemind program, 65, 72–74

behavioral health treatment component, 69

BICEPS principles, 66–68, 108

cohesion and morale and, 65

combat and operational stress behavior and, 61–64

combat and operational stress intervention model (figure), 67

combat and operational stress reactions, 63–64

combat and operational stressors (exhibit), 61

consultation and education component, 68

continuum of behaviors, 64

definition, 60, 108

“demedicalized” model of combat stress reactions and, 108

deployment cycle support phases (figure), 65

description, 64–65, 69–70

88th Regional Readiness Command COSC program for soldiers and their families, 361–366

examples of combat and operational stressors (exhibit), 62

functional areas, 68–69

goal of, 60, 64

indicated interventions, 66

interventions, 66–69

leadership component, 66, 70

management principles, 66–68

mental and physical stressors, 61

misconduct stress behaviors, 64

model of stress and its potential soldier and family outcomes 

(figure), 63

occupational therapy and, 360, 361–366

Operation Iraqi Freedom 05-07 and, 142, 143–144

postcombat and operational stress and, 64

posttraumatic growth and, 62, 64

potentially traumatic events and, 61, 62

professional disciplines and, 66, 70

purpose of, 65

reconstitution support and, 69

religious and spiritual support and, 66, 70

return to duty and, 66, 67, 69

selective interventions, 66

soldier reconditioning component, 69

soldier restoration component, 69

sources of stress, 61, 123

stabilization component, 69

stress threat and, 60–61

traumatic events management, 68–69

treatment interventions, 66

triage for, 69

unit needs assessment and, 68

universal interventions, 66

Combat and Operational Stress Control (Field Manual 4-02.51), 60, 

91, 154, 175, 219

Combat and Operational Stress Control Manual for Leaders and Soldiers (Field Manual 6-22.5), 60

Combat and operational stress first aid, principles of, 116, 117

Combat and operational stress reactions

combat and operational stress behavior and, 64

incidence of during the Vietnam War, 16

new pharmacologic agent use during the Vietnam War, 11–12

Operation Iraqi Freedom 05-07 and, 144, 146

percentage of battlefield casualties due to, 60

return to duty and, 60

symptoms, 60
Index

xxxix

Combat and Operational Stress/Staff Resiliency program

central point of contact for, 222

challenges and future directions, 221–222

chaplains’ role, 219, 220, 221

committee meetings, 221

confidential visits and, 220

daily operations, 221

data collection and, 222

debriefings, 220–221

director for, 220, 221

growth of, 222

hallway consultations versus office visits, 220

member dispersal, 221

operational stressors and, 219, 222

staff resiliency and, 221–222

stigma and, 222

structure and focus of, 219–221

surveys, 221, 222

team membership, 220

Combat driving behaviors, modification of for the home front, 372

“Combat Duty in Iraq and Afghanistan, Mental Health Problems, 

and Barriers to Care” (Hoge), 326

Combat/Operational Stress Control Workload Activity Reporting 

System, Operation Iraqi Freedom 05-07 and, 139, 144

Combat Psychiatry (Glass), 91–92

Combat Stress Control in a Theater of Operations: Tactics, Techniques, 

and Procedures (Field Manual 8-51), 91, 154

Combat stress control teams

chaplains and, 168–169

preventive psychiatry missions, 175–176

COMFORT scale, pain measurement in children, 346–347

Command interest profile. See Unit watch

Compassion fatigue. See also Provider fatigue

definition, 378

description and causes, 219, 376

Figley’s model of, 377–378, 385, 387–388

Compassion stress

definition, 377, 378

factors contributing to, 378–380

provider fatigue and, 378, 379

Compassion trap, definition, 378

Compassionate Therapy (Kottler), 377

Compazine, as most commonly used psychotropic medication 

during the Vietnam War, 152

Complex humanitarian emergencies

acute phase issues, 627–628

civil-military coordinations: four approaches to liaison arrangements (figure), 624

civil-military operations centers and, 623–624

clinical expertise and, 629

cultural competence and, 620, 629

environmental threats and, 626–627

event descriptions, 620

factors influencing survivor psychic distress, 625

gender-based violence and, 626

gradient of exposure and, 625

grief issues, 627

high-risk groups and, 626–627

humanitarian space and, 620, 629

importance of behavioral health services, 620

information sharing and, 623

international community and, 621–622

key players and, 620–622, 629

living conditions and, 626

magnitude of personal loss and, 625, 626

military support to other players, 622

most common behavioral health diagnoses, 627

nongovernmental organizations and, 620, 622, 623

ongoing threat of armed aggression and, 625

operating principles learned from successful civil-military 

operations centers (exhibit), 624

politically mediated excess mortality and morbidity and, 625

postconflict environment and, 625–626

practical considerations, 623–624

principles and practice of civil-military collaboration in behavioral health, 622–624

principles of behavioral healthcare in humanitarian environments, 627–628

psychic trauma and, 621

psychological first aid and, 628

reconsolidation phase issues, 628

reestablishment of basic services and, 627–628

reopening of schools and, 628

retributive violence and, 625–626

security needs and, 623

special behavioral health considerations, 624–627

survivor characteristics, 625

sustainable economic support programs and, 628

Composite Health Care System-Interactive Training Tool, Operation Iraqi Freedom 05-07 and, 140

Comprehensive Behavioral Health System of Care, description, 

749–750

Comprehensive Soldier Fitness program, description, vision, and 

mission, 748–749

Computed tomography, traumatic brain injury and, 230

Concussion. See Mild traumatic brain injury

Confidentiality issues. See Privacy and confidentiality issues

Connor, K., Connor-Davidson Resilience Scale and, 49

Connor-Davidson Resilience Scale, description, 49

Consultant to The Surgeon General, U.S. Army. See also Office of 

The Surgeon General

assignments and, 184

key functions, 184–185

location, 184

mental health record reviews, 185

position description, 184

strategic communications, 185

tasking for deployment, 184–185

Contingency aeromedical staging facilities

in Afghanistan, 201

attendants for psychiatric patients, 200

description, 192

in Kuwait, 201

locations for, 200–201

mission of, 200

Ramstein Air Base, Germany, facility, 201

restraints and, 200

staffing composition, 200

Continuum of care for veterans and their families

Battlemind training program and, 332

Department of Defense role, 326–336

Department of Veterans Affairs role, 326–336

Joint Conference on Postdeployment Mental Health and, 330

Mental Illness Research, Education, and Clinic Center, 333

new programs, 330–333

overview of the Department of Veterans Affairs, 326–328

Post-Deployment Health Reassessment and, 331–332

provisional mental health diagnoses among OEF/OIF veterans presenting for VA medical care (table), 329

public health model for deployment mental health, 330–331

seamless transition, care management and social work, 

327–328

Services for Returning Veterans-Mental Health, 332–333

services for veterans of OIF and OEF, 329–336

state and community partnerships, 334–336

U.S. Congress’s Handoff or Fumble? Do DoD and VA Provide 
xl

Combat and Operational Behavioral Health 

Seamless Health Care Coverage to Transitioning Veterans? and, 

326

Vet Centers and, 327

Controlled Substances Act, 477

Conversion disorders, traumatic injuries and, 253–254

Coping skills training, posttraumatic stress disorder and, 301–302

Coping with Death and Grief (Heegaard), 558

Core leader functions for psychological health

identify stress reactions, injuries, and illnesses, 114–116

mitigate stressors, 113–114

reintegrate stress casualties, 117

strengthen service members, 113

treat stress injuries and illnesses, 116–117

Cornum, Brig. Gen. Rhonda, Battlemind program and, 74

Corson, Lt. Col. (Ret.) William, demoralization of soldiers during 

the drawdown phase of the Vietnam War, 26

COSB. See Combat and operational stress behavior

COSC. See Combat and operational stress control

COSC-WARS. See Combat/Operational Stress Control Workload 

Activity Reporting System

COSFA. See Combat and operational stress first aid, principles of

COSR/SR. See Combat and Operational Stress/Staff Resiliency 

program

COSRs. See Combat and operational stress reactions

Covey, Dr. Jane, reunion after deployment workshops and, 574

Covey, Dr. John, reunion after deployment workshops and, 574

Cox, Lt. Col. Anthony, Battlemind program and, 72

COX-2 inhibitors. See Cyclooxygenase-2 inhibitors

CPT. See Cognitive processing therapy

Creamer, M., posttraumatic stress disorder program evaluation, 

310

Criminal Investigations Division, “Summary of Theater Suicides” 

and, 410–412

Criminal justice system. See Forensic mental health care

Croatia, Operation Provide Promise and, 76

CSCTs. See Combat stress control teams

CT. See Cognitive therapy

Cultural factors

care of combat-injured service members, 510

detained individuals and, 647, 650, 654

eating disorders, 453

hunger strikes and, 654, 655

presentation of psychosis and, 647

Cyclooxygenase-2 inhibitors. See also specific drugs

pain management and, 343, 344

Cymbalta, depressive disorder treatment, 158

Cyprohepadine, anorexia nervosa treatment, 460

D

Dads at a Distance, Web site, 501

Datel, W.E.

epidemiological data on the effects of the Vietnam War on the 

U.S. Army as a whole, 32

use of psychotropic medications by physicians deployed to 

Vietnam in 1967, 152–153

Davidson, J.R., Connor-Davidson Resilience Scale and, 49

Davison, E., late-onset stress symptomatology, 306–307

DCoE. See Defense Centers of Excellence

DCSP. See Deployment Cycle Support Program

DD Form 2624, Specimen Custody Document: Drug Testing, 

479–480

Deceased service members. See Children and families of fallen 

service members; Operations involving death and the dead

Defense and Veterans Brain Injury Center

in-theater management of TBI, 233, 253

traumatic brain injury definition, 226–227

Defense Centers of Excellence, mission statement, 748

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, combat and operational stress continuum 

model, 108–117

Dehydroepiandrosterone, resilience and, 46, 47

Dementia, suicide and, 426

Dental caries

causes, 261

extensive accumulation of bacterial plaque after cessation of 

oral hygiene (figure), 261

fluoride and, 261, 264

plaque accumulation, tobacco staining, gingival inflammation, 

and generalized caries resulting from a combination of inadequate oral hygiene, tobacco use, and refined carbohydrate 

intake (figure), 260

sugar consumption and, 261

Dental erosion, description and causes, 262

Deployment Cycle Support Program

behavioral health surveillance, 281

description, 276

families and, 278–279

reentry challenges and, 278–281

return-to-readiness period, 278

suicide prevention and, 169

Deployment Health Clinical Center, phone number and Web site, 

501

Deployment impact on military families and children. See also

Family maltreatment

children’s developmental responses, 493–495, 496

common emotional reactions to each stage of deployment 

(figure), 489

“deployment” definition, 488

deployment stage, 490–491

effects on spouses, 493, 564

foreign-born or non-English-speaking spouses and, 488

intergenerational transmission of the effects of war and combat trauma, 495–497

late deployment stage, 491–492

negative emotional and behavioral changes in children during 

deployment (table), 489

postdeployment stage, 492–493

predeployment stage, 489–490

resources for military families, 500–501

school enrollment issues, 488

stages of the deployment cycle, 488–493

sustainment stage, 491

varying length of missions, 488

Deployment Risk and Resilience Inventory

postwar factors, 49

prewar factors, 48–49

war-zone factors, 49

Deployment Risk and Resilience Inventory, posttraumatic stress 

disorder and, 301

Depression. See also Major depressive disorder; Postpartum depression; Premenstrual dysphoric disorder

age of onset, 442

anorexia nervosa and, 453

combat and operational stress continuum model red zone and, 

112

complex humanitarian emergency survivors and, 627, 628

deployment-related stress and, 60

exercise and, 705

guidelines on screening for depression in spouses of service 

members, 538

oral hygiene and, 264

percentage of soldiers returning from combat in Iraq and 

Afghanistan with, 78

Persian Gulf War veterans with PTSD and, 305

posttraumatic stress disorder and, 298, 305
Index

xli

prevalence during Operation Iraqi Freedom, 153

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 212

social support and, 46

suicide and, 395, 410

symptoms, 707

traumatic injuries and, 251

uncontrolled pain and, 246

Vietnam veterans with PTSD and, 305

women and, 707–709

Detainees

behavioral health issues, 646–656

Behavioral Science Consultation teams and, 699

ethical issues, 731–742

hunger strikes and, 653–656, 739–742

interrogation and, 732–739

medical treatment of, 738–739

nonmedical treatment of, 732–735

occupational therapy issues, 366–368

sanity boards on, 695–696

Developmental responses of children

to a combat-injured parent, 513–516

to deployment, 493–495, 496

Devilly, G., eye movement desensitization and reprocessing, 309

Dexedrine. See Dextroamphetamine

Dexmedetomidine, pain management and, 344

Dextroamphetamine, Vietnam War and use of, 152

DHEA. See Dehydroepiandrosterone

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, 

posttraumatic stress disorder and, 30, 33

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, 

revised, prevalence of mental health problems in the U.S. Navy 

and, 122

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition

anorexia nervosa definition, 451

bulimia nervosa definition, 451

postconcussive disorder diagnosis, 232

posttraumatic stress disorder and, 109

secondary trauma and, 377

severe psychiatric diagnosis basis, 442–446

Diebold, Col. C.J., Soldier Assistance Center and, 568

Diphenhydramine agitation treatment, 159

Disaster psychiatry

areas for future research, 587–588

community support, education, and definitive care and, 582

disaster stress reaction relation to physiological symptoms, 580

education of disaster psychiatrists and, 588

essential domains of disaster mental health interventions 

(table), 581

evolution of the field, 580

historical background, 580–582

mental health of disaster workers and, 582

Project Liberty and, 582

psychiatric conceptualization of trauma and response, 581–582

recent missions, 582–587

research needs, 588

self-soothing and, 582

self-triage and, 582

September 11, 2001, terrorist attacks and, 582, 583–585

Uniformed Services University of the Health Sciences Disaster 

Psychiatry Fellowship, 680

Disaster relief. See Complex humanitarian emergencies; Humanitarian assistance missions

Disengagement/detachment

definition, 378

provider fatigue and, 378, 379

Dissociative disorders, fitness for duty and, 180

Division mental health units

Army regulation outlining responsibilities, 90

combat operational stress course and, 98

current structure of (figure), 91

future directions for, 102

Military Medicine articles, 92

mission and role of, 91

modular structure, 90–91, 92, 102

“ownership” by the division and, 101

pre- and post-deployment screening and, 96

preventive psychiatry missions, 175–176

prior structure of (figure), 90

responsibilities, 92

traumatic event response and, 97

Division psychiatrists and brigade behavioral health officers

access to mental health technicians and, 101

administrative duties, 99–100

advice and consultant role, 93

AMEDD principles of treatment, evacuation, and restoration 

and, 93

Army Behavioral Health Short Course and, 98

Army regulation outlining responsibilities, 90

assumption of unanticipated roles and, 101

case studies, 94, 97

challenges of the position, 100–103

clinician role, 93

commanders’ expectations, 93–94

consultations to commanders and command surgeons on 

behavioral health trends and issues and, 97–98

continuing education and, 98

coordination of behavioral health resources and, 101

coordination of external resources and, 96–97

direct care of patients and, 99

discretionary and nondiscretionary referrals and, 99–100

distribution of resources and, 94

doctrine on responsibilities, 91–92

duties and responsibilities, 94–100, 185

duties and responsibilities of the unit behavioral health officer 

(exhibit), 95–96

future directions for, 102

as junior officers, 93, 100–101

licensure requirements, 93

personnel issues, 101–102

perspectives on the position of the division psychiatrist (figure), 93

perspectives on the positions, 92–94

planning and oversight for behavioral healthcare and, 94, 

96–97

pre- and post-deployment screening and, 96

primary care providers and, 98–99

psychotropic medications and, 94, 96

role as officers in the unit, 100

supervision of enlisted mental health technicians and, 98

Divorce

hospitalization of combat-injured service members and, 

508–509

Operation Iraqi Freedom and Operation Enduring Freedom 

and rates of, 277

posttraumatic stress disorder and, 307

“stress hypothesis” of, 538–539

suicide and, 426

DMHs. See Division mental health units

DoD. See U.S. Department of Defense

DoDSERs. See U.S. Department of Defense, Suicide Event Reports

Domestic violence. See Family maltreatment

Donald J. Cohen National Child Traumatic Stress Initiative, description of services, 500

Dopamine, eating disorders and, 452

Drawdown phase of the Vietnam War, 1969-1972
xlii

Combat and Operational Behavioral Health 

behavior problems and misconduct, 27, 32, 33

biopsychosocial stressors and, 25–26

cultural polarization and, 22–24

demoralization of soldiers and, 25–26

ethics of combat psychiatry and, 24–25

evacuations for psychiatric reasons, 26–27, 34

heroin epidemic, 27–28

My Lai massacre and, 22

negative effects of the abandonment of hopes for military 

victory, 22

Nixon’s “peace with honor,” 21

psychiatric overview, 26–28

psychiatrist reports, 28–29

“Vietnamization” concept, 21

Drinking behavior. See Alcohol use and abuse

DRRI. See Deployment Risk and Resilience Inventory

DSM-III. See Diagnostic and Statistical Manual of Mental Disorders,

3rd Edition

DSM-III-R. See Diagnostic and Statistical Manual of Mental Disorders,

3rd Edition, revised

Dual agency

graduate medical education and, 670, 679, 686

malingering and, 697–698

psychiatric consultation to command and, 182–183

Duckworth, Liz, Ragtail Remembers--A Story That Helps Children 

Understand Feelings of Guilt, 556–557

Duloxatine

pain management and, 344

posttraumatic stress disorder treatment, 303

Dunmore, E., social support effect on posttraumatic stress disorder, 46

Durkheim, Emile, suicide research, 404

DVBIC. See Defense and Veterans Brain Injury Center

Dyergrov, A., support for disaster workers, 255

Dysthymic disorder, in-theater treatment, 158–159

E

Earthquake disaster relief, description and factors in, 641

EAT model

description, 385

visual description (figure), 385

Eating disorder not otherwise specified

binge eating disorder and, 452, 462

deployment and, 463

examples of, 452

military population statistics, 456

mortality rate, 455–456

normal weight and, 454

prevalence of, 450, 452

treatment, 462

Eating disorders. See also specific disorders

biological factors, 452–453

body mass index and, 452, 454, 458

body weight “set point” or “settling point” and, 453

clinical features, 454–455

course and prognosis, 455–456

cultural factors, 453

deployment issues, 450, 463–464

description, 450

differential diagnosis, 455

etiology of, 452–454

excessive exercise and, 454

family factors, 453

future research needs, 463–464

genetic factors, 452–453

hidden nature of, 454

ideal body image as portrayed in the media, 450

laboratory studies, 455

medical and psychiatric treatment, 458–462

medical findings, 454–455

mortality rates, 464

obesity increase, 450

oral health effects of, 263–264

overview of, 450–452

personal fitness assessments and, 450, 456, 457, 463, 704

posttraumatic stress disorder and, 464

psychological factors, 453

rate of in the military, 450

research on abnormal eating in the military, 456–458

social factors, 453

summary of abnormal eating behavior studies in military 

populations (table), 457

treatment issues in the combat environment, 462–463

underdiagnosing of, 450

EDNOS. See Eating disorder not otherwise specified

Education and training

behavioral health liaison project, 573

disaster psychiatrists, 588

military psychiatrist graduate medical education, 670–689

Ehlers, A.

cognitive model of trauma, 45

Cognitive Theory of PTSD, 299–300

social support effect on posttraumatic stress disorder, 46

88th Regional Readiness Command COSC program

activity summary, April 2003-December 2006 (table), 364

bereavement support, 365–366

community outreach and, 366

core features, 364

deployment cycle support briefings (exhibit), 367

description, 363

educational stress briefings, number of participants, 2003-2007 

(figure), 363

expected outcomes, 363–364

family readiness groups and, 364

first responder training (exhibit), 365

goals of, 363

stress reduction techniques and, 364

well-being program, 364–365

Ellison, Chaplain James, death of a parent as a life-changing experience on three levels, 549

EMDR. See Eye movement desensitization and reprocessing

Emotional contagion, definition, 376, 377

Empathic ability

definition, 378

provider fatigue and, 378, 379

Empathic concern, definition, 377

Empathic responses

definition, 378

provider fatigue and, 378, 379

Empathic supportive exposure therapy, trauma patients and, 249, 

252

Employment issues

job fairs for military spouses, 572–573

provider fatigue, 382

work reintegration programs, 361, 369–371

Enemy Prisoners of War, Retained Personnel, Civilian Internees, and 

Other Detainees (Army Regulation 190-8), 101

Engel, C.C., article on division mental health units, 92

EPICONS. See Epidemiological consultations

Epidemiological consultations

activities on the ground, 416

agencies involved, 415

basic questions, 417–418

basic strategies, 417

common behavioral health epidemiological consultation 
Index

xliii

themes (table), 413

common findings, 418

daily situation reports and, 417

data sources, 416–417

description and background, 412–415, 418–419

“epi-curve” and, 418

Fort Bragg, NC, 414

Fort Campbell, KY, 414

Fort Leonard Wood, MO, 413–414

Fort Riley, KA, 414

G-1 responsibilities, 415

index cases, 418

initiation of, 415–416

media attention and, 418

methods in, 417–418

operational support for, 415–416

psychiatric EPICONS in the U.S. Army, 412–418

resources for, 414–415

results and lessons learned, 418

of suicide and homicide clusters, 77

suicide prevention, 406

team membership, 415

timeline for, 415

writing the report for, 418

Equanil, use of during the Vietnam War, 152

Escitalopram, posttraumatic stress disorder treatment, 303

Ethical issues

deployment phase, 731–742

detainees, 731–742

distress of deployment, 730

ethics of combat psychiatry, 24–25

interrogation of detainees, 732–739

medical treatment of detainees, 738–739

pain management, 349–350

postdeployment phase, 742–744

predeployment phase, 728–731

psychiatric consultation to command and, 182–184

psychotropic medication prescribing, 160

recruitment goals, 728–729

traumatic brain injury, 743

treatment concerns, 729–731

treatment decisions made “outside the box,” 743–744

verbal dissent by soldiers, 742

vignettes, 731

Ethnic factors. See Racial/ethnic factors

European Community Humanitarian Office, complex humanitarian emergencies and, 621

Everett Anderson’s Goodbye (Clifton), 557

Eye movement desensitization and reprocessing, posttraumatic 

stress disorder treatment, 302, 304, 308, 309

F

Faces Scale, pain assessment, 347

Facing Change: Falling Apart and Coming Together Again in the Teen 

Years (O’Toole), 560

The Fall of Freddie the Leaf (Bascaglia), 557

Fallen service members. See Children and families of fallen service 

members; Operations involving death and the dead

Families. See also Children; Children and families of combatinjured service members; Children and families of fallen service 

members; Deployment impact on military families and children

Battlemind program for spouses, 72, 80–81, 332

continuum of care for veterans of OIF and OEF and, 326–336

eating disorders and, 453–454

88th Regional Readiness Command COSC program and, 

363–366

family support link to resilience, 52

model of stress and its potential soldier and family outcomes 

(figure), 63

posttraumatic stress disorder and, 306, 307, 312

prolonged grief disorder and, 348

resetting the force and, 276, 277, 280–281, 284

supportive counseling for, 254–255

traumatic injuries and, 247, 253–255

United Kingdom armed forces’ research on the impact of 

military service on family life, 663

Family Advocacy Program

case review process, 536–537

description, 536

New Parent Support Program, 539

objective of, 536

sources of reports of abuse incidents, 536

Family maltreatment. See also Deployment impact on military 

families and children

Army’s response to family stress and deployment, 539–540

chaplains and, 539

child maltreatment, 537–538

child neglect, 538

communicating with the deployed person and, 536

definition of, 536

domestic violence, 306, 536–537

Family Advocacy Program and, 536–537, 538, 539, 540

family readiness support assistants and, 539

marriage and family therapy, 540

military life effect on, 537–538

prevalence of, 537–538

respite care for parents of children while the other parent is 

deployed, 540

“stress hypothesis,” 538–539

stress of deployment and, 536–540

traumatic brain injury and, 711

Family readiness groups

behavioral health liaison project and, 572, 573

88th Regional Readiness Command COSC program and, 364

family readiness group briefing topics (exhibit), 572

Family therapy

anorexia nervosa, 459

family maltreatment and, 540

FAP. See Family Advocacy Program

Farberow, Norman, key concepts in suicide, 404, 405

Farmer, Maj. Gen. Kenneth, Jr., Suicide Risk Management and 

Surveillance Office and, 397

FDA. See U.S. Food and Drug Administration

Federal Child Abuse Prevention and Treatment Act, 536

Federal Tort Claims Act, malpractice lawsuits and, 436

Fellowship programs

child and adolescent psychiatry, 680

geriatric psychiatry, 680

Military Forensic Psychiatry, 697

Fenfluramine, bulimia nervosa treatment, 462

Fentanyl, drug tests and, 477

Feres doctrine, malpractice lawsuits and, 436, 437

Ferguson, Dorothy, A Bunch of Balloons, 556

Field, N.P., bereavement and posttraumatic stress disorder, 306

Field Manual 6-22.5: Combat and Operational Stress Control Manual 

for Leaders and Soldiers, 60

Field Manual 8-51: Combat Stress Control in a Theater of Operations: 

Tactics, Techniques, and Procedures, 91, 154

Field Manual 4-02.5l: Combat and Operational Stress Control, 60, 91, 

144, 154, 175, 219

Figley, Charles, compassion fatigue model, 377–378, 385, 387–388

Finding My Way: A Teen’s Guide to Living With a Parent Who Has 

Experienced Trauma (Sherman and Sherman), 560

Fire in My Heart, Ice in My Veins--A Journal for Teenagers Experiencing Loss (Traisman), 559
xliv

Combat and Operational Behavioral Health 

Firearms access

posttraumatic stress disorder and, 306

unit watch and, 424, 425, 435

Fisher, Lt. Cdr. H.W., account of his Vietnam War experience, 29

Fitzgerald, Helen, The Grieving Teen: A Guide for Teenagers and Their 

Friends, 559

Fluoxetine

anorexia nervosa treatment, 460

bulimia nervosa treatment, 462

depressive disorder treatment, 158

posttraumatic stress disorder treatment, 303, 308

safety of use during pregnancy, 709

Flutamide, bulimia nervosa treatment, 462

Fluvoxamine, bulimia nervosa treatment, 462

Foa, E.

fear-related memories and PTSD, 299

prolonged exposure treatment, 302

Forbes, D., imagery rehearsal therapy, 309

Force feeding, hunger strikes and, 655–656, 739–742

Forensic mental health care

Article 32 investigations, 695

behavioral science consultation teams, 699–700

board certification requirements, 697

case studies, 695, 697, 698, 699

core topics, 694

criminal justice system and, 694–697

detainees and, 695–696

expert consultants and expert witnesses, 696–697

Fifth Amendment of the Constitution and, 695

forensic psychiatry in the military compared with the civilian 

world, 694

insanity defense and, 695

levels of courts-martial and, 694–695

malingering, 697–698

military law and, 694–695

Military Rules of Evidence and, 694, 696

psychological autopsies after suicides, 698–699

“sanity boards” and, 695–696

Formulary of medications

example psychiatric formulary for deployment (table), 155

Operation Iraqi Freedom 05-07 and, 139

pain management medications, 348

rationale for using for military operations, 153–154

Fort Bragg, NC

cluster of suicides and homicides, 77

EPICON following two murders and two murder-suicides, 

414, 418

Fort Campbell, KY, EPICON following 14 soldier suicides between 2006 and 2007, 414, 418

Fort Carson, CO, EPICON focusing on homicides, 414

Fort Hood, TX, EPICON following 22 suicides between 2003 and 

2005, 414, 418

Fort Leonard Wood, MO, EPICON following the deaths of two 

recruits by suicide, 413–414, 418

Fort Lewis, WA, Soldier Wellness Assessment Pilot Program, 

282–284

Fort Riley, KA, EPICON following six suicides in 14 months, 414, 

418

Fractures, anorexia nervosa and, 454

Frank, Jerome, resilience and, 330

Freedom of Information Act, 698

Freud, Sigmund, psychiatric conceptualization of trauma and 

response, 581–582

FRGs. See Family readiness groups

Friedman, Matthew, M.D., PhD., instruction of primary care providers at Schofield Barracks and, 568

Friedman, M.J., disaster psychiatry research, 581

Fry, Virginia Lynn, Part of Me Died, Too: Stories of Creative Survival 

Among Bereaved Children and Teenagers, 559

Fullerton, C.S., disaster psychiatry research, 581

G

G-1

Army Suicide Prevention Program, 405, 406, 409

epidemiological consultations, 415

Gabapentin

mechanism of action, 344

pain management and, 343, 344

Gabriel, R.A., incidence of soldiers attacking their superiors 

(“fragging”), 25

Galai-Gat, T., uncontrolled pain as a stressor, 246, 249

Galanin, resilience and, 46, 47

Galveston Orientation and Amnesia Test, traumatic brain injury 

and, 231

Gambling. See Pathological gambling

Garfield, R.M., World War I and World War II casualty rates, 625

Gastroesophageal reflux disease

oral health and, 262

treatment, 262

Gastrointestinal disorders

anorexia nervosa and, 454

bulimia nervosa and, 455

Gaynes, B.N., suicide research, 395

GCS. See Glascow Coma Scale

Gender factors. See also Men; Women

anxiety disorders, 709

bipolar disorder, 709

depression, 707

personal fitness assessments, 704

posttraumatic stress disorder, 709

seasonal affective disorder, 707

traumatic brain injury, 710–711, 710–712

Generalized anxiety disorder. See also Anxiety disorders

in-theater treatment, 159

percentage of soldiers returning from combat in Iraq and 

Afghanistan with, 78

posttraumatic stress disorder and, 303, 305

prevalence during Operation Iraqi Freedom, 153

treatment, 253, 303

Genetic factors

Alzheimer’s disease, 396

eating disorders, 452–453

pain management, 345–346

posttraumatic stress disorder, 46

Geneva Agreement, Vietnam War and, 12

Geneva Conventions, treatment of POWs, 731

Geodon, psychotic disorder treatment, 159

Geranium Morning (Powell), 557

GERD. See Gastroesophageal reflux disease

Gingivitis

management of, 265–266

oral hygiene and, 265

Ginsburg, Kenneth R., A Parent’s Guide to Building Resilience in 

Children and Teens: Giving Your Child Roots and Wings, 561

Girls Time Out program, mission and description, 510

Giuliani, Mayor Rudolph, effectiveness of communications after 

the September 11, 2001, terrorist attacks, 595

Glascow Coma Scale, traumatic brain injury and, 227, 231

Glass, Col. Albert

Combat Psychiatry, 91–92

combat stress control teams and, 176

Neuropsychiatry in World War II, 5, 91

PIES principles, 5, 6, 108

Glicken, D., Learning from Resilient People: Lessons We Can Apply to 

Counseling and Psychotherapy, 168
Index

xlv

Gliko-Brado, Majel, Grief Comes to Class: An Educator’s Guide, 561

Global Patient Movement Requirements Center

coordination with the Joint Patient Movement Requirement 

Centers to establish CONUS destinations for patients, 202

role and responsibilities, 195

Global war on terror

behavioral science consultation teams and, 699

graduate medical education and, 673

increase in behavioral health problems and, 672

posttraumatic stress disorder treatment and, 688

resetting the force and, 276, 284

special forces operations, 278

Support Assignment orders, 131

U.S. Navy and, 122, 128

Glynn, S.M., imaginal exposure for PTSD, 309

GME. See Graduate medical education

GOAT. See Galveston Orientation and Amnesia Test

Goiania, Brazil, radiological contamination accident

depression and anxiety in victims, 599

long-term effects, 601

outbreak of multiple unexplained symptoms and, 598

psychological casualties, 597

screening for radiation exposure and, 599

Gold Star Wives of America

description and services, 550, 555

Web site, 555

Goldberg, G., provider fatigue and, 381–382

Goldman, Linda

Life and Loss: A Guide to Help Grieving Children, 560

Raising Our Children to Be Resilient, 560

Goldstein, R.B., suicide research, 395

Gonzales, L., survival skills, 51

A Good Day (Henkes), 556

Gootman, Marilyn, When a Friend Dies: A Book for Teens about 

Grieving and Healing, 559

Gourevitch, P., gender-based violence in Rwanda, 626

Government Accountability Office

COSC-WARS reporting system and, 144

pre- and post-deployment screening and, 96

GPMRC. See Global Patient Movement Requirements Center

Graduate medical education

ACGME competencies and, 675

American Council of Graduate Medical Education accreditation and, 670, 671, 673, 675, 676, 678, 680, 681, 688

American Council of Graduate Medical Education Accreditation history of U.S. military psychiatry residencies (table), 

671

American Council of Graduate Medical Education competencies (exhibit), 675

as an essential aspect of military medicine, 670, 688

annual common task training, 670

case studies, 683–684, 687

characteristics of military psychiatrists, 686–687

closure of psychiatry residency programs, 671–672

completion requirements, 678

contracting to civilian schools, 687–688

core competencies, 676–677

curriculum, 675–680

Department of Defense command-directed mental health 

evaluations and, 683

deployment to combat zones and, 673

development of appropriate attitudes, 686–687

didactic learning and, 678

documents and reports prepared by military psychiatrists 

(exhibit), 685

dual agency and, 670, 679, 686

faculty development, 674–675

general psychiatry residency curriculum, 677–678

a graphic timeline of accredited U.S. military psychiatry programs (figure), 672

historical background, 670–672

interpersonal skills and, 684

issues emphasized in the military psychiatry curriculum, 679

knowledge aspects, 681–684

length of residency programs, 677

managed care and, 673, 677

military performance rating system and, 685–686

military psychiatrists as military officers, 679

military psychiatrists compared with civilian psychiatrists, 

684–685

military psychiatry curriculum, 679–680

military structure and, 679

military-unique tasks, 670

mission performance relevance, 680–687

official documents with which U.S. Army psychiatrists should 

be familiar (table), 682

postresidency fellowships, 680

primary mission of, 670

program director role, 673–674

program leadership, 672–675

psychotherapy competencies, 677

recruitment and retention of faculty and, 673–675, 688–689

research and scholarly activity, 678–679

residency review committees and, 676, 678, 680

Rule for Court-Martial 706 evaluations and, 670

skills required of military psychiatrists, 684–686

summary of American Council of Graduate Medical Education 

Residency Review Committee requirements for psychiatry 

residents, as of 2007 (exhibit), 678

team learning, practice, and interpersonal communication, 

676–677

technical skills requirements, 685

unique skills required of military psychiatrists (exhibit), 684

unit commanders and, 684

unit structure and dynamics and, 679

vignettes, 686, 687

Grenier, Lt. Col. Stephane, “operational stress injury” concept 

and, 109

Grief. See Bereavement; Children and families of fallen service 

members

Grief Comes to Class: An Educator’s Guide (Gliko-Brado), 561

The Grieving Teen: A Guide for Teenagers and Their Friends (Fitzgerald), 559

Gritzner, S., zinc deficiency in anorexia nervosa and, 460

Gross, Michael, military medical ethics, 732, 733

Group for the Advancement of Psychiatry, effectiveness of preventive psychiatry, 172

Group therapy, trauma patients and, 249, 252

GTO program. See Girls Time Out program

Guanfacine, posttraumatic stress disorder treatment and, 304

A Guide for the Survivors of Deceased Army Members, 544

Guide to the Prevention of Suicide and Self-Destructive Behavior (PAM 

600-70), 405

Guidelines on the Use of Military and Civil Defence Assets in Disaster 

Relief, 622

Gulf War syndrome

description, 600

expert witness testimony and, 696

Gull, Sir William, anorexia nervosa description, 450

Gusman, Frederick, MSW, instruction of primary care providers 

at Schofield Barracks and, 568

GWOT. See Global war on terror

H

Haas, D.M., survey of pregnant military and civilian women to 
xlvi

Combat and Operational Behavioral Health 

measure stress levels, 493

Haiti, Operation Uphold Democracy and, 76

Haldol, psychotic disorder treatment, 159

Hall-Jones, P., nongovernmental organizations, 622

Haloperidol

pain management and, 348

psychotic disorder treatment, 159

Hanson, Frederick, forward treatment of combat stress, 5

Harman, D.R., aeromedical evacuation of psychiatric patients, 203

Harris Poll, of Vietnam veterans, 30

Harvey, C., supportive counseling for families, 254–255

Hatkoff, Craig, Owen & Mzee, 558

Hatkoff, Isabella, Owen & Mzee, 558

Hawaii, integrated behavioral health services at Schofield Barracks, 564–575

The Healing Your Grieving Heart Journal for Teens (Wolfelt and 

Wolfelt), 559

Health Affairs Policy 9700029, substance abuse care for active 

duty service members, 481

Health Insurance Portability and Accountability Act, impact on 

psychiatric consultation to command, 183–184

Health Risk Appraisal questionnaires, description, 281

Heegaard, Marge Eaton, Coping with Death and Grief, 558

Helicopter ambulances, Vietnam War and, 14

Helping Children Cope With the Loss of a Loved One: A Guide for 

Grownups (Kroen), 560

Helping Children Grieve & Grow--A Guide for Those Who Care

(O’Toole), 561

Henkes, Kevin, A Good Day, 556

The Hero in My Pocket (Lee), 558

Heroin

drug tests and, 477

postdeployment effects of use, 28

Vietnam War and use of, 24, 25, 27–38, 34, 152

Heyman, R.E., relationship between the length of deployment and 

spousal aggression, 537

Hill, J.V., guidelines for psychiatry residents on becoming a division psychiatrist, 92

Hillbom, M., relationship of alcohol use to trauma, 233

HIPAA. See Health Insurance Portability and Accountability Act

Historical background

aeromedical evacuations, 192–194

Army psychiatry in the Vietnam War, 11–12

Battlemind program, 72

chaplains, 164–165

combat and behavioral health, 4–7

combat and operational stress continuum model, 108–110

community mental healthcare in the military, 564

disaster psychiatry, 580–582

family notification of combat deaths, 544

graduate medical education, 670–672

humanitarian assistance missions, 610–615

occupational therapy, 358–359, 373

Operational Stress Control and Readiness program, 126–127

pain management, 347

psychiatric command consultation, 172–173

psychiatry volumes of the textbooks of military medicine, 5–6

Special Psychiatric Rapid Intervention Teams, 124

suicide prevention in the Army, 404–405

Suicide Risk Management and Surveillance Office, 397

United Kingdom armed forces behavioral health, 658–660

U.S. Navy carrier psychology program, 125–126

use of psychotropic medications, 152–154

Hoge, Col. Charles

Battlemind program and, 72, 332

“Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care,” 326, 330

posttraumatic stress disorder research, 233, 329

prevalence of mental health problems among soldiers returning from OEF, 333, 564

stigma attached to seeking help, 568

trauma patients’ perception of psychiatry, 246

Holloway, Col. Harry C., survey of illegal drug use in the Vietnam 

War, 11, 28

Homicide

access to lethal means and, 437

EPICONs concerning, 414

managing suicide and homicide risk during deployment 

(table), 435

managing suicide and homicide risk in garrison (table), 427

“military-specific homicidal ideation” and, 425

risk factors, 437

suicidal or homicidal thoughts association with diagnosable 

mental illness, 424

unit watch concept and, 424–438

WRAIR epidemiological consultations of homicide clusters, 77

HOOAH4HEALTH--Deployment, Web site, 501

Horowitz, M.J., bereavement reaction to traumatic injury, 246

How Do We Tell Children: Helping Children Understand and Cope 

When Someone Dies (Lyons and Schaefer), 561

How It Feels When a Parent Dies (Krementz), 558–559

How to Go on Living When Someone You Love Dies (Rando), 561

How to Help Children Through a Parent’s Serious Illness (Bonn and 

McCue), 517

HRA I and II. See Health Risk Appraisal questionnaires

Huebner, A.J., adolescents’ responses to deployment, 494

Hughes, J., provider fatigue and, 381–382

Hughes, Lynne, You Are Not Alone: Teens Talk About Life After the 

Loss of a Parent, 559–560

Humanitarian assistance missions. See also Complex humanitarian emergencies; Medical civil-military operations in Operation 

Iraqi Freedom 05-07; specific missions and locations

civil dimensions, 611

earthquake disaster relief, 641

historical background, 610–615

importance of healthcare and, 610–611

purpose of, 610

Hunger strikes

assessment issues, 654–655

autonomy of the individual and, 739–742

behavioral healthcare providers and, 739–742

competence to fast and, 654

consultation with command, 655–656

cultural factors, 654, 655

daily reassessment of emotional and cognitive status, 654–655

depression and, 655

differential diagnosis, 653

ethical issues, 739–742

focus of psychological management, 655

follow-up assessments, 655

force feeding and, 655–656, 739–742

informed consent and, 654

initial interview and, 654

international standards for treatment, 654

intervention, 655

observation and, 654

political nature of, 654

primary care providers and, 654–655

reactive food refusal and, 654

theater policy and, 654

typical protocol for, 654

Hurricane Andrew, Special Psychiatric Rapid Intervention Teams 

role, 124

Hurricane Ivan, Special Psychiatric Rapid Intervention Teams 

role, 124

Hurricane Rita. See Hurricanes Katrina and Rita
Index

xlvii

Hurricanes Katrina and Rita

disaster response, 586

Disaster Response Teams and, 636

health surveillance by the CDC, 586–587

Mercy model of population-based disaster relief and, 635

Project Recovery and, 587

Special Psychiatric Rapid Intervention Teams role, 124

Hyams, K.C., reporting of mental health problems by OIF/OEF 

veterans, 329

Hydromorphone, drug tests and, 477

Hypnotherapy, trauma patients and, 249

I

I Don’t Have an Uncle Phil Anymore (Pellegrino), 557

I Had a Friend Named Peter: Talking to Children About the Death of a 

Friend (Cohn), 556

I Miss You--A First Look at Death (Thomas), 557–558

ICD-CM. See International Classification of Disease, 9th Edition, 

Clinical Modification

Illegal drugs. See also Substance use and abuse; specific drugs

“Amnesty Program” and, 28

Army Forensic Drug Testing Program, 141–142

Controlled Substances Act and, 477

Korean conflict and use of, 32

urine drug screening system and, 25, 28

Vietnam War and use of, 11, 17, 20–21, 24, 25, 27–28, 32, 34, 152

Imagery rehearsal therapy, posttraumatic stress disorder and, 309

In an Instant: A Family’s Journey of Love and Healing (Woodruff and 

Woodruff), 517

Indian Ocean tsunami

description, 634, 639

just-in-time training and, 586

Mercy model of population-based disaster relief and, 634–644

number of dead and missing, 585

operating environment, 620

Operation Unified Assistance and, 585, 634, 636

Project HOPE and, 585, 587

Individual augmentation

administrative issues, 131

description, 128–129

distance from Navy Medicine infrastructure and, 131

family support and, 131

isolation issues, 130–131

training and deployment cycle and, 129–130

unit cohesion and, 130–131

Warrior Transition Program and, 129–130

Indonesia. See Indian Ocean tsunami; Mercy model of populationbased disaster relief

Infants. See also Pregnancy

effects of deployment on, 493

grief responses, 547

response to a combat-injured parent, 513–514

Informed consent

hunger strikes and, 654

use of psychotropic drugs during pregnancy and, 708

Ingraham, L.H., heroin use during the Vietnam War, 27–28

Ingram, Lee M., That’s My Hope: Featuring a Gallery of Multigenerational Artwork, 517

Insanity Defense Reform Act, provisions, 695

Insomnia

behavioral interventions for, 159

in-theater treatment, 159–160

nursing care and, 250, 252

relaxation techniques and, 250

sleep hygiene and, 250

trauma patients and, 250

uncontrolled pain and, 246

Institute of Medicine

Committee on Treatment of Posttraumatic Stress Disorder, 309

Web site, 501

Integrated behavioral health services at Schofield Barracks, HI

ages and gender of children evaluated at Solomon Elementary 

School in the Solomon Wellness Educational Program, from 

August 2001 to February 2007 (figure), 571

algorithms for calculating provider numbers (exhibit), 567

allocation of mental health resources within the Army system 

and, 575

Army Community Service and, 565, 571

behavioral health liaison project, 571–575

Child and Adolescent Psychiatry Service and, 565

conflict within, 575

early efforts, 565–566

family readiness group briefing topics (exhibit), 572

family readiness groups and, 565, 572

monthly patient or client visits in the three Soldier and Family 

Assistance Center clinics, January 2005 to November 2006 

(figure), 569

projected demand for providers based on population (table), 

568

quality of welcome by unit in the behavioral health liaison 

project (figure), 572

recommendations developed from the program, 575

school-based mental healthcare, 569–571

Soldier and Family Assistance Center and, 565, 566–569, 575

Soldier and Family Assistance Center five areas of care (exhibit), 567

Solomon Wellness Educational Program, 569–571

Tripler Army Medical Center and, 565

InterAction, description, 622

Intergenerational trauma transmission

family communication patterns and, 496–497

Holocaust survivors and, 495

mechanisms of, 496

veterans’ posttraumatic stress disorder and, 495–496

International Association for the Study of Pain, pain definition, 

341

International Classification of Disease, 9th Edition, Clinical Modification, posttraumatic stress disorder and, 30, 77

International Classification of Disease, 10th Edition, Clinical Modification, postconcussive disorder and, 232

International Medical Corps, medical civil-military operations in 

Operation Iraqi Freedom 05-07 and, 616

International Organization for Migrations, complex humanitarian 

emergencies and, 621

International Red Cross and Red Crescent Movement. See also

American Red Cross

complex humanitarian emergencies and, 621

entities comprising, 621–622

observer status at the United Nations, 622

Interpersonal therapy, anorexia nervosa, 459

Interpreters. See Translators

Interrogation of detainees

improving conditions over time, 734–735

international codes and, 735

limits on, 733–734

military medical care provider involvement and, 735–739

permitted interrogation approaches, 732–734

persons’ dignity and, 733

IPT. See Interpersonal therapy

Iraq. See also Operation Iraqi Freedom; Operation Telic

civilian deaths in Haditha, 148, 778

IRCRCM. See International Red Cross and Red Crescent Movement

Ireland, UK Operation Banner and, 658

Israel, symptoms of Israeli civilians near Scud missile attacks, 580, 
xlviii

Combat and Operational Behavioral Health 

596, 598

Israeli Defence Forces

anorexia nervosa among female soldiers, 459

combat stress reactions and casualty rate, 52

operational use of tricyclic antidepressants during the war 

with Lebanon, 153

posttraumatic stress disorder and, 496

Iverson, G.L., traumatic brain injury research, 231

Ivins, B.J., trends in TBI-related hospitalizations, 226

J

Janet, Pierre, psychiatric conceptualization of trauma and response, 581–582

Japan

atomic weapons dropped on Hiroshima and Nagasaki, 

599–600, 601

Aum Shinrikyo cult’s sarin attack on the Tokyo subway system, 594, 597, 598, 599, 601–602

Japanese International Cooperation Agency, complex humanitarian emergencies and, 621

Jaycox, L., prolonged exposure treatment, 302

Jensen, P.S., children’s responses to deployment, 494

Jobs. See Employment issues

Johnson, A.W., Jr.

overview of Army psychiatry in Vietnam, 11, 15, 26, 27

use of psychotropic medications by physicians deployed to 

Vietnam in 1967, 152–153

Johnson, D.R., inpatient program for posttraumatic stress disorder 

among Vietnam veterans, 310

Johnson, Joy, What Does That Mean? A Dictionary of Death, Dying 

and Grief Terms for Grieving Children and Those Who Love Them,

558

Johnson, Pres. Lyndon, Vietnam War and, 13, 18

Johnston, J., draft issues during the Vietnam War, 23–24

Joinson, C., provider fatigue description, 376–377

Joint Commission, pain management and, 340

Joint Conference on Postdeployment Mental Health, description 

and participants, 330

Joint Patient Movement Requirement Centers

coordination with the Global Patient Movement Requirements 

Center to establish CONUS destinations for patients, 202

tracking of patients, 195

Jones, Col. Franklin Del

“evacuation syndromes,” 32–33

military psychiatry textbook, 5–6

overview of Army psychiatry in Vietnam, 11, 15, 26, 27, 30, 

32–33

War Psychiatry, 108

Just the Facts...Dealing With the Stress of Recovering Human Dead 

Bodies, 52

K

Kahumbu, Paula, Owen & Mzee, 558

Kang, H.K., reporting of mental health problems by OIF/OEF 

veterans, 329

Kanyer, Laurie A., 25 Things to Do: Activities to Help Children Suffering Loss or Change, 561

Kauffman, J., social support effect on the development of depression in traumatized foster children, 46

KBR, Operation Iraqi Freedom 05-07 and, 140, 142

KC-135 Stratotanker aircraft, aeromedical evacuations and, 195

KC-10A Extender aircraft, aeromedical evacuations and, 195

KCMHR. See King’s Centre for Military Health Research

Kelley, M.L., children’s responses to deployment, 494

Kennedy, Pres. John F., assassination of, 22, 23

Kennedy, Robert, assassination of, 23

Ketamine, pain management and, 344, 348

Kiley, Lt. Gen. Kevin, Baghdad ER HBO program and, 147

King, Rev. Martin Luther, assassination of, 23

King’s Centre for Military Health Research, description and 

research subjects, 663

Kirk, Donald, demoralization of troops fighting in Vietnam, 20, 26

Kirkland, Faris, War Psychiatry, 276–277

Kleiger, J.H., reintegration stress in families, 488

Kobasa, D.M., “mental toughness” models, 45

Koenen, K.C., PTSD among Vietnam War veterans, 298

Kolk, B.A., PTSD treatment modalities, 308

Korean War

Americans wounded in action, 13, 14

combat stress control teams and, 176

communication issues, 536

family notification of combat deaths, 544

fixed tours and, 18

helicopters used for aeromedical evacuations, 192–193

illegal drug use and, 32

indifference of the public toward returning soldiers, 277

psychiatric casualties, 11, 26

psychological casualties, 5

survival rates of those injured in, 226

Koren, D., posttraumatic stress disorder rates in injured Israeli 

war veterans, 233

Kosovo, Operation Joint Guardian and, 76

Kottler, J.A., Compassionate Therapy, 377

Kozak, M., fear-related memories and PTSD, 299

Krasney, Laurie, When Dinosaurs Die: A Guide to Understanding 

Death, 557

Krementz, Jill, How It Feels When a Parent Dies, 558–559

Kroen, William, Helping Children Cope With the Loss of a Loved One: 

A Guide for Grownups, 560

Kudler, Dr. Harold, Joint Conference on Postdeployment Mental 

Health and, 330

Kulka, R.A., Vietnam veterans with comorbid PTSD and alcohol 

abuse, 305

Kurds, Operation Provide Comfort and, 622

Kussman, Dr. Michael J., VA Seamless Transition Office and, 327

Kuwait

arrival of troops for Operation Iraqi Freedom One, 753–754

contingency aeromedical staging facility, 201

Saddam Hussein’s invasion of, 659

L

Lamberg, L., school enrollment issues, 488

Land Combat Study

Battlemind program and, 73

description, 77–78

posttraumatic stress disorder diagnosis and, 78

stigma and barriers to care and, 78

use in other research areas, 81

Landsman, I.S., bereavement reaction to traumatic injury, 246

Landstuhl Regional Medical Center

augmentees as staff, 214–215

case studies, 212–213, 216–217

catchment area, 210

challenges of providing psychiatric care to evacuees, 212–217

characteristics of psychiatric evacuees, 211–212

circumventing mental healthcare in theater (figure), 215

circumvention of evacuation channels and, 214

Combat and Operational Stress/Staff Resiliency program, 

219–222

comparison between Operation Iraqi Freedom/Operation 

Enduring Freedom evacuations and available clinicians at 

Landstuhl Outpatient Behavioral Health Clinic (figure), 215

compassion fatigue and, 219

dangerous patients, 212
Index

xlix

Deployed Warrior Medical Management Center, 211

emergency mental health model, 215–217

evacuation of patients to, 201

impact of Operation Iraqi Freedom and Operation Enduring 

Freedom on patient load: a typical day at Landstuhl. Comparison between 2001 and 2006 (table), 211

initial assessments, 210–211

inpatient psychiatry, 217–219

Joint Patient Movement Requirement Center coordination 

with the Global Patient Movement Requirements Center to 

establish CONUS destinations for patients, 202

Landstuhl Regional Medical Center inpatient admissions, 2002 

through July 2007 (figure), 218

Landstuhl Regional Medical Center inpatient admissions, 2003 

through July 2007 (figure), 218

Landstuhl Regional Medical Center psychiatric consultation to 

medical and surgical wards, September 1, 2006, to February 

1, 2007 (figure), 216

local area support area, 217

location of, 210

medical and surgical evacuees, 211

Medical Transient Detachment, 211

mission of, 210

nonactive duty patients and, 218

nursing personnel and, 217

Operation Enduring Freedom/Operation Iraqi Freedom 

evacuations by year (figure), 212

Operation Iraqi Freedom/Operation Enduring Freedom total 

evacuations compared to return to duty by year until February 2007 (figure), 214

outreach to wounded warriors, 215

patient actions and behaviors, 212–214

potential harm to self or others of psychiatric patients, 213

psychiatric patient load increase, 217–218

psychiatrist role in inpatient care, 217–218

psychological stressors for staff, 218–219

rear-echelon presentation of psychiatric patients, 214

resilience of staff and, 219

returning soldiers to combat duty stations for psychiatric care, 

214

rotating staff, 214–215

staff characteristics and actions, 210, 214–215

supervision of psychiatric patients, 212–213

top five Landstuhl Regional Medical Center outpatient psychiatry diagnoses for Operation Iraqi Freedom and Operation Enduring Freedom (figure), 212

wartime role, 210–212

Lange, C., guidelines for psychiatry residents on becoming a division psychiatrist, 92

Lao Tzu, Mercy model of population-based disaster relief and, 

634, 635

Lauder, T.D., eating disorders in military populations, 456

Learning from Resilient People: Lessons We Can Apply to Counseling 

and Psychotherapy (Glicken), 168

Lee, Marlene, The Hero in My Pocket, 558

Legal issues

Feres doctrine, 436, 437

medical decision-making by family members, 508

unit watch, 436–437

Leskin, Gregory, PhD, instruction of primary care providers at 

Schofield Barracks and, 568

Letterman, Dr. Jonathan, medical evacuation program and, 192

Letterman Army Medical Center, San Francisco, CA, behavioral 

health liaison project, 571

Librium, use of during the Vietnam War, 152

Lieberman, Alicia, Losing Parents to Death in the Early Years,

561–562

Life and Loss: A Guide to Help Grieving Children (Goldman), 560

Life disruptions

definition, 378

provider fatigue and, 378, 380

LIFELines organizations, help in dealing with issues facing children in military families, 500

Lifton, Robert Jay, atrocities during war, 148

Limited wars, description and reentry/reintegration responsibilities, 277

Lincoln, Pres. Abraham, Veterans Administration establishment, 

326

Linden, E., incidence of soldiers attacking their superiors (“fragging”), 26

LINN. See Living in the New Normal initiative

Lithium, safety of use during pregnancy, 709

Living in the New Normal initiative

description, 550, 554

Web site, 554

Living Works programs, suicide prevention and, 406

Llewellyn, Capt. D.M., support for Mercy model of populationbased disaster relief, 636–637

Lorazepam, insomnia treatment, 159–160

Los Angeles Suicide Prevention Center, description, 404

Losing Parents to Death in the Early Years (Lieberman), 561–562

LRMC. See Landstuhl Regional Medical Center

Lyons, Christine, How Do We Tell Children: Helping Children Understand and Cope When Someone Dies, 561

M

MACE. See Military Acute Concussion Evaluation

Maddi, S.R., “mental toughness” models, 45

Madigan Army Medical Center, Tacoma, WA, Army Family 

Readiness Course, 280

Magnetic resonance imaging, traumatic brain injury, 230

Major depressive disorder. See also Depression

effect on performance, 444–445

environmental stress and, 444

in-theater treatment, 158–159

posttraumatic stress disorder and, 298, 303

treatment, 444, 445

Major wars, description and reentry/reintegration responsibilities, 277

Malcolm Grow Air Force Hospital, National Capital Area Consortium and, 672

Malingering

challenge for forensic psychiatrists, 697

description, 697

diagnosis of compared with the criminal offense of, 698

dual agency and, 697–698

as a maladaptive response to stress, 697

posttraumatic stress disorder and, 694

reluctance to diagnose, 697

treatment of, 697–698

Man Against Himself (Menninger), 404

Mancini, J.A., adolescents’ responses to deployment, 494

Mann, J.J., suicide prevention research, 406

Marijuana

patterns of use, 477

Vietnam War and use of, 17, 20, 24, 152

Mark, M., anorexia nervosa treatment protocol, 459

Marrazzi, M.A., eating disorder treatment research, 460–461

Marriage therapy, family maltreatment and, 540

Marshall, Brig. Gen. (Ret.) S.L.A.

debriefing process, 175 

morale of troops fighting in Vietnam, 17

Marshall, Gen. George C., importance of religion to soldiers, 167

Marvingt, Marie, use of aircraft for medical evacuations and, 192

Mass casualties, effect on family members, 551
l

Combat and Operational Behavioral Health 

Mass panic

description, 595, 5997

mass anxiety compared with, 597

McBride, Lt. Col. Sharon, Battlemind program and, 73

McCue K., How to Help Children Through a Parent’s Serious Illness,

517

MCEC. See Military Child Education Coalition

McFall, M., smoking cessation intervention for PTSD, 305

McGurk, Maj. Dennis, Battlemind program and, 73

McHale, S., security and informational requirements in complex 

humanitarian emergencies, 623

McNulty, P.A., abnormal eating behaviors in military populations, 

456, 458

McVeigh, Timothy, Oklahoma City (OK) Murrah Federal Building 

bombing and, 594

MEDCAPS. See Medical civic action programs

MEDCOM. See Army Medical Command

Medevac program. See Aeromedical evacuations

Media

anthrax attacks and, 595, 598

Baghdad ER HBO program and, 147–148, 777–778

basics of interacting with, 776

epidemiological consultations and, 418

fallen service members and, 552

Haditha civilian deaths and, 148, 778

ideal body image portrayed in, 450

issues and concerns with behavioral health reporting on Iraq, 

776–778

Operation Iraqi Freedom 05-07 and, 6–7, 146–148, 776–779

pre- and post-deployment screening and, 96

protecting children from media exposure, 547

September 11, 2001, terrorist attacks and, 598

suicide rate increase and, 147

terrorism and chemical, biological, radiological, nuclear and 

explosive weapons and, 595, 596, 598

Medical civic action programs, Operation Iraqi Freedom 05-07 

and, 611, 613

Medical civil-military operations in Operation Iraqi Freedom 

05-07

assumptions made, 611–612

building projects focus, 611

compared with humanitarian missions in the 1990s, 611

cooperative medical engagements and, 613

eight tasks for, 612

G-5 role, 612–613

goals of, 613

historical background, 610–615

Iraqi healthcare officials’ involvement and, 613

Iraqi medical facilities takeover of the health “battlespace” 

and, 616

medical civic action programs, 611, 613

mission statement for, 612

Nine Principles of Reconstruction and Development (exhibit), 

613, 614–615

nongovernmental organizations and, 610, 616, 617

peacetime concepts and, 612

sewer, water, electricity, and trash projects, 616

Medical malpractice, lawsuits concerning, 436–437

Medical profiling

commanders and, 180–181

conditions that require a rating, 180

profile serial system, 180

Medical Record Consultation Sheet (Standard Form 513), 478

Medical review officers, role in substance abuse treatment, 

477–480

Memory String (Bunting), 558

Men. See also Gender factors; Women

age of onset for schizophrenia, 442

binge drinking definition, 475

drinking alcohol as a way to cope with stress, 260

eating as a way to cope with stress, 260

eating disorders and, 450, 455–456

heavy drinking amount, 475

light drinking amount, 475

moderate drinking amount, 475

periodontal disease prevalence (figure), 266

PTSD rates, 298

smoking as a way to cope with stress, 260

temporomandibular dysfunction and, 268

Menninger, Dr. William C.

failure to meet basic needs as a contributor to the incidence of 

psychiatric casualties in combat, 173

Psychiatry in a Troubled World, 33–34

Menninger, Karl, Man Against Himself, 404

Mental Health Advisory Team II Report, 101

Mental Health Advisory Team IV

Battlemind and, 73

findings in Operation Iraqi Freedom 05-07, 139

Haditha civilian deaths and, 148

mail system reliability and, 140–141

Mental Health Advisory Team V, Operation Iraqi Freedom suicide 

prevention and surveillance program, 409–412

Mental Health Advisory Teams

composition of, 185

key recommendations, 185

responsibilities, 185

Mental Health Casualty Tracker for OIF

information sources, 145

suicide rates, 147

Mental Illness Research, Education, and Clinic Centers, role of, 

333

Mercy model of population-based disaster relief

“assembly line” for choosing program content, 639, 644

case study, 637–638

description, 634–635, 643

“diplomatic pants” incident, 637–638

evaluation of, 644

final preparation, 639

focus on paraprofessionals and nonprofessionals, 643–644

future planning needs, 636

“Go West and Do Good Things” precept, 636–639, 643

initial assessments and collaboration, 637

initial decision points, 637

integrating USPHS teams, 638

“Leadership of the Open Hand” concept, 635–636

mission definition and, 636

nongovernmental organizations and, 634, 637

partnering with Indonesian colleagues and, 638–639

precepts of, 635, 643–644

program development and delivery, 638–639

PsySTART program and, 636, 640

public health leadership approach, 635

sensitivity of the behavioral health climate, 637

Sternberg’s “wisdom, intelligence, and creativity, synthesized” 

model and, 636

success of the program, 640

support for, 636–637

suspicion of U.S. personnel and efforts, 637, 639–640, 643

training programs, 639

western psychological/psychiatric interventions and, 637, 641

Messer, Dr. Steven, Battlemind program and, 72

Methylphenidate, Vietnam War and use of, 152

Meyer, Adolf, occupational therapy and, 358

MHATs. See Mental Health Advisory Teams

MHCTO. See Mental Health Casualty Tracker for OIF

Mild traumatic brain injury
Index

li

cognitive sequelae, 231–235, 253

comorbidity with other physical injuries, 505

educational interventions, 235

Galveston Orientation and Amnesia Test and, 231

hormonal issues, 710

in-theater management of, 233

initial management of concussion in a deployed setting (figure), 234–235

postconcussive disorder, 231–233

postconcussive symptoms, 230–231, 710–711

posttraumatic stress disorder and, 233, 307, 711

psychological therapies for, 235

rest and, 235

return-to-duty and, 235

Standardized Assessment of Concussion, 233

substance abuse and, 233

symptom treatment, 235

underreporting of, 230

variability in rate of recovery, 231

women and, 710–711

Military Acute Concussion Evaluation

form (exhibit), 236–237

mild traumatic brain injury and, 230, 233

Military Assistance Program, description of services, 500

Military care team, children and families of fallen service members and, 545–546

Military Child Education Coalition

Living in the New Normal initiative, 550, 554

recommended books for children coping with trauma, grief, 

and loss, 556–562

Military children and families

combat-injured service members and, 504–534

fallen military service members and, 544–562

family maltreatment and military deployment, 536–540

impact of deployment, 488–501

integrated behavioral health services at Schofield Barracks, 

564–575

Military funerals

children and families of fallen service members and, 549

dignified care for the dead and, 724

Military Homefront, description and Web site, 554

Military Life: The Psychology of Serving in Peace and Combat, 81

Military Medicine, articles on division mental health units, 92

Military OneSource

combat driving behavior modification brochures, 372

description and services, 331, 335, 336, 554

88th Regional Readiness Command COSC program and, 365

phone number, 501

resource for identifying community services for families, 551

services offered to Army Reserves and Army National Guard 

service members, 409, 554

Sesame Workshop Talk, Listen, Connect: Deployments, Homecomings, Changes DVD, 517

support for soldiers and their families, 500

Web site, 500, 501, 517, 554

Military Psychiatry: Preparing in Peace for War, 6

role of division psychiatrists, 92

Military Support for Stability, Security, Transition, and Reconstruction 

Operations (Department of Defense Directive 3000.05), 586

Military training

physical fitness component, 52, 450, 456, 457, 463, 704–705, 706

resilience and, 51–52

Military Widow: A Survival Guide (Steen and Asaro), 551, 560

Millikin, Col. Charles S., Battlemind program and, 72–73

Mimesulide, pain management and, 344

MIRECCs. See Mental Illness Research, Education, and Clinic 

Centers

Mirtazapine

insomnia treatment, 250

posttraumatic stress disorder treatment, 303

Missing in action soldiers, effect on family members, 551

Mississippi, Project Recovery and, 587

MNC-I. See Multi-National Corps-Iraq

MNF-I. See Multi-National Force-Iraq

Monoamine oxidase inhibitors

bulimia nervosa treatment, 461–462

posttraumatic stress disorder treatment, 303

Mood disorders. See also specific disorders

bulimia nervosa and, 453

complex humanitarian emergency survivors and, 627

fitness for duty and, 180

in-theater treatment of, 158–159

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 203

suicide and, 395, 426

traumatic injuries and, 251

Morphine

nonmedical use of, 477

pain management and, 344

Mortuary operations. See Operations involving death and the 

dead

Moskos, Charles, morale of troops fighting in Vietnam, 17

Mott, R., humanitarian assistance missions, 610, 611, 612, 613

Mozambique, kidnapping and induction of male adolescents, 626

MRI. See Magnetic resonance imaging

MROs. See Medical review officers

mTBI. See Mild traumatic brain injury

Multi-National Corps-Iraq

Focused Stabilization Task Force, 610

Humanitarian Assistance Working Group, 616

medical civil-military operations in Iraq and, 610–617

Operation Iraqi Freedom 05-07 and, 142, 143, 146, 147

Operation Iraqi Freedom theater suicide prevention, 410–412

Multi-National Force-Iraq, Operation Iraqi Freedom 05-07 and, 

139, 140, 144

Muriel, Anna C., Raising an Emotionally Healthy Child When a Parent Is Sick, 517, 560

Myers, Charles S., military psychologist role, 658

N

Naltrexone, bulimia nervosa treatment, 462

Narcotics. See Illegal drugs; specific drugs

National Association of State Directors of Veterans Affairs, program description, 334

National Athletic Trainers’ Association, traumatic brain injury 

definition, 227

National Capital Area Consortium

medical centers participating in, 672

Military Forensic Psychiatry Fellowship Program, 697

National Cemetery Administration, description of services, 326

National Center for Grieving Children and Families, 35 Ways to 

Help a Grieving Child, 561

National Center for Posttraumatic Stress Disorder

combat and operational stress first aid and, 116

instruction of primary care providers at Schofield Barracks, 

568

long-term tasks for behavioral health providers in complex 

humanitarian emergencies, 628

Response to Stressful Experiences Scale, 49

Web site, 501

National Center on Shaken Baby Syndrome, awareness campaign, 

539

National Child Traumatic Stress Network

description and services, 555

online guideline for help with children’s responses to trauma, 
lii

Combat and Operational Behavioral Health 

500

psychological first aid and, 116

Web site, 555

National Comorbidity Survey, PTSD findings, 298

National Comorbidity Survey Replication, prevalence of bulimia 

nervosa in men, 450

National Defense Authorization Act, 545

National Geographic Society, For Children of Valor: Arlington National Cemetery gift book, 554

National Guard. See U.S. Army National Guard

National Guard Bureau, partnership with the Department of 

Veterans Affairs, 328

National Institute of Mental Health, Behavioral and Social Health 

Outcomes Program and, 409

National Long Distance Relationship Building Institute, Dads at a 

Distance Web site, 501

National Mental Health Act, provisions, 671

National Military Family Association

description and services, 550, 555

Web site, 555

National Naval Medical Center, National Capital Area Consortium and, 672

National Practitioner Data Bank, adverse privileging information 

and, 437

National Survey on Drug Use, patterns of illegal drug use, 477

National Vietnam Veterans Readjustment Study

findings, 333, 495

posttraumatic stress disorder rates among veterans, 30, 298

purpose of, 495

Natsios, A.

local ownership, capacity building, and sustainability as the 

“iron triad” of successful reconstruction and development 

projects, 628

Nine Principles of Reconstruction and Development (exhibit), 

613, 614–615

NE. See Norepinephrine

Necrotizing ulcerative gingivitis, prevention and treatment, 268

Neel, Maj. Gen. Spurgeon, Army Medical Support in Vietnam, 16, 28

Nefazodone

in-theater treatment and, 159

posttraumatic stress disorder treatment, 303

Neidig, P.H., relationship between the length of deployment and 

spousal aggression, 537

NES. See Night-eating syndrome

Neugut, A.E., World War I and World War II noncombatant casualty rates, 625

Neuroleptics. See also specific drugs

use of during Operation Restore Hope, 153

Vietnam War use, 11–12, 34

Neuropeptide Y, resilience and, 46–47

Neuropsychiatry and Mental Health (Army Regulation 40-216), 90, 

91

Neuropsychiatry in World War II (Glass), 5, 91

New Parent Support Program, description of services, 539

New York University Child Study Center, Web site dedicated to 

advancing the field of child mental health, 500

Nichols, Terry, Oklahoma City (OK) Murrah Federal Building 

bombing and, 594

Niemela, O., relationship of alcohol use to trauma, 233

Night-eating syndrome, description and prevalence of, 452

Nightingale, L., guided imagery and, 368

Nixon, Pres. Richard, Vietnam War and, 21, 22

Nongovernmental organizations. See also specific organizations

behavioral health issues for detained individuals and, 646, 649

complex humanitarian emergencies and, 620, 622, 623

Indian Ocean tsunami and, 585, 587

medical civil-military operations in Operation Iraqi Freedom 

05-07 and, 610, 616, 617

Mercy model of population-based disaster relief and, 634, 637

neutrality of, 616, 620

World Bank definition of, 622

Nonsteroidal antiinflammatory drugs, pain management and, 

344, 347

Norepinephrine

eating disorders and, 452

resilience and, 47

North, C.S., elevated rates of posttraumatic stress disorder following the Oklahoma City bombing, 580

North Carolina, Governor’s Focus on Returning Combat Veterans 

and Their Families, 335

Nortriptyline, posttraumatic stress disorder treatment, 303

Norwood, A.E., disaster psychiatry research, 581

Notification of service member’s injury

communicating with children about, 506–507

effect of adults’ reactions on children, 506–507

family separations and, 507–508

process of, 505–506

travel to military medical facilities and, 507

vignettes, 507–508

withholding information from children, 507

NPDB. See National Practitioner Data Bank

NPSP. See New Parent Support Program

NPY. See Neuropeptide Y

Nuclear weapons. See Chemical, biological, radiological, nuclear 

and explosive weapons

NVVRS. See National Vietnam Veterans Readjustment Study

O

Obesity

binge eating disorder and, 452

body mass index and, 452

night-eating syndrome and, 452

prevalence of, 452

social and cultural factors, 453

Obsessive-compulsive disorder

in-theater treatment, 159

posttraumatic stress disorder and, 305

Occupational therapy

combat and operational stress control and, 360, 361–363

combat driving behavior modification and, 372

current services, 359–363

description, 358, 374

educational component, 359, 362

88th Regional Readiness Command COSC program for soldiers and their families, 363–366

functional approach of, 373

historical background, 358–359, 373

on the home front, 372

job task analysis and, 359

mission of, 360

observation component, 362

occupational therapy assistant role, 361

Operation Iraqi Freedom detainee healthcare and, 366–368

peak performance training and, 360–361, 368–369

recreational programs and, 359

service-dog training and, 361

specialty areas, 360

stressor identification and, 362

therapeutic riding programs and, 361

training and licensure of practitioners, 361, 371

unit needs assessment and, 362–363

U.S. Army occupational therapy scope of practice (exhibit), 

360

warrior transition units and, 361, 363, 369–372

work reintegration programs, 361, 369–372
Index

liii

Wounded Warrior Clothing Support Program and, 361

Office of The Surgeon General. See also Consultant to The Surgeon 

General, U.S. Army

Army Suicide Prevention Program and, 405, 406–407

Division of Physical Reconstruction, 358

EPICON responsibilities, 415

occupational therapy and, 358

survey instrument assessing the mental health effects of employees after the September 11, 2001, terrorist attacks, 77

OIH. See Opioid-induced hyperalgesia

Oklahoma City (OK) Murrah Federal Building bombing

description, 594

posttraumatic stress disorder following, 580, 602

Olanzepine

anorexia nervosa treatment, 460

bipolar disorder treatment, 158

psychotic disorder treatment, 159

Olson, Maj. Gen. Eric, integrated behavioral health services at 

Schofield Barracks, HI and, 565–566

OMUS. See Outbreaks of multiple unexplained symptoms

Ondansetron, bulimia nervosa treatment, 462

ONE. See Operation Noble Eagle

Operation Banner, United Kingdom armed forces behavioral 

health and, 658

Operation Enduring Freedom

aeromedical evacuations and, 192, 203–204, 244

case studies, 773–774

casualty rates, 203, 244

the characteristics of major wars, limited wars, and rapid 

deployment operations overlap in Operation Iraqi Freedom 

and Operation Enduring Freedom (figure), 277

clinical operations, 771

common mental health presentations, 771

communication issues, 772

consultation with command, 771, 772

continuum of care for veterans of, 326–336

data collection, 772

divorce rate for soldiers, 277

documentation of medical information, 772

eating disorders and, 462–463

education plan, 771

logistical issues, 772

mental health operations in Afghanistan, 771–772

mental health operations in deployment, 769–771

most common health problems of veterans, 329

operational psychiatry in, 768–774

outreach efforts, 769–770

peak performance training and, 368

Pincus’s emotional cycle of deployment and, 488

Post-Deployment Health Assessment and, 79, 203, 327, 

331–332

posttraumatic stress disorder and, 564

predeployment planning, 769

prevalence of mental health problems, 122, 203

prevention of mental health issues, 770–771

principles of forward treatment of casualties and, 6

returning home after combat and, 276

survival rates of those injured in, 226, 244

traumatic brain injury and, 710

traumatic event management and, 770, 771

travel through the area of operations, 772

treatment at Landstuhl Regional Medical Center, 210, 211

Walter Reed Army Institute of Research and, 76–82

Web site, 501

Operation Granby, United Kingdom armed forces behavioral 

health and, 659

Operation Iraqi Freedom

aeromedical evacuations and, 192, 203–204, 244

casualty rates, 203, 244

the characteristics of major wars, limited wars, and rapid 

deployment operations overlap in Operation Iraqi Freedom 

and Operation Enduring Freedom (figure), 277

continuum of care for veterans of, 326–336

detainee healthcare and, 366–368

divorce rate for soldiers, 277

eating disorders and, 462–463

media coverage and, 6–7, 776–779

most common health problems of veterans, 329

occupational therapy in support of detainees and, 366–368

peak performance training and, 368

Pincus’s emotional cycle of deployment and, 488

Post-Deployment Health Assessment and, 79, 203, 327, 

331–332

posttraumatic stress disorder and, 299, 564

prevalence of mental health problems, 122, 203

principles of forward treatment of casualties and, 6

released psychiatric inpatients and, 646

returning home after combat and, 276

review of psychiatric service use during, 153

suicide assessment, 409–412

survival rates of those injured in, 226, 244

traumatic brain injury and, 710

treatment at Landstuhl Regional Medical Center, 210, 211

Walter Reed Army Institute of Research and, 76–82

Web site, 501

Operation Iraqi Freedom 05-07

Baghdad ER special on HBO and, 147–148, 777–778

BICEPS principles and, 148

casualty statistics and, 144–145

changing dynamics of the conflict, 138–146

civilian deaths in Haditha reports, 148, 778

clinical environments for mental health services, 139

Combat/Operational Stress Control Workload Activity Reporting System and, 139, 144

command and control of echelon-above-division stress control 

personnel improvements, 142–143

communications improvements, 140

Composite Health Care System-Interactive Training Tool, 140

convoy procedure standardization, 138

documentation of COSR cases, 144

DoD policy changes, 141–142

enemy sophistication and, 138

formulary for medications, 139

forward operating base developments and, 138–141

increase in psychiatric patients, 139

increased mental health services, 140–141

KBR employees and, 140, 142

living and working condition improvements, 138–140

mail system reliability and, 140–141

media and, 6–7, 146–148, 776–779

medical civil-military operations, 610–617

Mental Health Advisory Team IV and, 139, 148

Mental Health Casualty Tracker for OIF, 145, 147

Multi-National Corps-Iraq and, 142, 143, 146, 147

Multi-National Force-Iraq and, 139, 140, 144

multiple deployments and, 141

Operational Stress Control and Readiness teams and, 142

peer review of mental health charts and, 146

planning improvements, 142–143

psychotropic medication prescribing guidelines, 145

psychotropic prescription data challenges, 139–140

quality of care and, 145–146

sexual assault and, 141

situational awareness improvement, 142

staff assistance visits, 145–146

standardization of practices and, 143–145
liv

Combat and Operational Behavioral Health 

suicide rate and, 145, 147, 777

Operation Iraqi Freedom One

arrival in Kuwait, 753–754

behavioral health service provision during, 752–766

case studies, 758–759, 760, 763

combat stress control units and, 759–762

combat support hospitals and, 754–759

division mental health sections, 762–765

echelons in treatment in the combat theater, 752–753

Operation Joint Endeavor

integrated use of combat stress detachments and division 

mental health assets during, 153

psychological health of soldiers and, 76, 79

Operation Joint Guardian, psychological health of soldiers and, 76

Operation Just Cause, psychological health of soldiers and, 76

Operation Noble Eagle

Pincus’s emotional cycle of deployment and, 488

Web site, 501

Operation Provide Comfort, description, 622

Operation Provide Promise, psychological health of soldiers and, 

76

Operation Restore Hope

psychological health of soldiers and, 76

use of psychotropic medications during, 153

Operation Solace, description, 77, 679–680

Operation Special Delivery, services for pregnant women, 500–501

Operation Unified Assistance

division into three groups, 585

Mercy model of population-based disaster relief and, 634–644

providing care in situ and, 585

telecommunications and, 586

USNS Mercy and, 585–586

Operation Uphold Democracy, psychological health of soldiers 

and, 76

Operational behavioral health

behavioral health issues for detained individuals, 646–656

complex humanitarian emergencies, 620–629

disaster psychiatry, 580–588

medical civil-military operations in Operation Iraqi Freedom 

05-07, 610–617

Mercy model of population-based disaster relief, 634–644

terrorism and chemical, biological, radiological, nuclear, and 

explosive weapons, 594–603

United Kingdom armed forces and, 658–664

Operational Navy Instruction 5350.4C, drug testing and, 481

Operational Stress Control and Readiness program

capabilities, 127–128

historical background, 126–127

Operation Iraqi Freedom 05-07 and, 142

staffing issues, 127

team design, 128

U.S. Marine Corps and, 102, 116, 126–128

U.S. Navy and, 126–128

Operational stress injuries

elements of, 109

“injury” definition, 109

working group on, 109–110

Operations Desert Shield/Storm

aeromedical evacuations and, 193

reintegration stress in families and, 488

Operations involving death and the dead

Army Quartermaster Corps and, 718–719

assisting soldiers with exposure to mass death, 722–724

emotional involvement and, 720–721

“exposure to death” definition, 718

“exposure to the dead” definition, 718

guidelines for assisting soldiers and commanders in caring for 

the dead (exhibit), 722

how do mortuary affairs soldiers say they deal with stress 

(exhibit), 722

level of exposure relationship to level of distress, 721

logistical support for workers, 724

military care-of-the-dead policy and training, 718–719

organizational support for workers, 723–724

personal effects of the deceased and, 720–721

personal safety issues, 720

personal support for workers, 723

physical characteristics of remains and, 719–720

psychological effects of caring for remains, 721

reasons why mental health personnel should be familiar with 

the topic, 718

reinforce the positive (exhibit), 723

role of the mental healthcare provider in mass death situations, 721–724

signs of stress, 721–722

signs of stress in mortuary operations and coping with the 

work (exhibit), 722

social effects of proper care of the dead, 724

stresses of exposure to remains, 719–721

terminology, 718

types of remains causing the most distress, 720

Opiates. See also specific drugs

nonmedical use of, 477

opioid-induced hyperalgesia and, 344

pain management and, 340, 344, 347

Opioid-induced hyperalgesia, description and effects of, 344

Oral contraceptives

periodontitis and, 267–268

temporomandibular dysfunction and, 268–269

Oral health effects of combat stress

beverages and, 260, 262, 265

a case of gingivitis (figure), 266

causes of oral disease, 260

dehydration and, 261

dental caries, 261

dental emergency rates in combat, 260

dental erosion, 262

dental hard-tissue diseases and, 261–265

Department of Defense Survey of Health-Related Behaviors 

Among Active-Duty Military Personnel findings, 260

Department of Defense Survey of Health-Related Behaviors in 

the Reserve Component findings, 260

dietary changes during deployment and, 261

duty performance and, 260

eating disorders and, 263–264

eating habits and, 260, 265

erosion of enamel and exposure of the dentin layer in a patient 

with GERD (figure), 262

erosion of the facial enamel and exposure of the underlying 

dentin (figure), 264

erosion of the lingual, occlusal, and incisal surfaces of the 

maxillary teeth in a patient with bulimia (figure), 263

extensive accumulation of bacterial plaque after cessation of 

oral hygiene (figure), 261

fluoride and, 261, 264

foods and, 260, 265

gastroesophageal reflux disease and, 262

generalized demineralization and loss of enamel on the facial 

surfaces of teeth (figure), 262

gingival edema, erythema, and cratering of the interdental 

papilla and purulent exudate are visible in this patient with 

acute necrotizing ulcerative gingivitis (figure), 268

gingival erythema edema, and recession...in patient with periodontal disease (figure), 266

gingivitis, 265–266

health literacy and, 260
Index

lv

necrotizing ulcerative gingivitis, 268

occlusal wear and dentin exposure due to erosion in a patient 

with bulimia (figure), 263

oral disease prevalence as nonbattle injuries, 260

oral hygiene effects, 260–261, 264

periodontal disease, 265–268

periodontitis, 266–268

plaque accumulation, tobacco staining, gingival inflammation, 

and generalized caries resulting from a combination of inadequate oral hygiene, tobacco use, and refined carbohydrate 

intake (figure), 260

prevalence of periodontal disease (figure), 266

prevention strategies, 260, 264–265

refined carbohydrates as a cause of oral disease, 260

temporomandibular dysfunction, 268–269

tobacco use and, 260

translucency of the maxillary central incisors due to erosion in 

a patient with bulimia (figure), 263

treatment, 265

undernutrition and, 261

xerostomia, 265

xylitol gum or mints and, 264–265

Orlistat, obesity treatment, 462

Orman, Col. David, Soldier Assistance Center and, 568

OSCAR. See Operational Stress Control and Readiness program

Oslo Guidelines. See Guidelines on the Use of Military and Civil 

Defence Assets in Disaster Relief

Osteoporosis, anorexia nervosa and, 454

OT. See Occupational therapy

O’Toole, Donna

Facing Change: Falling Apart and Coming Together Again in the 

Teen Years, 560

Helping Children Grieve & Grow--A Guide for Those Who Care, 561

OTSG. See Office of The Surgeon General

OUA. See Operation Unified Assistance

Out of the Darkened Room: When a Parent is Depressed (Beardslee), 

517

Outbreaks of multiple unexplained symptoms

chemical, biological, radiological, nuclear and explosive weapons and, 594, 597–599, 600–601

Overweight. See Obesity

Owen & Mzee (Hatkoff, Hatkoff, and Kahumbu), 558

Oxycodone, drug tests and, 477

P

Pain management

acute pain and, 340

adverse effects of pain, 345

amputations of limbs and, 349

anatomic locations and, 340, 341

behavioral measurements, 346–347

benzodiazepines and, 340

biology of pain, 343–344, 350

burn casualties and, 340, 343–344, 345, 349

case studies, 341–342

children and, 340, 346–347, 349

chronic pain and, 340

endogenous opioid pathways and, 344

ethical issues, 349–350

ethnic and social factors, 346

gene therapy, 346

genetic factors, 345–346

hyperalgesia and, 343

inflammation and, 343–344

Joint Commission focus, 340

multidisciplinary teams for, 340, 350

multiple traumas and, 349

nerve blocks and, 340

nociceptors and, 343

nonopiate pain adjuncts, 343

opiates and, 340, 344

opioid system and, 343

overview of methods, 347

pain assessment methods, 346–347

pain definition, 341

pharmacological management of acute pain, 347–348

physiological dependence and, 347

posttraumatic stress disorder and, 340, 350

principles of, 344

prior alcohol or substance addiction, 349

prolonged grief disorder and, 348

psychiatric risk factors for pain complications, 349

psychological effects of pain, 345

psychological management, 340, 348

psychophysiological indices, 346

relief of pain as a primary task of medical personnel, 340

research needs, 340

self-report measures, 346

somatic sensory and association cortex and, 343

special problems, 349

spinthalamic tract and, 343

uncontrolled pain as a stressor, 246, 340

ventilated patients, 349

weaning regimen, 347, 349

PAM 40-11: Preventive Medicine, 415

PAM 600-24: Suicide Prevention and Psychological Autopsy, 405, 406

PAM 600-70: Guide to the Prevention of Suicide and Self-Destructive 

Behavior, 405

Panama, Operation Just Cause and, 76

Panic disorder

in-theater treatment, 159

posttraumatic stress disorder and, 303, 305

treatment, 253, 303, 710

women and, 709–710

Parent Guidance Assessment--Combat Injury, 513, 521–532

A Parent’s Guide to Building Resilience in Children and Teens: Giving 

Your Child Roots and Wings (Ginsburg), 561

Pargament, K.I., The Psychology of Religion and Coping, 168

Paris, J., suicide research, 395

Paroxetine

depressive disorder treatment, 158

posttraumatic stress disorder treatment, 303

safety of use during pregnancy, 709

Parrish, Col. Matthew, overview of U.S. Army mental health 

activities in Vietnam, 16, 20

Parsons, T., disease as a biomedical process, 330

Part of Me Died, Too: Stories of Creative Survival Among Bereaved 

Children and Teenagers (Fry), 559

Pathological gambling, posttraumatic stress disorder and, 305

Patient privacy. See Privacy and confidentiality issues

Pavlov, Ivan Petrovich, psychiatric conceptualization of trauma 

and response, 581–582

PCLS. See Psychiatry Consultation Liaison Service

PCOS. See Postcombat and operational stress

PDHA. See Post-Deployment Health Assessment

PDHRA. See Post-Deployment Health Reassessment

PE. See Prolonged exposure

Peak performance training

biofeedback and, 369

case study, 369

concept of, 368

core elements, 368

group intervention and, 368

individual training and, 368

mental imagery and, 368
lvi

Combat and Operational Behavioral Health 

occupational therapy and, 360–361, 368–369

stress and energy management model, 369

Warrior Training and Rehabilitation Program and, 369, 370

Pechacek, Mary Ann, EAT model and, 385

Pecko, Col. Joseph

Battlemind program and, 73

role of leadership in provider fatigue resolution, 387

Peebles-Kleiger, M.J., reintegration stress in families, 488

Pellegrino, Marjorie, I Don’t Have an Uncle Phil Anymore, 557

Pennsylvania, Three Mile Island nuclear accident and, 599, 601

Periodontitis

bone loss and, 266–267

classification of, 266

description, 266

model of periodontitis depicting the multifactorial nature of 

periodontal disease (figure), 267

oral contraceptives and, 267–268

risk factors, 266

untreated gingivitis and, 266

Persian Gulf War. See also Operations Desert Shield/Storm

Gulf War syndrome and, 600

symptoms of Israeli civilians near Scud missile attacks, 580, 

596, 598

use of psychotropic medications during, 153

younger wives’ ability to cope with the absence of their husbands and, 536

Personal fitness assessments

body fat measurement and, 704

eating disorders and, 450, 456, 457, 463, 704

weight control programs and, 704

women and, 704–705, 706

Personality disorders. See also specific disorders

fitness for duty and, 180

homicidal ideation and, 437

prevalence of the diagnosis during Operation Enduring Freedom and Operation Iraqi Freedom, 203

Peterson, A.L., bulemic weight-loss behaviors in the Air Force, 458

PFAs. See Personal fitness assessments

PGA-CI. See Parent Guidance Assessment--Combat Injury instrument

Phantom limb pain, treatment for, 246

PHC(P). See Public Health Command (Provisional)

Phentermine, obesity treatment, 462

Philipson, Sandra J., Annie Loses Her Leg But Finds Her Way, 558

Phobias. See also Social phobia

posttraumatic stress disorder and, 305

PIES principles. See Proximity, immediacy, expectancy, and simplicity

Pincus, Simon

emotional cycle of deployment concept, 488, 572

integrated use of combat stress detachments and division 

mental health assets during Operation Joint Endeavor, 153

Pivar, I.L., bereavement and posttraumatic stress disorder, 306

Plague outbreaks, effects on behavior, 598

PMDD. See Premenstrual dysphoric disorder

PMP. See Preventive Medical Psychiatry

Poker Chip Tool, pain assessment in children, 347

Pokorny, A.D., suicide research, 395

Policy Guidance for Deployment-Limiting Psychiatric Conditions and 

Medications, 156

Post-Deployment Health Assessment

description, 77, 174, 327

Operation Iraqi Freedom and Operation Enduring Freedom 

and, 79, 203

population-wide assessment, 79

sample form (exhibit), 288–290

timing of the screening process, 79

validation of, 79

Post-Deployment Health Reassessment

DD Form 2900 and, 331

description, 331

development of, 331

goal of, 331–332

local events, 335–336

timing of, 79, 174

validation of, 79

Postcombat and operational stress

combat and operational stress and, 62

combat and operational stress behavior and, 62–63, 64

length of effects, 62–63

posttraumatic stress disorder and, 64

Postconcussive disorder

research criteria for postconcussive disorder (exhibit), 232

scope of, 232–233

symptoms, 231–232

women and, 710–711

Postpartum depression, description and treatment, 709

Postpartum psychosis, description and risks, 709

Posttraumatic growth

combat and operational stress and, 62, 64

combat and operational stress behavior and, 64

description, 64

Posttraumatic stress disorder

active engagement and alliance building and, 300–301

anger and violence and, 306

assessment and monitoring of treatment effectiveness and, 301

barriers to seeking help, 300

basic dimensions of, 298

challenging negative thoughts and, 302

children and, 345

children of combat veterans with, 496

chronic, 299, 309–310

cognitive processing therapy, 302, 308, 309, 311

cognitive theory of, 299–300

cognitive therapy, 302, 304

combat and operational stress behavior and, 64

combat and operational stress continuum model red zone and, 

112

combat-related physical injuries and, 204, 245

comorbid mental health disorders, 298, 304–307, 312, 445

complex humanitarian emergency survivors and, 627, 628

complicated or traumatic bereavement, 306

coping skills training and, 301–302

“copycat” scenario, 742–743

dangerous firearm-related behaviors and, 306

delayed-onset PTSD, 298

Department of Defense and VA Clinical Practice Guidelines for 

Management of Post-Traumatic Stress, 116, 300–301, 311, 326

deployment-related stress and, 60, 298–312, 495

Deployment Risk and Resilience Inventory and, 301

description, 298

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition and, 30, 33

divorce and, 307

domestic violence and, 306

dual representation theory, 299

early detection and treatment, 126

eating disorders and, 464

emotional processing theory, 299

ethical issues, 742–743

event characteristics that increase the risk for, 298

expert witnesses and, 696

eye movement desensitization and reprocessing and, 302, 304, 

308, 309

families and, 307, 312

functional impairment and, 298, 307–308
Index

lvii

future research needs, 310

genetic factors, 46

imagery rehearsal therapy, 309

imaginal exposure and, 308–309

improvement of services for, 311

in-theater treatment, 159

International Classification of Disease, 9th Edition, Clinical Modification and, 30, 77

Land Combat Study and, 78

late-onset stress symptomatology and, 306–307

level of exposure to combat and, 108

level of traumatic injury and, 249

malingering and, 694

mild traumatic brain injury and, 233

multiple deployments and, 300

Oklahoma City (OK) Murrah Federal Building bombing and, 

580, 602

Operation Enduring Freedom and Operation Iraqi Freedom 

and, 6, 212, 329

outreach interventions, 300–301

pain management and, 340, 345, 350

patient education and, 301

patterns of, 298

percentage of soldiers returning from combat in Iraq and 

Afghanistan with, 78

pharmacotherapy, 303–304

physical health problems and, 306–307

postcombat and operational stress and, 64

program evaluation, 310

prolonged exposure treatment, 302, 308, 309, 311

psychological theories of PTSD and treatment, 299–300

quality of life issues, 304–305

relapse prevention, 304

research with veterans and active duty military personnel, 

308–310

Response to Stressful Experiences Scale, 49

risk factors for developing, 298

sarin attacks on the Tokyo subway system and, 602

screening programs and, 300

sexual trauma and, 298

social connections and, 307

social support and, 46, 53

stigma and, 300, 303, 329

stress inoculation training and, 302, 308

stress reactions and, 47

subthreshold presentations, 298

symptoms, 298, 345, 445

trauma and, 44–45, 48

traumatic brain injury and, 108, 307, 711

traumatic grief and, 550

treatment, 253, 299, 300–304

treatment delivery and accessibility, 311

treatment outcome research, 308–310

uncontrolled pain and, 246

United Kingdom legal case concerning, 661–662

veterans versus civilians with, 310

vicarious victimization and, 377

Vietnam War and, 29–30, 33

workplace and work performance issues, 308

Potentially traumatic events, combat and operational stress 

behavior and, 62

Powell, Sandy, Geranium Morning, 557

Prazosin

anxiety disorder treatment, 159

insomnia treatment, 160, 250

posttraumatic stress disorder treatment, 304, 309

Pre-Deployment Health Assessment, sample form (exhibit), 

286–287

Pregnancy

administrative separation and, 706

bipolar disorder and, 709

deployment and, 706

FDA guidance on safety of medications during, 708–709

maternity leave and, 706

physical fitness requirements and, 706

physical training and, 706–707

postpartum depression and, 709

resentment of the pregnant soldier by the other soldiers in the 

unit, 706

schizophrenia and, 707

schizophrenia treatment and, 707

6-month bonding period and, 706–707

U.S. Food and Drug Administration categories and labeling 

requirements for drug use during pregnancy (exhibit), 708

Premenstrual dysphoric disorder

description, 707–708

emotional symptoms, 708

physical symptoms, 708

treatment, 708

Preparing for deployment

resilience models, 45–53

stress models, 44, 53

trauma models, 44–45, 53

Preschool-age children

effects of deployment on, 494

response to a combat-injured parent, 514

Prescription drugs. See also specific drugs

abuse of, 477

President’s New Freedom Commission on Mental Health, principles of, 330

Preventive Medical Psychiatry

families and, 254–255

follow-up care, 254

goals of, 256

hospitalized combat-injured service members and families 

and, 509–510

Psychiatry Consultation Liaison Service changed to, 246

Therapeutic Intervention for the Prevention of Psychiatric 

Stress model, 247–256

traumatic brain injury and, 253

Preventive Medicine (Army Regulation 40-5), 415

Preventive Medicine (PAM 40-11), 415

Preventive psychiatric consultation

postdeployment psychological screening and, 174

primary prevention, 174

secondary prevention, 174–175

tertiary prevention, 175

Primary traumatic stress, definition, 377

Principi, Anthony, VA Seamless Transition Office and, 327

“Principles of Caring for Combat-Injured Families and Their 

Children,” 517, 533–534

Prisoners of war. See Detainees

Privacy and confidentiality issues

chaplains and, 165–166

Combat and Operational Stress/Staff Resiliency program and, 

220

Composite Health Care System-Interactive Training Tool and, 

140

detained individuals and, 653, 654

hunger strikes and, 654

military rule of evidence and, 166

psychiatric consultation to command and, 183

sanity boards and, 695

Pro-QOL. See Professional Quality of Life Scale

Professional Quality of Life Scale

data analysis, 383–384
lviii

Combat and Operational Behavioral Health 

description, 376, 382

Medical Command observed compassion fatigue cut score 

frequencies compared to expected frequencies based on 

ProQOL data (table), 384

percentage of Medical Command personnel who meet compassion fatigue cut score (table), 383

percentage of ProQOL respondents with compassion fatigue 

compared to U.S. Army Medical Command personnel with 

compassion fatigue (figure), 384

percentage of U.S. Army Medical Command personnel, by 

specialty, who completed the ProQOL survey in 2008 (figure), 383

Trauma/Compassion Fatigue Scale items, 382–383

Project HOPE

Hurricane Katrina response and, 587

Indian Ocean tsunami rescue efforts and, 585

Project Liberty, description, 582

Prolonged exposure

definition, 378

posttraumatic stress disorder treatment, 302, 308, 309, 311

provider fatigue and, 378, 379

Prolonged grief disorder, description and symptoms, 348

Propofol, pain management and, 348

Propranolol, posttraumatic stress disorder treatment and, 304

“Protecting the Force,” 749

Provider fatigue

behavior changes after exposure to trauma, 381–382

behavioral markers for, 381

cognitive markers for, 381

combatting, 385–387

compassion stress and, 378, 379

“cost of caring” and, 376

description, 376–377

detachment and, 378, 379

EAT model and, 385

elements of, 377–378

emotional markers for, 381

emotional renewal and, 386

empathic ability and, 378, 379

empathic concern and, 379

empathic response and, 378, 379

empathy and, 378

exposure to the client and, 379

factors contributing to, 378–380

Figley’s model, 377–378, 385, 387–388

focus on the provider is essential to combating (figure), 385

holistic approach to renewal, 386–387

identification of, 381–384

leadership and, 387

life disruption and, 378, 380

markers for, 381

mental renewal and, 386

military-specific operational stress elements, 380

personal history of trauma and, 378

physical renewal and, 386

posttraumatic stress disorder and, 377

Professional Quality of Life Scale and, 376, 382–384

prolonged exposure and, 378, 379

Provider Resiliency Training and, 376

secondary trauma concept and, 376

sense of achievement and, 378, 379

social markers for, 381

social renewal and, 387

somatic markers for, 381

spiritual markers for, 381

spiritual renewal and, 386–387

synergistic effects of, 380

synergistic effects of primary, secondary, and operational 

stress, combined with burnout symptoms, on providers 

(figure), 380

terms and definitions, 376–377

traumatic recollections and, 378, 379–380

Provider Resiliency Training

focus of, 376

maintenance phase, 376

phases of, 376

Professional Quality of Life Scale and, 376, 382–384

self-care plans and, 376

Proximity, immediacy, expectancy, and simplicity

description, 5, 6, 108

unit watch and, 424

PRT. See Provider Resiliency Training

Psychiatric consultation to command

assignments and, 184

case studies, 177, 178

command-directed evaluations, 182

confidentiality issues, 183

consultant to The Surgeon General, U.S. Army, 184–185

consultative team formation, 176–177

cross-service consultations, 178

deployed versus garrison environment, 174

deployment clearance, 181

development of relationships with commanders, 183

discretionary command-directed referrals, 182

disqualifying conditions, 180

division mental health versus combat stress detachment 

resources, 175–176

division psychiatrist/brigade behavioral health officer role 

and responsibilities, 185

double agency and, 182–183

establishing rapport with the unit, 177

ethical issues, 182–184

explaining the purpose of the consultation, 177–178

factors associated with, 174–176

fitness for duty, 180–182

formulating the consultation question, 177

getting soldiers to “buy in” to the process, 179

impact of HIPAA, 183–184

investigation versus consultation, 183

level of professional degree and, 182

local versus remote behavioral health resource, 176

medical profiling, 180–181

Mental Health Advisory Team membership, 185

mental health records review, 185

nondiscretionary command-directed referrals, 182

objectivity and, 183

origin and history of, 172–173

performing the consultation, 176–180

positions and descriptions of responsibilities, 184–185

preventive consultation level, 174

preventive psychiatry, 173

primary prevention, 174

realistic interventions and, 179

recruiting and retaining medical personnel and, 185

risks to the consultant, 182–184

screening for vulnerability and determining fitness for duty, 

172–173

secondary prevention, 174–175

separation from the military, 181–182

short versus long consultations, 183

tasking for deployment, 184–185

terminating the consultation, 179

terminology and language and, 178

tertiary prevention, 175

uniforms and, 178

unit structures and functions and, 178
Index

lix

written report of the consultation, 179–180

Psychiatry Consultation Liaison Service

description, 244

goal of, 244

goals of PCLS for disaster injured (exhibit), 584

name change to Preventive Medical Psychiatry, 246

PCLS lessons learned in the response to the September 11, 

2001, attacks (exhibit), 585

Preventive Medical Psychiatry service, 509–510

role following the September 11, 2001, attacks on the Pentagon, 244

September 11, 2001, terrorist attacks and, 583, 584

Psychiatry in a Troubled World (Menninger), 33–34

Psychodynamic therapy

psychiatry residency programs and competency in, 677

traumatic injury patients and, 252

Psychoeducation, traumatic injury patients and, 252

Psychological autopsies

cases requiring, 698–699

privacy issues, 698

suicide and, 404, 698–699

Psychological simple triage and rapid treatment program, description, 636

Psychologists. See Division psychiatrists and brigade behavioral 

health officers

The Psychology of Religion and Coping (Pargament), 168

Psychotic disorders. See also specific disorders

cultural factors in the presentation of, 647

early intervention and, 443

fitness for duty and, 180

in-theater treatment, 159

postpartum psychosis, 709

presentation of in the military setting compared with the civilian setting, 443

suicide and, 426

Psychotropic medications. See also specific medications

anxiety disorder in-theater treatment, 159

case studies, 156–157

clearance for deployment and, 156–157

data challenges during Operation Iraqi Freedom 05-07, 

139–140

dispensing in theater, 157–158

doctrine and policy for the use of, 154–156

DoD’s Policy Guidance for Deployment-Limiting Psychiatric Conditions and Medications and, 156

ethical issues, 160

example psychiatric formulary for deployment (table), 155

extrapyramidal side effects, 443

FDA guidance on safety of use during pregnancy, 708–709

history of use of, 152–154

hoarding of, 652

insomnia in-theater treatment, 159–160

key points in the November 2006 Policy Guidance for Deployment-Limiting Psychiatric Conditions and Medications (exhibit), 

156

management and distribution of to detained individuals, 652

mood disorder in-theater treatment, 158–159

oversight and monitoring of, 94, 96

pharmacologic treatment of mental health conditions during 

deployment, 158–160

posttraumatic stress disorder treatment, 303–304

predeployment actions, 156–157

prescribing guidelines, 145

psychopharmacologic planning for deployment, 157

psychotic disorder in-theater treatment, 159

schizophrenia treatment, 443

security issues, 157–158

storage issues, 157–158

trauma patients and, 249

waivers for, 157

“Zoloft with a Rifle” article and, 147

PsySTART program. See Psychological simple triage and rapid 

treatment program

PTG. See Posttraumatic growth

PTSD. See Posttraumatic stress disorder

Public Health Command (Provisional). See also U.S. Army Center 

for Health Promotion and Preventive Medicine

Behavioral and Social Health Outcomes Program, 409

88th Regional Readiness Command COSC program and, 365

EPICON responsibilities, 415

EPICON surveys and, 417

renaming of U.S. Army Center for Health Promotion and 

Preventive Medicine as, 406

Public health model for deployment mental health. See also U.S. 

Public Health Service

allies in, 331

chaplains and, 331

origin of, 330

President’s New Freedom Commission on Mental Health 

principles and, 330

problems in living for veterans and families, 330

“recovery” and, 330

“resilience” and, 330

stigma issues and, 331

traditional medical model and, 330–331

veterans’ families and, 331

Q

QPR Institute. See Question, Persuade, Refer Institute

Quantity Frequency Questionnaire, alcohol use and abuse and, 

475

Question, Persuade, Refer Institute, description, 406

Quetiapine, bipolar disorder treatment, 158

R

Racial/ethnic factors

pain management, 346

spouse maltreatment, 537

Radiological weapons. See Chemical, biological, radiological, 

nuclear and explosive weapons

Ragtail Remembers--A Story That Helps Children Understand Feelings 

of Guilt (Duckworth), 556–557

Raising an Emotionally Healthy Child When a Parent is Sick (Muriel 

and Rauch), 517, 560

Raising Our Children to Be Resilient (Goldman), 560

Ramstein Air Base, Germany, contingency aeromedical staging 

facility, 201

RAND Corporation, Center for Military Health Policy Research 

study of the prevalence of mental health problems among U.S. 

Navy servicemen, 122

Rando, Terese A., How to Go on Living When Someone You Love Dies,

561

Rapid-deployment operations, description and reentry/reintegration responsibilities, 277–278

Ratner, Maj. R., account of his Vietnam War experience, 28–29

Rauch, Paula K., Raising an Emotionally Healthy Child When a Parent Is Sick, 517, 560

RCS. See Vet Centers

Readjustment Counseling Service. See Vet Centers

Ready, D.J., posttraumatic stress disorder program evaluation, 310

Reagan, Pres. Ronald, Executive Order 12564 mandating federal 

drug testing, 477

Recovery, definition, 330

Recruitment and retention issues

criminal history of recruits, 728
lx

Combat and Operational Behavioral Health 

ethical issues, 728–729

graduate medical education faculty, 673–675, 688–689

lowering of ASVAB scores, 728

posttraumatic stress disorder and, 743

“probational” track for special populations, 728–729

racist or gang membership of recruits, 728

recruiting and retaining medical personnel, 185

Redeployment. See Resetting the force

Reentry. See Resetting the force

Regehr, C., provider fatigue and, 381–382

Relaxation techniques

premenstrual dysphoric disorder and, 708

sleep disturbances and, 250

traumatic injury patients and, 252–253

Religious and spiritual issues. See also Chaplains

combat stress, 66, 70

provider fatigue, 381, 386–387

Remeron

depressive disorder treatment, 158–159

insomnia treatment, 158–159

Renner, Lt. Cdr. J.A., Jr., rise of psychiatric disorders during the 

Vietnam War, 21

Reserve Affairs--Mobilization and Demobilization, Web site, 501

Reserve units. See U.S. Army Reserves

Resetting the force

background, 276–278

Battlemind program (exhibit), 283

case studies, 280, 283

the characteristics of major wars, limited wars, and rapid 

deployment operations overlap in Operation Iraqi Freedom 

and Operation Enduring Freedom (figure), 277

demobilization and, 277, 280

Deployment Cycle Support Program, 276

description, 276

families and, 276, 277, 280–281, 284

health assessments after redeployment and, 279

Health Risk Appraisal questionnaires, 281

health services for returning service members, 280

identification of at-risk soldiers, 279

key components in decompression and reintegration (figure), 

279

limited wars and, 277

major wars and, 277

National Guard and Army Reserve members and, 279–280

post-deployment health assessment form (exhibit), 288–290

pre-deployment health assessment form (exhibit), 286–287

rapid-deployment operations and, 277–278

redeployment programs, 281–284

reentry challenges by population, 278–281

regular Army soldiers and family members and, 278–279

Soldier Wellness Assessment Pilot Program, 281

Soldier Wellness Assessment Pilot Program (exhibit), 282–283

stigma of behavioral health problems and, 276

stressors in, 276

Resilience. See also Provider Resiliency Training

Battlemind deployment support program and, 52

brain regions involved in, 47

collective efficacy characteristic, 46

coping self-efficacy characteristic, 45–46, 53

definitions, 45, 47–48, 219, 330, 377

dynamics of faith in soldier resilience and recovery, 167–168

evaluating resilience as an outcome, 48

factors in, 45–47

family support and, 52

future research ideas, 52–53

hardiness characteristic, 45

interventions for building resilience and preparedness, 49–52, 

53

Landstuhl Regional Medical Center’s Combat and Operational 

Stress/Staff Resiliency program, 219–222

measurement of resilience factors in the military, 48–49

mechanisms of, 49

neurobiological factors, 46–47

postwar factors, 49

prewar factors, 48–49

provider fatigue and, 385–386

reinforcing skills through military training, 51–52

“resilient trajectories,” 47–48

self-confronting and, 385, 386

self-help programs and, 50

self-soothing and, 385–386

social support and, 46, 53, 564

Survival, Evasion, Resistance, and Escape schools and, 51–52

survival skills strategies and, 50–51

toughening responses to stress, 50, 52–53

training programs for building strengths, 50

unit cohesiveness and, 51–52

war-zone factors, 49

Resources for Recovery--The Combat Injured Family: Guidelines for 

Care, 517

Response to Stressful Experiences Scale, description, 49

Return to duty

combat and operational stress continuum model and, 117

combat and operational stress control and, 60, 66, 67, 69

mild traumatic brain injury and, 235

Operation Iraqi Freedom/Operation Enduring Freedom total 

evacuations compared to return to duty by year until February 2007 (figure), 214

Rich Clarkson and Associates, For Children of Valor: Arlington 

National Cemetery gift book, 554

Risperidone, bipolar disorder treatment, 158

Ritalin. See Methylphenidate

Ritchie, Col. Elspeth C.

disaster psychiatry research, 581

guidelines for becoming a division psychiatrist, 92

humanitarian assistance missions, 610, 611, 612, 613

Joint Conference on Postdeployment Mental Health and, 330

use of psychotropic medications during Operation Restore 

Hope in Somalia, 153

Rivers, William H., military psychologist role, 658

Robins, L.N., Vietnam veterans’ drug use, 27

Rock, Col. Nicholas L.

suicide research, 404

War Psychiatry, 92

Roffman, R.A., survey of illegal drug use in the Vietnam War, 11, 

17, 20, 24

Roque, H., gender-based violence, 626

Rosen, L.N.

children’s responses to deployment, 494

impact of deployment on service members and family wellbeing, 493

Rosenheck, R., workplace and work performance issues for patients with PTSD, 308

Rothberg, Dr. Joseph, suicide research, 404

Rudd, M.D., suicide research, 395

Rundell, J.R., aeromedical evacuation of psychiatric patients, 203

Rwanda, complex humanitarian emergency example, 625, 626

S

Saddam Hussein

invasion of Kuwait, 659

surrender of, 138

SAFAC. See Soldier and Family Assistance Center
Index

lxi

Saint, Gen. Crosby, Battlemind program and, 72

Salmon, Dr. Thomas, forward treatment of combat stress during 

World War I and, 5, 90, 658

Salvation Army, September 11, 2001, terrorist attack response, 583

SAMHSA. See Substance Abuse and Mental Health Services 

Administration

Sanity boards

criminal responsibility issue, 695

on detainees, 695–696

membership of, 695

privacy issues, 695

Sapol, E., survey of illegal drug use in the Vietnam War, 11, 17, 20, 

24

Sareen, J., posttraumatic stress disorder link with suicide, 305

Sarin attack on the Tokyo subway system. See Aum Shinrikyo 

cult’s sarin attack on the Tokyo subway system

SARS. See Severe acute respiratory syndrome

Savage, P.L., incidence of soldiers attacking their superiors (“fragging”), 25

Savoca, E., workplace and work performance issues for patients 

with PTSD, 308

Savola, O., relationship of alcohol use to trauma, 233

SAVs. See Staff assistance visits

Schaefer, Dan, How Do We Tell Children: Helping Children Understand and Cope When Someone Dies, 561

Schizophrenia

age of onset, 442, 707

disabling nature of, 443

fitness for duty and, 180

pharmacologic treatment, 443, 707

women and, 707

Schizophreniform disorder

description and symptoms, 442–443

progression to schizophrenia, 443

Schlechte, J., eating disorder research, 454

Schneider, B.J., rationale for using a formulary for military operations, 153–154

Schneidman, Edwin S., key concepts in suicide, 404, 405

Schnurr, P.P., posttraumatic stress disorder treatment, 309

Schobitz, Capt. Richard, Soldier and Family Assistance Center 

and, 568

Schofield Barracks, HI. See also Integrated behavioral health services at Schofield Barracks, HI

Health Clinic, 565, 566

high cost of living and, 565

number of active duty soldiers, civilian employees, and contract employees, 565

School-age children

books recommended for dealing with trauma and grief, 

556–559

effects of deployment on, 494

grief responses, 547

response to a combat-injured parent, 514–515

Schoomaker, Lt. Gen. Eric, ProQOL Scale and, 383

Schreiber, S., uncontrolled pain as a stressor, 246, 249

Scott, Col. Brian, Battlemind program and, 73

Seasonal affective disorder, gender factors, 707

SEATO. See Southeast Asia Treaty Organization, U.S. involvement 

and

Seki, K., overview of problems in civil-military cooperation, 623

Selective serotonin reuptake inhibitors. See also specific drugs

anorexia nervosa treatment, 460

anxiety treatment, 253

bulimia nervosa treatment, 462

depressive disorder treatment, 158–159

full therapeutic response time, 303

generalized anxiety disorder treatment, 303

indications for use of, 153

introduction of, 152

panic disorder treatment, 253, 303

posttraumatic stress disorder treatment, 253, 303, 304

premenstrual dysphoric disorder treatment, 708

safety of use during pregnancy, 709

side effects, 303

social phobia treatment, 253

trauma patients and, 249, 253

Self-hypnosis

anxiety and, 253

trauma treatment, 246, 249

Seligman, Martin E.P.

Authentic Happiness: Using the New Positive Psychology to Realize 

Your Potential for Lasting Fulfillment, 560

training to build strengths, 50

Sense of achievement

definition, 378

provider fatigue and, 378, 379

September 11, 2001, terrorist attacks

Americans’ spiritual response to, 167–168

effects on civilians following, 580–581

family assistance center establishment, 583

lack of military administrative support and, 584–585

mental health impact of, 77

need for a joint doctrine of disaster response and, 584

Operation Solace and, 77, 679–680

principles of forward treatment of casualties and, 6

Project Liberty and, 582

Psychiatry Consultation Liaison Service role following, 244

psychiatry residents and, 584

rescue and recovery response, 583–585

“therapeutic debriefing” and, 583, 584

weaknesses in the response to, 584–585

Seroquel, insomnia treatment, 250

Serotonin, eating disorders and, 452

Serotonin-norepinephrine reuptake inhibitors, trauma patients 

and, 249

Sertraline

bulimia nervosa treatment, 462

posttraumatic stress disorder treatment, 303

SeRV-MH. See Services for Returning Veterans-Mental Health

Service-dog training, description, 361

Services for Returning Veterans-Mental Health

goals, 332

role of, 332–333

teams for, 333

training and, 333

Sesame Workshop Talk, Listen, Connect: Deployments, Homecomings, Changes, 517

706 boards. See Sanity boards

Severe acute respiratory syndrome

description, 594

psychosocial effects, 598

survey findings, 596

Severe psychiatric illness in the military. See also specific disorders

air evacuation and, 445–446

descriptions and symptoms, 442–445

remote site treatment considerations, 445

Sexual assault and abuse

DoD policy, 141

eating disorders and, 453–454

posttraumatic stress disorder and, 298

traumatic brain injury and, 711

Sexual Assault Prevention and Response Program, description, 

141

SGT Mom’s, interactive Web site for military spouses, 501
lxii

Combat and Operational Behavioral Health 

Shay, Jonathan, Achilles in Vietnam, 130

Sherman, DeAnne, Finding My Way: A Teen’s Guide to Living With a 

Parent Who Has Experienced Trauma, 560

Sherman, Michelle D., Finding My Way: A Teen’s Guide to Living 

With a Parent Who Has Experienced Trauma, 560

Sibutramine, obesity treatment, 462

SIT. See Stress inoculation training

Sleep disorders

alcohol use and abuse and, 475

anxiety and, 252

image reversal therapy and, 252

treatment, 250, 309

Smith, Doris Buchanan, A Taste of Blackberries, 558

Smith, Harold, What Does That Mean? A Dictionary of Death, Dying 

and Grief Terms for Grieving Children and Those Who Love Them,

558

Smokeless tobacco. See Tobacco use

Smoking. See Tobacco use

Snyder, W.M., “communities of practice” concept, 565

Social anxiety disorder, posttraumatic stress disorder and, 305, 

307

Social factors, eating disorders, 453

Social phobia

treatment, 253

women and, 709

Social support

mental well-being and, 564

resilience and, 46, 53

Social workers. See Division psychiatrists and brigade behavioral 

health officers

Society of Medical Consultants to the Armed Forces, military 

graduate education, 681

Soldier and Family Assistance Center

Adult Family Member Assistance Center and, 567, 568, 569

advertising campaign for, 568

algorithms for calculating provider numbers (exhibit), 567

Child and Adolescent Assistant Center and, 567, 568, 569

concept development, 566

current activities, 569

estimating the number of providers needed in each specialty, 

566

five areas of care (exhibit), 567

funding for, 567

Marriage and Family Assistance Center and, 567, 569

monthly patient or client visits in the three Soldier and Family 

Assistance Center clinics, January 2005 to November 2006 

(figure), 569

outcomes, 569

outreach activities, 569

principles for development, 566

projected demand for providers based on population (table), 

568

purpose of, 566

recruitment of staff for, 568

Soldier Assistance Center and, 567, 568, 569

Soldier Readiness Program and, 568

staffing level issues, 575

Triage Assistance Center and, 567, 568

Soldier Wellness Assessment Pilot Program

description, 281

exhibit detailing, 282–283

Soldiers Rehabilitation Act, 369

Solomon Wellness Educational Program

ages and gender of children evaluated at Solomon Elementary 

School in the Solomon Wellness Educational Program, from 

August 2001 to February 2007 (figure), 571

Child and Adolescent Psychiatry Service and, 569

early history, 570

future directions for, 571

goals of, 570

Primary School Adjustment Program, 571

program evaluation, 570–571

school enrollment, 569

special education students and, 569–570

Strengths and Difficulties Questionnaire and, 571

student demographics, 569, 570–571

tenets of, 570

vision for, 570

Somalia, Operation Restore Hope and, 76, 153

Southeast Asia Treaty Organization, U.S. involvement and, 12

Soviet Union, biological warfare program, 594

Special Psychiatric Rapid Intervention Teams

combat and operational stress first aid and, 125

composition and mission, 124–125

critical incident stress management and, 125

history of, 124

intervention strategies, 125

training for, 125

unit leader responsibilities, 124–125

Specimen Custody Document: Drug Testing (DD Form 2624), 

479–480

Spector, Ronald

casualty rates of the Vietnam War compared with World War 

II, 13

demoralization of troops fighting in Vietnam, 20

illegal drug use by troops fighting in Vietnam, 28

Spiegel, H.X., unit cohesiveness and resilience, 51–52

Spiritual issues. See Religious and spiritual issues

Spouse maltreatment. See Family maltreatment

Spouses. See Deployment impact on military families and children; Families

SPRINTs. See Special Psychiatric Rapid Intervention Teams

Sri Lanka. See Indian Ocean tsunami

SRMSO. See Suicide Risk Management and Surveillance Office

SSRIs. See Selective serotonin reuptake inhibitors

Staff assistance visits, Operation Iraqi Freedom 05-07 and, 145–146

Staff issues

contingency aeromedical staging facilities and, 200

Landstuhl Regional Medical Center and, 210, 212–214, 218–219

Operation Iraqi Freedom 05-07 and, 145–146

Operational Stress Control and Readiness program, 127

supportive counseling for medical staff who care for medically 

injured trauma victims, 255–256

Stamm, B.H., provider fatigue and, 384

Standard Form 513, Medical Record Consultation Sheet, 478

Standardized Assessment of Concussion, description, 233

Stanton, M.D., illegal drug use by troops during the Vietnam War, 

20–21, 24, 27, 28

State and community partnerships. See also specific states

Area Health Education Centers, 335

chaplains and religious leaders and, 336

DoD and VA partnerings, 334–336

joint training efforts, 335

key elements, 335–336

National Association of State Directors of Veterans Affairs, 334

outreach efforts, 335

summit meetings and, 334–335

States. See also specific states

psychiatrist liability for violent actions of their patients and, 

437

suicide prevention program managers, 408

Staudenmeier, J.J., use of psychotropic medications during the 

Persian Gulf War, 153

Steen, Joanne M., Military Widow: A Survival Guide, 551, 560

Sterba, J.P., attitudes of soldiers fighting in Vietnam, 20

Sternberg, Robert, “wisdom, intelligence, and creativity, synthe-
Index

lxiii

sized” model and, 636

Stetz, M.C., aeromedical evacuation of psychiatric patients, 203

Stimulants. See also Amphetamines; specific drugs

pain management and, 246

potential for abuse of, 158

Stress. See also Combat and operational stress continuum model; 

Combat and operational stress control; Oral health effects of 

combat stress

adaptive stress reactions, 63

brain regions involved in, 47

deployment-related stressor link to subsequent health problems, 60

drinking alcohol as a coping mechanism, 260

eating as a coping mechanism, 260

factors in, 44

family maltreatment and, 536–540

“leaky bucket” metaphor for stress (figure), 114

malingering and, 697

mental stressors, 61

mitigating stressors, 113–114

model of stress and its potential soldier and family outcomes 

(figure), 63

neurobiological factors, 46–47

operations involving death and the dead and, 719–722

physical and behavioral effects of, 61–62

physical stressors, 61

psychosocial stressors for women in military service, 704–707

Response to Stressful Experiences Scale, 49

smoking cigarettes as a coping mechanism, 260

sources of, 61, 123

theoretical models, 44, 66

toughening responses to, 50, 52–53

Stress inoculation training, posttraumatic stress disorder and, 302, 

308

Substance Abuse and Mental health Services Administration, 

Hurricane Katrina disaster response and, 587

Substance use and abuse. See also Alcohol use and abuse; Tobacco 

use; specific substances

alcohol and drug control officer role, 479

Army substance abuse program, 480–482

bulimia nervosa and, 453

combat and operational stress continuum model red zone and, 

112

DD Form 2624, Specimen Custody Document: Drug Testing 

(figure), 479–480

Drug and Alcohol Management Information System and, 480

drugs of abuse, 476–477

installation biochemical testing coordinator role, 479

medical review officer role, 477–480

mild traumatic brain injury and, 233

pain management and, 347, 349

posttraumatic stress disorder and, 298, 305

Standard Form 513, Medical Record Consultation Sheet (figure), 478

substance-induced psychosis, 443

suicide and, 425, 426

withdrawal and, 443

Sudan, gender-based violence and, 626

Suicide

access to lethal methods and, 411

anorexia nervosa and, 455

Army Suicide Event Reports, 145, 397–400, 404

Army suicide surveillance, 394–400

during basic or preliminary combat training, 729–730

behavioral changes and, 410

career loss as a cause of, 410, 411

causal factors (figure), 414

chaplains and, 169

Deployment Cycle Support program and, 169

depression and, 410

ethical issues, 729–730

grieving process for families members, 551

incidence of, 4

increase in rate of, 404

managing suicide and homicide risk during deployment 

(table), 435

managing suicide and homicide risk in garrison (table), 427

media reports on and increase in rates of, 147, 777

“military-specific suicidal ideation” and, 425

Operation Iraqi Freedom 05-07 and, 145, 147, 777

posttraumatic stress disorder and, 305

prison environments and, 436

protective factors, 412

relationship loss as a cause of, 410, 411, 426

risk factors, 411, 426

spectrum of suicide behaviors, 404

stigma associated with seeking behavioral healthcare (exhibit), 

411

suicidal or homicidal thoughts association with diagnosable 

mental illness, 424

suicide factors to consider (figure), 414

U.S. Army Center for Health Promotion and Preventive Medicine suicide awareness program, 169

WRAIR epidemiological consultations of suicide clusters, 77

Suicide prediction

case-controlled studies, 397

cohort studies, 397

definition of, 394

epidemiological surveillance studies, 396–397

importance of, 395–396

randomized controlled trials, 397

“reasonably foreseeable” definition, 394

research challenges, 394–395

risk factors and, 394–395

Suicide Risk Management and Surveillance Office, 397–400

Suicide prevention

active duty suicides in the U.S. Army January 1, 2001, through 

June 15, 2009 (figure), 405

history of efforts, 404–405

Los Angeles Suicide Prevention Center, 404

Operation Iraqi Freedom and suicide prevention (exhibit), 410

primary prevention description, 405

“psychological autopsies” and, 404, 698–699

secondary prevention description, 405

tertiary prevention description, 405

unit watch concept, 424–438

Suicide Prevention: A Resource Manual for the United States Army,

405

Suicide Prevention and Psychological Autopsy (PAM 600-24), 405, 406

Suicide Prevention Conference, description, 404

Suicide Risk Management and Surveillance Office

Army Suicide Event Reports and, 397–400

future directions, 399–400

history of, 397

improving accessibility of ASER data, 399

reports of findings, 399

“Summary of Theater Suicides” and, 410–412

user-friendly data reporting options, 399–400

Sullivan, Harry Stack, development of screening interviews, 172

Supportive therapy, psychiatry residency programs and competency in, 677

Survey of Health-Related Behaviors, obesity in the military population, 452

Survival, Evasion, Resistance, and Escape schools, description, 

51–52

Survival skills, resilience and, 50–51
lxiv

Combat and Operational Behavioral Health 

SWAPP. See Soldier Wellness Assessment Pilot Program

SWEP. See Solomon Wellness Educational Program

T

TAI. See Traumatic axonal injury

Takatch, Robert, Annie Loses Her Leg But Finds Her Way, 558

TAMC. See Tripler Army Medical Center

TAPS. See Tragedy Assistance Program for Survivors

Task Force Medical 115, behavioral healthcare for detainees and, 

646–656

Task Force Medical 344, behavioral healthcare for detainees and, 

646–656

Task Force on Mental Health

barriers blocking access of bereaved military family members 

to care, 551

recommendations, 126, 127

Task Force 30th Medical Brigade

funding for humanitarian needs, 610

mandate for, 610

Medical Civil-Military Operations, 610–617

Operation Iraqi Freedom 05-07 and, 610–617

A Taste of Blackberries (Smith), 558

Taylor, S.E., support for medical staff, 255

TBI. See Traumatic brain injury

TCAs. See Tricyclic antidepressants

Teenagers. See Adolescents

TEM. See Traumatic event management

Temporomandibular dysfunction

causes, 268

gender and age factors, 268

oral contraceptives and, 268–269

prevention, 269

stress and, 268

treatment, 269

Terrorism. See Chemical, biological, radiological, nuclear and 

explosive weapons; specific attacks and locations

Tet offensives of the Vietnam War, 18, 20, 34

TF30. See Task Force 30th Medical Brigade

Thailand. See Indian Ocean tsunami

That’s My Hope: Featuring a Gallery of Multigenerational Artwork

(Ingram), 517

Therapeutic debriefing

September 11, 2001, terrorist attacks and, 583, 584

treatment goals of (exhibit), 584

Therapeutic Intervention for the Prevention of Psychiatric Stress 

model

components, 248

countertransferance and, 248, 376

description, 247

empathic supportive exposure therapy and, 249, 252

group therapy and, 249

hypnotherapy and, 249

individual therapeutic components, 249–250

insomnia and, 250

pharmacological interventions and, 249

support for medical staff, 255–256

therapeutic alliance and, 248

transference and, 248

trauma patient’s family and, 254–255

treatment issues, 250–255

Therapeutic riding programs, description, 361

35 Ways to Help a Grieving Child, 561

30th Medical Brigade, Operation Iraqi Freedom 05-07 and, 

139–148

Thomas, Pat, I Miss You--A First Look at Death, 557–558

Thompson, Tommy G., importance of healthcare in medical civilmilitary operations, 611

Thorazine, use of during the Vietnam War, 152

Thought disorders. See specific disorders

Three Mile Island, PA, nuclear accident, 599, 601

Tiagabine, posttraumatic stress disorder treatment and, 304

TIPPS. See Therapeutic Intervention for the Prevention of Psychiatric Stress model

TMD. See Temporomandibular dysfunction

TMI. See Three Mile Island, PA

Tobacco use

bupropion for smoking cessation, 303

coping with stress and, 260

posttraumatic stress disorder and, 305, 476

smoking cessation programs, 281

Toddlers

effects of deployment on, 493

grief responses, 547

response to a combat-injured parent, 513–514

Topical lidocaine, pain management and, 344

Topiramate

bulimia nervosa treatment, 462

posttraumatic stress disorder treatment and, 304

TRAC2ES. See U.S. Transportation Command Regulating and 

Command and Control Evacuation System

Tragedy Assistance Program for Survivors

description of services, 501, 550, 555

Web site, 555

Traisman, Enid Samuel, Fire in My Heart, Ice in My Veins--A Journal 

for Teenagers Experiencing Loss, 559

Tramadol, pain management and, 344

Trammel v. U.S., Supreme Court case on confidentiality, 166

Transition from buildup to drawdown of the Vietnam War, 1968-

1969

atrocities and, 20

demoralization of troops and, 20, 34

illegal drug use and, 20

psychiatric overview, 20–21

psychiatrist reports, 21

racial incidents and, 20

Tet offensives and, 18, 20

Translators

behavioral health terminology and, 650

detained individuals and, 649–650

rotating among sites, 649

use of detainees as, 650

Trauma

behavior changes after exposure to, 381–382

intergenerational transmission of the effects of war and combat trauma, 495–497

Trauma Risk Management program, description, 662–663

Traumatic axonal injury

description, 229–230

neuroimaging findings, 230

Traumatic brain injury. See also Mild traumatic brain injury

alteration of consciousness and, 227, 233

burden on family members, 711

causes of, 694, 710

CDC estimates of prevalence and mortality, 226

cognitive sequelae, 231–235, 253

combat-related, 230–231

contusions occur when the brain moves within the skull 

enough to impact bone, causing bruising (figure), 229

cost of, 226

Defense and Veterans Brain Injury Center and, 226–227, 233, 

253

definition of, 226–227, 710

due to domestic violence, 711

effect on children and families of service members, 504–505

ethical issues, 743
Index

lxv

evolution of, 229–230

family and vocational issues for women, 711–712

forces that can cause the injury, 228

Glascow Coma Scale and, 227, 231

hormone treatment, 710

initial management of concussion in a deployed setting (figure), 234–235

loss of consciousness and, 227, 233

mortality rate, 710

neuroimaging findings, 230

outcome and, 710

penetrating or closed types, 226

the physical forces exerted on the brain during most of the 

events that can cause traumatic brain injury are reasonably 

well understood (figure), 228

polytrauma and, 253

posttraumatic amnesia and, 227, 230

posttraumatic stress disorder and, 711

Preventive Medical Psychiatry role, 253

psychological sequelae in women, 711

retrograde amnesia and, 227

return to active duty and, 712

risk of to military service members, 226

screening for, 694

sexual function and, 711–712

traumatic axonal injury and, 229–230

traumatic axonal injury (TAI) results when shearing, stretching, or angular forces pull on axons and small vessels 

(figure), 229

traumatic brain injury description (table), 227

traumatic subdural hemorrhage occurs when the brain moves 

within the skull enough to tear the vessels that bridge from 

the brain surface to the dural venous sinus (figure), 228

underreporting of, 226

vulnerable areas, 228–229

women and, 710–712

Traumatic event management

debriefings, 175

description, 68, 175

effectiveness of, 175

goal of, 68

leadership requests for assessments, 68–69

potentially traumatic events examples, 68

responses included, 69

Traumatic grief

children and, 550

posttraumatic stress disorder and, 550

symptoms of, 550

traumatic death compared with anticipated death, 549

Traumatic injuries. See also Potentially traumatic events

adaptive functioning and, 247

body part affected and, 246

case studies, 247, 251, 253–254

cognitive symptoms and, 245–246

conversion disorder and, 253–254

early psychiatric intervention importance, 246, 252, 256

effect of, 245

emotional trauma and, 245

families and, 247, 253–255

grieving over losses, 246, 250

hospitalization and the meaning of injury, 246–247

medical treatment and, 245

normalization of feelings and, 250

overwhelming emotion following, 244

pain issues, 245, 246

personality structures and, 247

phantom limb pain and, 246

posttraumatic stress disorder and, 44–45, 48

psychiatric illness development risk and, 246

psychological history of the patient and, 245

psychological responses, 245–246

regressive behavior and, 247

role of psychiatry following, 247

self-hypnosis treatment, 246, 249, 253

stress of injuries following, 244–247

survivor guilt and, 251

theoretical models of trauma, 44–45, 53

Traumatic recollections

definition, 378

provider fatigue and, 378, 379–380

Trazodone

insomnia treatment, 159

posttraumatic stress disorder treatment, 303

Treating Trauma and Traumatic Grief in Children and Adolescents

(Cohen), 562

TRICARE

description and services, 335, 336, 554

mental health treatment, 551

Web site, 554

Tricyclic antidepressants. See also Antidepressants; specific drugs

anorexia nervosa treatment, 460

bulimia nervosa treatment, 461–462

in-theater treatment and, 159

pain management and, 344

posttraumatic stress disorder treatment, 303

safety of use during pregnancy, 709

use of by Israeli forces, 153

Vietnam War use, 11–12

TRiM. See Trauma Risk Management program

Tripler Army Medical Center

behavioral health liaison project, 571–575

child and adolescent psychiatry fellowship programs, 680

Child and Adolescent Psychiatry Service, 565, 569, 570

clinical clerkship rotations for psychiatric residents, 677

location of, 565

Turner, M.A., aeromedical evacuation of psychiatric patients, 203

TWA Flight 800 disaster, Special Psychiatric Rapid Intervention 

Teams role, 125

24-hour watch

in deployed settings, 434

in garrison, 431–433

25 Things to Do: Activities to Help Children Suffering Loss or Change

(Kanyer), 561

25th ID. See 25th Infantry Division Light

25th Infantry Division Light

behavioral health liaison project and, 572, 574

deployment to Afghanistan, 565

funding for the Soldier and Family Assistance Center, 567

integrated behavioral health services at Schofield Barracks, HI 

and, 565–566, 572

Soldier and Family Assistance Center and, 566, 567–568

Tropic Lighting University reunion program and, 574

U

UCMJ. See Uniform Code of Military Justice

UH-60 Black Hawk helicopters, aeromedical evacuations and, 194

UNHCR. See United Nations High Commissioner for Refugees

Uniform Code of Military Justice

description, 694

expert witnesses and consultants and, 696

levels of courts-martial, 694–695

sanity boards and, 695

Uniformed Services University of the Health Sciences

Center for the Study of Traumatic Stress, 513, 521–532, 555

clinical clerkship rotations for psychiatric residents, 677
lxvi

Combat and Operational Behavioral Health 

concepts of team learning, practice, and interpersonal communication and, 677

Disaster Psychiatry Fellowship, 680

“Principles of Caring for Combat-Injured Families and Their 

Children,” 517, 533–534

survey instrument assessing the mental health effects of employees after the September 11, 2001, terrorist attacks, 77

Workgroup on Intervention With Combat-Injured Families, 

517

Unit Behavioral Health Needs Assessment, description, 175

Unit cohesion

combat and operational stress reaction and, 65

“80% solution” concept, 65

resilience and, 51–52

Unit watch

access to lethal means and, 424, 425, 435, 437

alcohol and substance use and, 425

basic precaution elements, 434

basic precautions (exhibit), 434

buddy watch and, 428–431, 432

buddy watch memorandum (exhibit), 428

case studies, 434–435

caveats concerning, 426

command team and, 425

deployed settings and, 425–426, 434–436

documentation requirements, 426–427, 436

in garrison, 425–426, 427–433

incorporation into behavioral health training programs, 

437–438

inexperience of the soldier performing the watch and, 436

information paper for commanders (exhibit), 430–431

interventions involved, 424

lack of research on, 426

lack of suicide risk factors and, 426–427

legal issues, 436–437

management of suicidal or homicidal patients in the military 

compared with civilian settings, 424

managing suicide and homicide risk during deployment 

(table), 435

managing suicide and homicide risk in garrison (table), 427

medical issues, 436–437

memorandum format and, 427–428

military duty avoidance and, 425

“military-specific homicidal ideation” and, 425

“military-specific suicidal ideation” and, 425

misperceptions about the soldier’s condition and, 424

as part of a multifaceted treatment plan, 426

“patient holds” and, 434

PIES principles and, 424

psychiatric hospitalization and, 424

rationale for, 424–426

recommendations for procedures, 427–436

standard operating procedures for buddy watch and 24-hour 

watch (exhibit), 432

stigma and, 425

suicidal or homicidal thoughts association with diagnosable 

mental illness, 424

suicide risk assessment and, 426–427

24-hour watch, 431–433, 434

24-hour watch memorandum (exhibit), 429

unit watch discontinuation memorandum (exhibit), 433

United Kingdom armed forces behavioral health

Academic Centre for Defence Mental Health, 664

chain of command and, 660

contemporary services, 660–663

current research and future directions, 663–664

defense mental health services and, 658, 660

Department of Community Mental Health and, 658, 660

during deployment, 661

field mental health teams, 658, 660, 661

historical background, 658–660

impact of military service on family life, 663

King’s Centre for Military Health Research, 663

“lack of moral fiber” diagnosis and, 658–659

levels of mental healthcare provision, 660

Operation Banner and, 658

Operation Granby, 659

Operation Telic, 660

operational mental health referral flowchart (figure), 662

operational organization, 660–661

postdeployment, 661

posttraumatic stress disorder legal case, 661–662

predeployment, 661

Trauma Risk Management program, 662–663

United Kingdom Department for International Development, 

complex humanitarian emergencies and, 621

United Nations

Guidelines on the Use of Military and Civil Defence Assets in 

Disaster Relief, 622

Office for Coordination of Humanitarian Affairs, 625

program for the reintegration of former child combatants, 626

United Nations Children’s Fund

complex humanitarian emergencies and, 621

Indian Ocean tsunami relief efforts and, 637–638

United Nations Development Program, complex humanitarian 

emergencies and, 621

United Nations High Commissioner for Refugees, complex humanitarian emergencies and, 621

United Nations Inter-Agency Standing Committee

Civil-Military Relationship in Complex Emergencies, 620

psychic environment of complex humanitarian emergencies, 

624–625

United States v. Toledo, expert witnesses and, 696

University of Minnesota, combat driving behavior modification 

brochures, 372

Ursano, R.J., disaster psychiatry research, 581

U.S. Agency for International Development, complex humanitarian emergencies and, 621

U.S. Air Force

aeromedical evacuations and, 195

eating, drinking alcohol, and smoking as a means of coping 

with stress and, 260

eating disorders and, 456, 458

Operation Iraqi Freedom 05-07 and, 140, 142, 143

September 11, 2001, terrorist attack response, 583

U.S. Army

Army Forensic Drug Testing Program, 141–142

Army Physical Disability Evaluation System, 328

Casualty and Mortuary Affairs operation center, 545

Comprehensive Behavioral Health System of Care, 749–750

Comprehensive Soldier Fitness Office, 74

current number of behavioral health providers, 750

Deployment Cycle Support Program and, 278–279

eating, drinking alcohol, and smoking as a means of coping 

with stress and, 260

eating disorders and, 456

Families First Casualty Call Center, 545

Family Advocacy Program, 536–537, 538, 539, 540

A Guide for the Survivors of Deceased Army Members, 544

Guide to the Prevention of Suicide and Self-Destructive Behavior,

405

Just the Facts...Dealing With the Stress of Recovering Human Dead 

Bodies, 52

Manpower and Reserve Affairs, 328

Medical Specialist Corps, 359

military care team for children and families of fallen service 
Index

lxvii

members, 545–546

Office of Strategic Services, 172

Proponency Office for Rehabilitation and Reintegration, 369

“Protecting the Force,” 749

provider hiring difficulties, 750

response to family stress and deployment, 539–540

September 11, 2001, terrorist attack response, 583

substance abuse program, 480–482

Suicide Prevention and Psychological Autopsy (PAM 600-24), 405

suicide prevention programs, 404–419, 424–438

Suicide Prevention Task Force, 749

suicide rate increase, 404

Suicide Risk Management and Surveillance Office, 397–400

Survival, Evasion, Resistance, and Escape schools, 51–52

Women’s Medical Specialist Corps, 359

Wounded Warrior program and, 328

U.S. Army Center for Health Promotion and Preventive Medicine. 

See also Public Health Command (Provisional) 

ACE acronym development, 407, 408

“ACE” card developed by CHPPM (figure), 407

Army Knowledge Online Web site, 407

Behavioral and Social Health Outcomes Program, 749

EPICON mission and, 413

Health Information Operations Web site, 407

new parent educational materials, 539

posters for suicide awareness, 407

renaming of as Public Health Command (Provisional), 406

suicide awareness program, 169

suicide awareness training kits for chaplains, 406–407

survey assessing the mental health effects of employees after 

the September 11, 2001, terrorist attacks, 77

training courses, 595

Web site, 595

U.S. Army Chaplain Corps. See also Chaplains

advanced civilian schooling program for midcareer chaplains, 

165

chaplains as partners in operational psychology, 168–169

chaplains as religious strength facilitators, 167

combat and operational stress control and, 66

combat stress control teams and, 168–169

confidentiality issues, 165–166

dynamics of faith in soldier resilience and recovery, 167–168

familiarity with home situations of soldiers and, 168

Family Life Centers and, 165

historical background, 164, 165

pastoral care and, 165

pastoral counselor role, 164–168

pastoral education programs, 165

primary role of, 168

resource for mental health providers, 169

training in care and counseling, 165

unit ministry team membership, 165

U.S. Army Family and Morale, Welfare, and Recreation Command, Family Advocacy Program, 536–537, 538, 539, 540

U.S. Army National Guard

benefits available to service members, 409

Deployment Cycle Support Program and, 279–280

divorce rate relationship to deployment, 538–539

Hurricane Katrina response and, 586

mobilization of the Hawaii National Guard for Operation 

Enduring Freedom, 565

“One Army” concept and, 279

Operations Desert Shield/Storm deployment, 488

partnerships with DoD and VA for care, 334

suicide awareness posters, 407

Suicide Prevention Program, 408–409

Vietnam War and, 12, 16

U.S. Army Reserves

Deployment Cycle Support Program and, 279–280

divorce rate relationship to deployment, 538–539

“One Army” concept and, 279

Operations Desert Shield/Storm deployment, 488

suicide awareness posters, 407

suicide prevention efforts, 409

Vietnam War and, 12, 16

U.S. Congress. See also specific legislation

Handoff or Fumble? Do DoD and VA Provide Seamless Health Care 

Coverage to Transitioning Veterans?, 326

U.S. Department of Defense

behavioral health issues for detained individuals and, 646, 647

civil-military operations centers description, 623–624

Clinical Practice Guidelines for Management of Post-Traumatic Stress, 116, 300–301, 310, 311, 326

combat and operational stress control implementation and, 

108–109

department-wide psychological screening, 79

Health Affairs policy letter, 698

illegal drug use during the Vietnam War, 27

Integrated Mental Health Strategy, 750

Joint Conference on Postdeployment Mental Health and, 330

Joint VA/DoD Federal Recovery Coordination Program, 328, 

332

military and family life consultants, 539

Military Assistance Program, 500

National Center on Shaken Baby Syndrome partnership, 539

policy changes for Operation Iraqi Freedom 05-07, 141–142

Policy Guidance for Deployment-Limiting Psychiatric Conditions 

and Medications, 156

Post-Deployment Health Assessment, 77, 174, 288–290, 327

Post-Deployment Health Reassessment, 79, 174, 327, 331–332, 

335–336

posttraumatic stress disorder treatment guidelines, 116

prevalence of mental health problems among soldiers returning from OEF, 333

Preventive Medicine (PAM 40-11), 415

“radiation response syndrome” and, 600

September 11, 2001, terrorist attack response, 583

Sexual Assault Prevention and Response Program, 141

Suicide Event Reports, 406, 407

Survey of Health-Related Behaviors, 452

Task Force on Mental Health, 126, 127, 551

Technology and Telehealth Initiative, 280

U.S. Department of Defense Base Realignment and Closure Act, 

provisions, 671

U.S. Department of Defense Directive 3000.05: Military Support for 

Stability, Security, Transition, and Reconstruction Operations, 586, 

613

U.S. Department of Defense Directive 6025.13, medical malpractice and, 436–437

U.S. Department of Defense Directive 6400.1, Family Advocacy 

Program and, 536

U.S. Department of Defense Directive 6490.1, division psychiatrists and brigade behavioral health officers and, 99–100, 102

U.S. Department of Defense Instructions 6490.4, command-directed mental health evaluations, 99–100

U.S. Department of Defense Patient Movement System

aeromedical evacuation patient classification codes (table), 198

Global Patient Movement Requirements Center and, 195

Joint Patient Movement Requirement Centers and, 195

mission of, 195

patient classification codes, 197–198

patient movement precedence, 195, 197

patient movement records and, 198, 200

patient movement requests and, 195

sample patient movement request (exhibit), 199

U.S. Transportation Command Regulating and Command and 
lxviii

Combat and Operational Behavioral Health 

Control Evacuation System and, 195

U.S. Department of Defense Survey of Health-Related Behaviors 

Among Active-Duty Military Personnel, oral health findings, 

260

U.S. Department of Defense Survey of Health-Related Behaviors 

in the Reserve Component, oral health findings, 260

U.S. Department of Education, “outcomes” movement, 676

U.S. Department of Health and Human Services, PsySTART 

program, 636, 640

U.S. Department of State, medical civil-military operations in Iraq 

and, 610, 613, 616

U.S. Department of the Army. See U.S. Army

U.S. Department of Veterans Affairs. See also Vet Centers; Veterans 

Health Administration

annual spending, 326

Care Management and Social Work Service, 328

chaplains, 336

Clinical Practice Guidelines for Management of Post-Traumatic Stress, 116, 300–301, 310, 311, 326

88th Regional Readiness Command COSC program and, 365

Environmental Epidemiology Service, 329

“Evolving Paradigms: Providing Health Care to Transitioning 

Combat Veterans” conference, 328

graduate medical education, 326

Integrated Mental Health Strategy, 750

Joint Conference on Postdeployment Mental Health and, 330

Joint VA/DoD Federal Recovery Coordination Program, 328, 

332

Mental Illness Research, Education, and Clinic Centers, 333

National Center for Posttraumatic Stress Disorder, 49, 116, 501, 

568, 628

overview, 326–328

partnership with the National Guard Bureau, 328

percentage of former soldiers who seek care through, 4

polytrauma call center, 328

posttraumatic stress disorder treatment guidelines, 116

program managers and, 328

Seamless Transition Office, 327–328

Services for Returning Veterans-Mental Health, 332–333

sites, 326

Suicide Prevention Conference participation, 404

transition of care for soldiers from active duty to the VA, 6

transition patient advocates, 328

Web site, 501

work internships and, 371

U.S. Food and Drug Administration, categories and labeling 

requirements for drug use during pregnancy (exhibit), 708

U.S. Marine Corps

combat and operational stress continuum model, 108–117

eating, drinking alcohol, and smoking as a means of coping 

with stress and, 260

eating disorders and, 456

family intervention program for service members, 52

Land Combat Study and, 78

Operation Iraqi Freedom 05-07 and, 141, 142, 143, 148

Operational Stress Control and Readiness program, 102, 116, 

126–128

September 11, 2001, terrorist attack response, 583

Vietnam War role, 13, 18, 21, 26

Warrior Transition Program, 332, 336

U.S. Navy

caregiver support, 131–133

carrier psychology program, 125–126, 133

casualty assistance call officers’ role in death notification, 544

combat and operational stress continuum model, 108–117, 

122–133

combat and operational stress control elements, 124–128

disaster drills, 52

diversity of operations, 122

eating, drinking alcohol, and smoking as a means of coping 

with stress and, 260

eating disorders and, 456, 458

emerging challenges for operational Navy Medicine, 128–133

expeditionary medical facilities, 124

expeditionary medical platforms, 123–124, 133

family intervention program for service members, 52

global war on terror and, 122

hospital ships, 123

individual augmentation issues, 128–131, 133

Land Combat Study and, 78

Operation Iraqi Freedom 05-07 and, 141, 142

Operational Stress Control and Readiness, 126–128, 133

operational stress control assessment and response communication (exhibit), 132

prevalence of mental health problems, 122

September 11, 2001, terrorist attack response, 583

Special Psychiatric Rapid Intervention Teams, 124–125, 133

Vietnam War role, 13

Warrior Transition Program, 129–130

U.S. Navy Medicine Support Command, combat and operational 

stress continuum model and, 122–133

U.S. Public Health Service

Commissioned Corps, 634

Disaster Response Teams, 636

Mercy model of population-based disaster relief and, 634–644

protective factors, 412

suicide risk factors, 411

U.S. Transportation Command Regulating and Command and 

Control Evacuation System

description and uses, 202

patient movement requests and, 195

US Army Vietnam Medical Journal, articles on psychiatric issues, 11

USAID. See U.S. Agency for International Development

USAR. See U.S. Army Reserves

USNS Comfort

description, 123

as first echelon of care in deployed locations, 195

Hurricane Katrina response and, 587

USNS Mercy

description, 123

as first echelon of care in deployed locations, 195

Mercy model of population-based disaster relief and, 634–644

Operation Unified Assistance and, 585–586

USS Belknap, collision with the USS John F. Kennedy, 124

USS Carl Vinson, number of medevacs for psychological problems, 

126

USS Cole

military burial for victims, 52

Special Psychiatric Rapid Intervention Teams role, 124–125

USS Enterprise, number of medevacs for psychological problems, 

126

USS John F. Kennedy

collision with the USS Belknap, 124

number of medevacs for psychological problems, 126

USUHS. See Uniformed Services University of the Health Sciences

V

VA. See U.S. Department of Veterans Affairs

Valium, use of during the Vietnam War, 152

Valproate

posttraumatic stress disorder treatment and, 304

safety of use during pregnancy, 709

Vanderwagen, Rear Admiral William C., support for Mercy model 

of population-based disaster relief, 636–637

VBA. See Veterans Benefits Administration
Index

lxix

Venlafaxine

anxiety disorder treatment, 159, 253

depressive disorder treatment, 158

pain management and, 344

posttraumatic stress disorder treatment, 303

Vet Centers

description, 33, 327, 331

early intervention efforts, 327

establishment of, 327

locations, 326

number of, 326

number of soldiers served by, 327

outreach workers for, 327

public health principles, 331

readjustment counseling role, 327

services included, 327

stigma issues and, 327

Veterans Administration, establishment of, 326

Veterans Benefits Administration

description of services, 326

phone number, 501

VA benefits counselors and, 327

Veterans Health Administration

description of services, 326

Directive 2002-049 on hospital care, medical services, and 

nursing home care, 328

number of people served by, 326

phone number, 501

VHA. See Veterans Health Administration

Vietnam Veterans Against the War, 24

Vietnam War

Agent Orange exposure and, 600

air war, 13

American troop strength, 12, 21–22

Americans killed in action, 12, 13, 14, 18

Americans wounded in action, 12, 13, 14, 20

antiwar protests, 10, 22–23, 33

Army psychiatric component, 33

black pride movement and, 23

buildup phase, 1965-1967, 13–18

civil rights movement and, 22, 23

combat psychiatry “doctrine” of brief, simple, mostly field 

treatments and, 11, 14–15, 17, 35

combat stress reactions and, 5, 16

communication issues, 536

cost of, 10

“counterculture” youth movement and, 10, 22–23, 34

counterinsurgency/guerrilla conflict, 10

cultural polarization of Americans and, 12, 22–24

demoralization of soldiers and, 10, 20, 25–26, 34

“domino theory” and, 12

draft issues, 12–13, 16–17, 22–23

drawdown phase, 21–29

effects on soldiers who served in Vietnam, 32–33

effects on the Army as a whole, 32

family notification of combat deaths, 544

“generation gap” and, 22, 23

ground war and, 10, 12

helicopters used for aeromedical evacuations, 193

high ratio of combat support and service support troops, 16

history of Army psychiatry in, 11–12

hostility toward returning soldiers, 277

illegal drug use and, 11, 17, 20–21, 24, 25, 27–28, 32, 34, 152

lack of psychiatric data, 11

lack of psychiatric documentation and, 10

lack of support for returning veterans, 496

language issues, 13

lingering questions and considerations, 32–34

as “low-intensity” combat, 13, 35

new pharmacologic agent use, 11–12, 34

number of psychiatrists serving during, 11

one-year duty tours and, 16–17, 25

posttraumatic stress disorder and, 29–30, 33, 298, 306, 309

postwar features, 29–32

psychiatric casualty rate, 11, 20, 277

psychosis rate, 27

racial tensions and, 20, 23

rationale and provocation of, 12

readjustment problems of troops after, 29–30, 33

relationship of U.S. troops to South Vietnamese citizens, 13–14

role of psychiatry in providing preventive care, 172

scope of American involvement, 12–13, 34

selected publications by buildup-phase Army psychiatrists 

(including research reports) (exhibit), 19

selected publications by drawdown-phase Army psychiatrists 

(including research reports) (exhibit), 29

selected publications by transition-phase Army psychiatrists 

(including research reports) (exhibit), 21

“short-timer’s syndrome” and, 18, 32

social and political upheaval in the United States and, 10, 34

social stress and “disease” model and, 33

soldier resistance and, 23–24

soldiers attacking their superiors (“fragging”), 25, 26, 34

survey of veteran Army psychiatrists who served in Vietnam, 

31–32

survival rates of those injured in, 226

terrain and weather issues, 13

Tet offensives, 18, 20, 34

transition from buildup to drawdown, 18–21

types of wounds sustained, 13

unit cohesiveness and, 51

U.S. Army Vietnam rates per 1,000 for battle deaths, psychiatric hospitalization, and psychosis (figure), 27

U.S. combat strategy, 14, 16

use of psychotropic medications, 152

Vistaril, use of during the Vietnam War, 152

Vitamin E, Alzheimer’s disease and, 396

Vomiting, oral health effects, 263, 264

W

Wain, H., “therapeutic debriefing” concept, 584

The Wall (Bunting), 557

Walter Reed Army Institute of Research

Army Medical Department general officers behavioral health 

summit, 81

Battlemind program and, 72–74, 80–81

deployment mental health screening research, 79

EPICON mission and, 413

EPICON surveys and, 417

epidemiological consultations of suicide and homicide clusters, 77

funding for posttraumatic stress disorder research, 81

future directions for research, 82

Health Risk Appraisal questionnaires, 281

impact of September 11, 2001, terrorist attacks, 77

Land Combat Study, 73, 77–78

Land Combat Study and, 81

leadership and unit factor research, 79–80

lme4 software, 81

ltm software, 81

mental health advisory teams, 73, 78–79

Military Life: The Psychology of Serving in Peace and Combat, 81

Operation Enduring Freedom and, 76–82

Operation Iraqi Freedom and, 76–82

pre-September 11, 2001, research on the impact of mental 
lxx

Combat and Operational Behavioral Health 

disorders, 77

psychological autopsies and, 698

soldiers diagnosed with PTSD and, 329

statistical software development, 81

study of physiological, psychological, and social correlates of 

stress, 11

suicide prevention and, 404

survey of veteran Army psychiatrists who served in Vietnam, 

12, 31–32, 34

Walter Reed Army Medical Center

child and adolescent psychiatry fellowship programs, 680

Child and Adolescent Psychiatry Service, 511, 512–513

evacuation of patients to, 201, 244

family assistance center, 254

forensic psychiatry fellowship program, 680, 697

geriatric psychiatry fellowship program, 680

Girls Time Out program, 510

National Capital Area Consortium and, 672

Parent Guidance Assessment--Combat Injury instrument and, 

513, 521–532

Preventive Medical Psychiatry, 246–256, 509–510

proposed closure of, 672

Psychiatry Consultation Liaison Service, 244–246, 583, 584, 585

September 11, 2001, terrorist attack response, 583, 584

VA Seamless Transition Office and, 327

War Psychiatry (Jones), 6, 108

War Psychiatry (Kirkland), 276–277

War Psychiatry (Rock), 92

Warner, C.H.

abnormal eating in military populations, 458

articles on the roles and responsibilities of division mental 

health units, 92

review of psychiatric service use during Operation Iraqi Freedom in 2005, 153

Warrior Training and Rehabilitation Program, peak performance 

training and, 368, 369

Warrior Transition Program

description, 129–130

goal of, 130

length of, 130

Warrior transition units

active rehabilitation and, 370

comprehensive transition plans and, 370

goal of, 369

occupational therapy and, 361, 363, 369–372

Warrior Toolkits and, 370

work reintegration and, 369–370

Washington, Gen. George, U.S. Army Chaplain Corps establishment and, 165

Washington state, memorandum of agreement with federal agencies to shore up local reintegration and reentry of returning 

service members, 280

Watchlist Project, gender-based violence and, 626

Watson, P.J., disaster psychiatry research, 581

Watson, T., eating disorder research, 454

Webb, Maj. Gen. Joseph, Jr., Suicide Risk Management and Surveillance Office and, 397

Wegner, E., “communities of practice” concept, 565, 574–575

Weight control programs, physical fitness assessments and, 704

Westmoreland, Gen. William

characterization of troops fighting in Vietnam, 17

replacement of by Gen. Creighton Abrams, 18

What Does That Mean? A Dictionary of Death, Dying and Grief Terms 

for Grieving Children and Those Who Love Them (Johnson and 

Smith), 558

What We Do When Someone Dies (Arnold), 559

Whealin, Julia, PhD, instruction of primary care providers at 

Schofield Barracks and, 568

When a Friend Dies: A Book for Teens about Grieving and Healing

(Gootman), 559

When Dinosaurs Die: A Guide to Understanding Death (Brown and 

Krasney), 557

White, R., guidelines for becoming a division psychiatrist, 92

WHO. See World Health Organization

Wilford Hall Air Force Medical Center

clinical clerkship rotations for psychiatric residents, 677

merger with Brooke Army Medical Center, 672

Winkenwerder, Assistant Secretary of Defense for Health Affairs 

Dr. William Jr., goal of the U.S. Government in world health 

concerns, 613

Wise, Col. (Ret.) Michael G., graduate medical education and, 

670–671

Wolfelt, Alan, The Healing Your Grieving Heart Journal for Teens, 559

Wolfelt, Megan, The Healing Your Grieving Heart Journal for Teens,

559

Women. See also Gender factors; Men

age of onset for schizophrenia, 442, 707

assignment locations and, 705

binge drinking definition, 475

deployments and, 705–706

drinking alcohol as a way to cope with stress, 260

eating as a way to cope with stress, 260

eating disorders and, 450, 453–454, 455–456, 459, 462–463

field conditions and, 705–706

gender-based violence in complex humanitarian emergencies, 

626

heavy drinking amount for, 475

job assignments and, 705

light drinking amount for, 475

mental health disorders in, 707–710

moderate drinking amount for, 475

noncombat role, 704

number of psychiatric patients compared with men, 203

percentage of women in the military, 704

periodontal disease prevalence (figure), 266

periodontitis and, 267–268

physical fitness issues, 704–705

posttraumatic stress disorder and, 298, 309, 709

pregnancy issues, 706–707

provider fatigue and, 376

psychosocial stressors for, 704–707

smoking as a way to cope with stress, 260

social conflicts with unit mates and, 706

social support issues, 705

temporomandibular dysfunction and, 268–269

traumatic brain injury and, 226, 710–712

Women’s Medical Specialist Corps and, 359

Woodruff, L. and B., In an Instant: A Family’s Journey of Love and 

Healing, 517

Work reintegration programs

data collection and, 372

definition, 369

objectives of, 370–371

occupational therapy focus for, 371–372

work internships, 371

World Bank, nongovernmental organization definition, 622

World Food Program, complex humanitarian emergencies and, 

621

World Health Organization

complex humanitarian emergencies and, 621

Department of Mental Health and Substance Dependence, 627

traumatic brain injury outcome research, 231–232

World War I

Army Alpha and Beta testing, 172

gas attacks, 597, 600

motorized ambulances and, 192
Index

lxxi

noncombatant casualties, 625

number of psychiatrists in the Army, 671

occupational therapy and, 358, 373

psychological casualties, 5

United Kingdom armed forces behavioral health and, 658

use of psychotropic medications, 152

World War II

aeromedical evacuations and, 192

Americans’ response to the invasion of Normandy, 167

battle fatigue casualties, 594, 597

casualty rates of the Vietnam War compared with, 13, 14

communication issues, 536

community mental healthcare in the military and, 564

family notification of combat deaths, 544

humanitarian assistance missions, 611

“lack of moral fiber” diagnosis and, 658–659

noncombatant casualties, 625

occupational therapy and, 358–359

Office of Strategic Services and, 172

psychiatric casualties, 5, 11, 26

psychological screening and, 172

survival rates of those injured in, 226

unit cohesiveness and, 51

United Kingdom armed forces behavioral health and, 658–659

use of psychiatrists in a preventive fashion, 172

use of psychotropic medications, 152

Wounded Warrior Clothing Support Program, establishment of, 

361

Wounded Warrior program, description, 328

WRAIR. See Walter Reed Army Institute of Research

WRAMC. See Walter Reed Army Medical Center

WTP. See Warrior Transition Program

WTRP. See Warrior Training and Rehabilitation Program

WTUs. See Warrior transition units Y

Yeltsin, Pres. Boris (Russia), biological warfare program, 594

Yosick, Maj. Todd, Battlemind program and, 73

You Are Not Alone: Teens Talk About Life After the Loss of a Parent

(Hughes), 559–560

Yugoslavia, complex humanitarian emergency example, 625 Z

Zero to Three, Coming Together Around Military Families program, description and Web site, 550, 555

Zinberg, Norman, M.D., survey of illegal drug use in the Vietnam 

War, 11, 28

Zinc deficiency, anorexia nervosa and, 460

Ziprasidone, bipolar disorder treatment, 158

Zoloft, depressive disorder treatment, 158

“Zoloft with a Rifle” article, 147

Zolpidem, insomnia treatment, 159

Zonisamide, obesity treatment, 462

Zyprexa, psychotic disorder treatment, 159
lxxii

Combat and Operational Behavioral Health