FM 90-44/6-22.5 

NTTP 1-15M 

MCRP 6-11C 

Combat Stress

U.S. Marine Corps

PCN 144 000083 00
DEPARTMENT OF THE NAVY

Headquarters United States Marine Corps

Washington, D.C. 20380-1775

23 June 2000

FOREWORD

1. PURPOSE

Marine Corps Reference Publication (MCRP) 6-11C, Combat

Stress; Navy Tactics, Techniques, and Procedures (NTTP) 1-15M,

Commander’s Handbook on Combat Stress; and Army Field Manual

(FM) 90-44/6-22.5, Combat Stress, provide the tactics, techniques,

and procedures required for small-unit leaders to effectively prevent,

identify, and manage combat stress when it occurs in their units/

commands.

2. SCOPE

This publication contains essential information about combat and

combat-related stress. It describes, in layman’s terms, techniques to

prevent, identify, and treat harmful combat stress reactions at the

lowest level or until professional medical assistance is available. It

provides a basic understanding of the causes of stress and describes

the preventive actions that can be taken to avoid or reduce its harmful effects. It describes how to identify and manage combat stress

symptoms when they appear, and provides techniques to prepare

units to handle combat stress reactions when they occur. All smallunit leaders should read this publication. 

Unless otherwise stated, whenever the masculine gender is used,

both men and women are included.

3. SUPERSESSION

FMFM 4-55, Combat Stress, dated 13 April 1992.
4. CERTIFICATION

Reviewed and approved this date.

BY DIRECTION OF THE COMMANDANT OF THE MARINE CORPS

J. E. RHODES

Lieutenant General, U.S. Marine Corps

Commanding General

Marine Corps Combat Development Command

B. J. SMITH

Rear Admiral, U.S. Navy

Commander, Navy Warfare

Development Command

By Order of the Secretary of the Army:

Official:

JOEL B. HUDSON

Administrative Assistant to the

Secretary of the Army

05932

DISTRIBUTION: 144 000083 00
PREFACE

Combat Stress is the mental, emotional or physical tension, strain,

or distress resulting from exposure to combat and combat-related

conditions. Controlling combat stress is a command responsibility.

In terms of Service members lost from action and reduced performance, combat stress seriously affects mission accomplishment. It

is a leader's responsibility to take action to strengthen Service members’ tolerance to combat stress and manage it in his or her unit.

Combat stress reactions are the result of exposure to the same

conditions during military actions that cause physical injury and

disease in battle or its immediate aftermath, and many combat stress

reactions occur in persons who are also wounded or ill with disease.

Rates of combat stress casualties vary greatly, with higher ratios

during lengthy periods of intense combat. In Okinawa 1945, during

a peak month of battle, the combat stress casualties among Marine

Forces were reported as high as one for every two wounded in

action (WIA). Under less lengthy periods, as suggested by data

acquired from the Israeli Defense Forces fighting in Lebanon 1982,

the ratio of combat stress casualties to WIA in small units can be as

high as one to one. In the past, we have generally suffered as many

as one battle stress casualty for every three to five WIA in heavy

fighting. However, highly trained units with strong leadership and

high esprit de corps have fewer combat stress casualties.

While this manual focuses on combat-induced stress reactions, it is

important to emphasize that “combat stress” is not restricted only to

combat, but may also arise from combat-like conditions present

during military operations other than war. In an area of operations

characterized by continuous action and high danger, our forces may

experience high rates of stress casualties unless small-unit leaders

are trained and prepared to manage stress.
This publication is written to inform small-unit leaders of stress

characteristics and management techniques in order to prevent,

reduce, identify, and treat combat stress reactions in the Service

member’s own unit to the maximum extent possible. A significant part of training is learning to control and cope with stress.

Leaders must learn to cope with their own stress and then assist

junior personnel in managing their stress. The application of

combat stress management techniques helps conserve fighting

strength and provides one more step toward achieving success.
Table of Contents

Page

Chapter 1. Combat Stress Identification

1001 INTRODUCTION ...............................................................1

1002 HISTORY............................................................................1

1003 REACTIONS TO COMBAT STRESS ...............................2

1004 OBSERVING AND RECOGNIZING COMMON

REACTIONS TO COMBAT STRESS.............................3

Fatigue ............................................................................6

Muscular Tension ...........................................................6

Shaking and Tremors......................................................6

Perspiration.....................................................................7

Digestive and Urinary Systems ......................................7

Circulatory and Respiratory Systems.............................8

Sleep Disturbance ...........................................................8

Visual/Hearing Problems and Partial Paralysis............10

Bodily Arousal..............................................................11

Anxiety (Fear of Death, Pain, and Injury)....................12

Irritability......................................................................12

Depression ....................................................................13

Substance Abuse...........................................................14

Loss of Adaptability .....................................................14

Disruptive Reactions.....................................................14

Referral to the Chaplain, Medical Officer or 

 Combat Stress Control Team......................................15

1005 SUICIDE AWARENESS ..................................................16
Chapter 2. Combat Stress Prevention, 

Management, and Control 

2001 PREVENTING AND MANAGING

 COMBAT STRESS ......................................................17

2002 STRESS-REDUCTION TECHNIQUES

 FOR LEADERS...........................................................17

2003 PERFORMANCE DEGREDATION

 PREVENTIVE MEASURES.......................................20

Safety ........................................................................21

Food Intake ...............................................................21 

Combat Load.............................................................23

Physical Fitness.........................................................23

2004 EFFECTIVE LEADERSHIP .........................................24

2005 COMBAT STRESS MANAGEMENT

 BUILDING BLOCKS .................................................26

Confidence in Leaders ..............................................26

Confidence in Training .............................................27

Confidence in Unit....................................................27

Confidence in Equipment .........................................28

Cohesion and Morale ................................................28

Physical Conditioning...............................................28

Family Care...............................................................29

Coping with Individual Stress...................................30

2006 CRITICAL EVENT DEBRIEF AND UNIT

 LEADER’S AFTER ACTION REVIEW...................32

Critical Event Debrief...............................................32

After Action Review.................................................33

vi
2007 EFFECTIVE COMBAT STRESS

 CONTROL PROGRAM............................................. 34

Phase 1: Predeployment............................................ 34

Phase 2: Deployment and Combat............................ 41

Phase 3: Post-Combat............................................... 45

Chapter 3. Command Leadership Actions

3001 LEADERSHIP ACTIONS AND INTERVENTIONS

 FOR COMBAT STRESS ........................................... 47

3002 SAFETY CONSIDERATIONS .................................... 49

3003 COMBAT STRESS CASUALTY INTERVENTION

 MODELS ................................................................... 51

Chapter 4. Sleep Deprivation

4001 CHALLENGES OF SLEEP DEPRIVATION .............. 57

4002 EFFECTS OF SUSTAINED OPERATIONS

 ON PERFORMANCE................................................ 61

Adverse Conditions .................................................. 62

Sleep Loss Indicators................................................ 63

Loss of Concentration............................................... 65

4003 ACHIEVING SLEEP IN COMBAT............................. 66

Rhythmic Variations................................................. 66

Sleep Shifts............................................................... 68

Sleep/Rest Guidelines............................................... 68

Measuring Sleep Loss............................................... 70

Sleep Loss Alternative.............................................. 70

vii
4004 SLEEP/REST PLANNNING.........................................71

Pre-Deployment Stage ..............................................71

Deployment Stage.....................................................72

Pre-Combat Stage .....................................................72

Combat Stage ............................................................72

Post-Combat Stage....................................................73

Appendices

A Suicide Awareness Information...................................A-1

B Religious Ministry Team’s Role .................................B-1

C Glossary .......................................................................C-1

Section I. Acronyms ...............................................C-1

Section II. Definitions.............................................C-2

D References....................................................................D-1

viii
Chapter 1

Combat Stress Identification

1001. INTRODUCTION

The Marine Corps’ success as a fighting force is dependent on leadership that maintains a balanced focus between mission accomplishment and troop welfare. The small-unit leader is the key to

building and maintaining high unit morale and peak efficiency. He

achieves this in part by knowing his troops and understanding their

strengths and weaknesses. To maintain that same level of morale

and efficiency in combat, the small-unit leader must understand

how to recognize, prevent, and even personally contend with reactions to combat stress when it occurs in his unit. If a condition

accounted for as many casualties in combat and the condition was

at least partially preventable, the prudent combat leader would be

interested in knowing more about it. Combat stress reaction(s), also

called battle fatigue, is that condition. It has the potential to disable

the most courageous Service member and influence the success or

failure of a unit in accomplishing its mission.

1002. HISTORY

During the 1942-45 period in the European Theater, there was a

ratio of one combat stress casualty for every three WIA. In a month

of especially horrible, continuous fighting in Okinawa in 1945, the

6th Marine division had one stress casualty for every 1.8 WIA.

However, the airborne divisions in Europe never had more than one

for ten WIA, and usually less, even though they experienced very

high casualties in some battles. 
2 ________________________________________________ MCRP 6-11C

To accomplish a mission successfully, planners must use some

guidelines to estimate losses from combat stress. What are the

reasons for the tremendous range between high and low battle

stress casualty rates? While the answer to this question is complex,

it is clear that better-trained troops have fewer killed and wounded,

and proportionally fewer stress casualties. Service members—

especially leaders—can learn to recognize the symptoms and

prevent or reduce the disruptive effects of combat stress. 

1003. REACTIONS TO COMBAT STRESS

Service members exposed to danger experience physical and

emotional reactions that are not present under more tranquil

circumstances. Some reactions sharpen abilities to survive and

win; other reactions may produce disruptive behaviors and

threaten individual and unit safety. These adverse behaviors are

collectively called combat stress reaction. The operative word is

“behaviors.” People in combat experience a range of emotions, but

their behavior influences immediate safety 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 substances. These, in

combination with other influences—such as concerns about problems back home—affect the ability to cope with the perception of

danger, and diminish the skills needed to accomplish the mission.

Environmental stressors often play an important part in causing

the adverse or disruptive combat stress reaction behaviors. The

leader must work to keep each Service member's perception of

danger balanced by the sense that the unit has the means to prevail over it. The leader must keep himself and his unit working at
Combat Stress ______________________________________________ 3

the level of stress that sustains performance and confidence.

When troops begin to lose confidence in themselves and their

leader, adverse stress reactions are most likely to occur. 

It is important for the small-unit leader to recognize these adverse

behaviors at the onset in order to intervene promptly for the

safety and benefit of individual Service members and the unit.

These behaviors may take many forms and can range from subtle

to dramatic. Any Service member who shows persistent, progressive behavior that deviates from his baseline behavior may be

demonstrating the early warning signs and symptoms of a combat

stress reaction. Trying to memorize every possible sign and

symptom is less useful to prompt diagnosis than to keep one simple rule in mind: Know your troops, and be alert for any sudden,

persistent or progressive change in their behavior that threatens

the functioning and safety of your unit.

1004. OBSERVING AND RECOGNIZING COMMON 

REACTIONS TO COMBAT STRESS

Ranges of fatigue, fear, anxiety, and depression affect most Service members in combat and in some military operations other

than war. Mild stress reaction may be signaled by changes in

behavior and only be discernible by the person himself or by

close comrades. The unit leader and medical personnel depend on

information from the Service member or his comrades for early

recognition of combat stress reactions to provide prompt and

appropriate help. Table 1-1 lists some mild stress reactions.
4 ________________________________________________ MCRP 6-11C

Severe stress reactions may prevent the individual from performing his duties or create a concern for personal safety or the safety

of others. A variety of more serious reactions or warning signs

are listed in Table 1-2. These do not necessarily mean that the

person must be relieved from duty, but warrant immediate evaluation and help by the small-unit leader.

Table 1-1. Mild Stress Reactions.

PHYSICAL EMOTIONAL

Trembling Anxiety, indecisiveness 

Jumpiness Irritability, complaining

Cold sweats, dry mouth Forgetfulness, inability to concentrate

Insomnia Nightmares

Pounding heart Easily startled by noise, 

movement, and light

Dizziness Tears, crying

Nausea, vomiting or diarrhea Anger, loss of confidence in 

self and unit

Fatigue

“Thousand-yard” stare

Difficulty thinking, speaking, 

and communicating
Combat Stress ______________________________________________ 5

Table 1-2. Severe Stress Reactions.

PHYSICAL EMOTIONAL

Constantly moves around Talks rapidly and/or inappropriately

Flinches or ducks at sudden 

sound and movement

Argumentative; acts recklessly

Shakes, trembles Indifferent to danger

Cannot use part of body 

(hand, arm leg) for no apparent physical reason

Memory loss

Inability to see, hear or feel Stutters severely, mumbles or

cannot speak at all

Is physically exhausted; cries Insomnia; severe nightmares

Freezes under fire or it totally 

immobile

Sees or hears things that do 

not exist

States vacantly, staggers or 

sways when standing

Has rapid emotional shifts

Panics, runs under fire Socially withdrawn

Apathetic

Hysterical outbursts

Frantic or strange behavior
6 ________________________________________________ MCRP 6-11C

Fatigue

The most common stress reactions include:

l Slow reaction time.

l Difficulty sorting out priorities.

l Difficulty starting routine tasks. 

l Excessive concern with seemingly minor issues. 

l Indecision, difficulty-focusing attention.

l A tendency to do familiar tasks and preoccupation with familiar details. These reactions may reach a point where the person

becomes very passive, or wanders aimlessly.

l Loss of initiative with fatigue and exhaustion. 

Muscular Tension

Headaches, Backache 

Muscular tension increases strain on the scalp and spine and often

leads to headaches, pain, and cramps.

Inability to Relax

Prolonged muscular tension wastes energy and leads to fatigue

and exhaustion. Muscles must relax periodically to enable free

blood flow, waste product flushing, and nutrient replenishment.

Shaking and Tremors

Mild Shaking

During incoming rounds, the individual may experience mild

shaking. This symptom appears and disappears rapidly and is

considered a normal reaction to conditions of great danger.
Combat Stress ______________________________________________ 7

Marked or Violent Shaking 

A common post-battle reaction, marked or violent shaking can be

incapacitating if it occurs during the action. If shaking persists

long after the precipitating stimulus ceases, or if there was no

stimulus, the individual should be checked by medical personnel.

Perspiration 

It is normal to experience either mild or heavy sweating or sensations of chilliness under combat stress.

Digestive and Urinary Systems

Nausea and Vomiting

“Butterflies in the stomach” is a common stress feeling. Vomiting

may occur as a result of an extreme experience like that of a firefight, shelling, etc., or in anticipation of danger.

Loss of Appetite

Appetite loss may result as a reaction to stress. It becomes a significant problem if rapid weight loss occurs, or the person does

not eat a sufficiently balanced diet to keep his muscles and brain

supplied for sustained operations.

Abdominal Distress 

Acute abdominal pain (“knotted stomach,” “heartburn”) may

occur during combat. Persistent and severe abdominal pain is a

disruptive reaction, and may indicate a medical condition.

Frequent Urination

Frequent urination may occur, especially at night.
8 ________________________________________________ MCRP 6-11C

Incontinence

During extremely dangerous moments, inability to control bowel

and/or bladder functions may occur. Incontinence is embarrassing, but it is not abnormal under these circumstances.

Circulatory and Respiratory Systems

Heart Palpitations 

Rapid heartbeat, a sense of pressure in the chest, occasional

skipped beats, and sometimes chest pains are common with anxiety or fear. Very irregular heartbeats need to be checked by medical personnel.

Hyperventilation 

Hyperventilation is identified by rapid respiration, shortness of

breath, dizziness, and a sense of choking. It is often accompanied

with tingling and cramping of fingers and toes. Simple solutions are

increased exercise and breathing with a paper bag over the nose and

mouth; or breathing slowly using abdominal muscles (called

“abdominal breathing”). 

Faintness and Giddiness 

These reactions occur in tandem with generalized muscular

weakness, lack of energy, physical fatigue, and extreme stress.

Brief rest should be arranged, if possible. 

Sleep Disturbance 

Difficulty Falling Asleep 

Sometimes a Service member who has experienced intense battle

conditions often cannot fall asleep even when the situation permits, or, when he does fall asleep, he frequently wakes up and has

difficulty getting back to sleep. 
Combat Stress ______________________________________________ 9

Nightmares 

Terror dreams, battle dreams, and nightmares of other kinds

cause difficulty in staying asleep. Sleep disturbances in the form

of dreams are part of the coping process. This process of working

through combat experiences is a means of increasing the level of

tolerance of combat stress. The individual may have battle-related

nightmares or dreams that a close relative (spouse, parent) or

another person important in his life has been killed in the battle.

As time passes, the nightmares usually occur with less intensity

and less frequency. In some cases, a Service member, even when

awake, may re-experience the memory of the stressful experience

as if it were recurring (called a “flashback”). This is usually triggered by a smell, sound or sight, and is not harmful as long as the

Service member realizes it is only a memory and does not react

inappropriately or feel overwhelmed. However, if it happens frequently or is very distressing, help should be sought from the

chaplain or medical.

Restless Sleep

When a person is asleep, the sleep is not restful sleep if the person

is constantly being half-wakened by noise, movement, or other

stimuli. Heavy snoring often indicates poor quality sleep. The

individual wakes up as tired as when he went to sleep. Finding a

more comfortable position, away from distractions, can help. 

Excessive Sleep

Individuals exhibiting a need for excessive sleep may be exhibiting symptoms of combat stress; however, excessive sleep is also

a sign of substance abuse or depression (Persistent insomnia is a

more common indicator of possible depression.)
10 _______________________________________________ MCRP 6-11C

Visual/Hearing Problems and Partial Paralysis

Stress-related blindness, deafness, loss of other sensations, and

partial paralysis are not true physical injuries, but physical symptoms that unconsciously enable the individual to escape or avoid

a seemingly intolerably stressful situation. These symptoms can

quickly improve with reassurance and encouragement from comrades, unit medical personnel or battalion physician. If they persist, the physician must examine the individual to be sure there is

not a physical cause; for example, laser range finders can cause

temporary or partial blindness, and nearby explosions can cause

ear damage. Individuals with these physical conditions are

unaware of the causative relationship with their inability to cope

with stress. They are honestly concerned with their physical

symptoms and want to get better. They are willing to discuss

them, and do not mind being examined. This is contrary to

“malingerers” faking a physical illness, who are often reluctant to

talk, or over-dramatize their disability and refuse an examination.

Visual problems include blurred vision, double vision, difficulty

in focusing, or total blindness. Hearing problems include inability

to hear orders and/or nearby conversations or complete deafness

occurs. Paralysis or loss of sensation is usually confined to one

arm or leg. Prickling sensations or rigidity of the larger joints

occur. However, temporary complete immobility (with normal

breathing and reflexes) can occur. If these reactions do not

recover quickly with immediate reassurance, care must be taken

in moving the casualty to medical for an evaluation to avoid making a possible nerve or spinal cord injury worse.
Combat Stress _____________________________________________ 11

Bodily Arousal 

Not all emotional reactions to stress are necessarily negative. For

example, the body may become aroused to a higher degree of

awareness and sensitivity.

Threat

In response to threat, the brain sends out chemicals arousing the

various body systems. The body is ready to fight or take flight.

The alerting systems of the experienced combat veteran become

finely tuned, so that he may ignore loud stimuli that pose no danger (such as the firing of nearby friendly artillery). However, he

may awaken from sleep at the sound of an enemy mortar being

fired and take cover before the round hits. The senses of vision

and smell can also become very sensitive to warning stimuli. The

Service member may instantly focus and be ready to react.

Hyperalert 

Hyperalert refers to being distracted by any external stimuli that

might signal danger, and overreacting to things that are, in fact,

safe. The hyperalert Service member is not truly in tune with his

environment, but is “on a hair trigger.” He is likely to over-react,

misinterpret reassuring information as threats, and react without

adequate critical thinking. Consequences can range from firing at

an innocent noise to designating as hostile an innocent target. 

Startle Reactions

Startle reactions are part of an increased sensitivity to minor

external stimuli (on-guard reactions). Leaping, jumping, cringing,

jerking, or other forms of involuntary self-protective motor
12 _______________________________________________ MCRP 6-11C

responses to sudden noises are noted. The noises are not necessarily very loud. Sudden noise, movement, and light cause startle

reactions; for example, unexpected movement of an animal (or

person) precipitates weapon firing.

Anxiety (Fear of Death, Pain, and Injury)

Fear of death, pain, and injury causes anxiety reactions. After

witnessing the loss of a comrade in combat, a Service member

may lose self-confidence and feel overly vulnerable or incapable.

The death of a buddy leads to serious loss of emotional support.

Feelings of “survivor guilt” are common. The survivors each

brood silently, second-guessing what they think they might have

done differently to prevent the loss. While the Service member

feels glad he survived, he also feels guilty about having such feelings. Understanding support and open grieving shared within the

unit can help alleviate this.

Irritability

Reaction 

Mild irritable reactions range from angry looks to a few sharp

words, but can progress to more serious acts of violence. Mild

irritability is exhibited by sharp, verbal overreaction to normal,

everyday comments or incidents; flare-ups involving profanity;

and crying in response to relatively slight frustrations.

Explosion of Aggressive Behavior 

Sporadic and unpredictable explosions of aggressive behavior

(violence) can occur with little or no provocation. For example, a
Combat Stress _____________________________________________ 13

Service member tries to pick a fight with another Service member. The provocation may be a noise, such as the closing of a window, an accidental bumping or normal, verbal interaction.

Short Attention Span

Persons under stress have short attention spans. They find it difficult to concentrate. Short attention span causes a Service member

to have difficulty following orders. The Service member does not

easily understand what others are saying. The person has difficulty

following directions, aiding others or performing unfamiliar tasks.

Depression

People respond to stress with protective defensive reactions

against painful perceptions. Emotional dulling or numbing of

normal responsiveness is a result. The reactions are easily

observed changes from the individual’s usual self.

Low Energy Level

The observer notes decreased effectiveness on the job, decreased

ability to think clearly, excessive sleeping or difficulty falling

asleep, and chronic tiredness. Emotions such as pride, shame,

hope, grief, and gratitude no longer matter to the person.

Social Withdrawal

A Service member is less talkative than usual, shows limited

response to jokes or cries. He is unable to enjoy relaxation and

companionship, even when the tactical situation permits.
14 _______________________________________________ MCRP 6-11C

Change in Outward Appearance

If the Service member is in a depressed mood, he may be

observed to exhibit very little body movement and an almost

expressionless (mask-like) face. 

Substance Abuse

Some Service members may attempt to use substances such as

alcohol or other drugs as a means of escaping combat stress. The

use of substances in a combat area makes some Service members

less capable of functioning on the job. They are less able to adapt

to the tremendous demands placed on them in combat.

Loss of Adaptability

Less common reactions include uncontrolled emotional outbursts

such as crying, yelling, or laughing. Some Service members may

become withdrawn, silent, and try to isolate themselves. Uncontrolled reactions can appear singly or in combination with a number of other symptoms. In this state, the individual may become

restless, unable to keep still, and move aimlessly about. He may

feel rage or fear, which he demonstrates by aggressive acts, angry

outbursts or irritability.

Disruptive Reactions

Service members with disruptive, combat stress reactions—

l Cannot function on the job. In some cases, stress produces

symptoms often associated with head injuries. For example,

the person may appear dazed and may wander around aimlessly. He may appear confused and disoriented, and exhibit
Combat Stress _____________________________________________ 15

either a complete or partial memory loss. Service members

exhibiting this behavior should be removed from duties until

the cause for this behavior can be determined.

l Compromise their own safety. In a desperate attempt to

escape the danger that has overwhelmed him, an individual

may panic and become confused. The term panic run refers to

a person rushing about without self-control. In combat, such a

Service member easily compromises his safety and could possibly get killed. His mental ability becomes impaired to the

degree that he cannot think clearly or follow simple commands. He stands up in a firefight because his judgment is

clouded and he cannot understand the likely consequences of

his behavior. He loses his ability to move and seems paralyzed.

l Compromise the safety of others. If panic is not quelled

early, it can easily spread to others. A person in panic is virtually out of control and needs to be protected from himself.

More than one person may be needed to exert control over the

individual experiencing panic. However, it is also important to

avoid threatening actions, such as striking him. 

Referral to the Chaplain, Medical Officer or 

Combat Stress Control Team

Although the more serious or warning behaviors described in the

preceding paragraphs usually diminish with help from comrades

and small unit leaders, and time, some do not. An individual usually improves when able to get warm food, rest and an opportunity to share his feelings with comrades or small unit leader. If

the symptoms endanger the individual, others or the mission, or if

they do not improve within a day or two, or seem to worsen, get

the individual to talk with the unit chaplain or medical officer.

Access to mental health/combat stress control specialists may be
16 _______________________________________________ MCRP 6-11C

sought, if available. Do not wait too long to see if the experience

is better with time. Specialized training is not required to recognize severe stress reactions. The small-unit leader can usually

determine if the individual is not performing his duties normally,

not taking care of himself, behaving in an unusual fashion, or acting out of character.

1005. SUICIDE AWARENESS

Some behaviors and symptoms previously described are not only

signs of stress reaction, but can also signal potential suicide risks.

Service members must be ever vigilant for the signs and signals of

a potential threat of suicide given by their fellow Service members.

Appendix A provides useful tools for identifying these signals.
Chapter 2

Combat Stress Prevention,

 Management, and Control

2001. PREVENTING AND MANAGING

COMBAT STRESS

The same leadership skills that apply to troop welfare and

warfighting can effectively reduce or prevent combat stress

reactions. Leaders should take preventive actions and address stress

symptoms as they appear. Ignoring the early warning signs can

increase the severity of stress reactions. Positive action to reduce

combat stress also helps Service members cope with normal,

everyday situations and makes them less likely to experience

harmful combat stress reactions. Table 2-1 lists stress management

techniques.

2002. STRESS-REDUCTION TECHNIQUES

FOR LEADERS

To reduce stress, the leader should— 

l Lead by inspiration, not fear or intimidation. 

l Initiate and support stress management programs.

l Provide information to focus stress positively.

l Ensure each Service member has mastered at least two stress

coping (relaxation) techniques, a slow one for deep relaxation

and a quick one for on the job.
18 _______________________________________________ MCRP 6-11C

Table 2-1. Stress Management Techniques.

Assure every effort is made to provide for the troops’ welfare.

Instill confidence in each Service member and his equipment, 

unit, and leadership.

Be decisive and assertive; demonstrate competence and fair 

leadership.

Provide sleep and/or rest, especially during continuous operations, whenever possible.

Ensure sleep for decisionmaking personnel.

Set realistic goals for progressive development of the individual and team.

Systematically test the achievement of these goals.

Recognize that battle duration and intensity increase stress.

Be aware of environmental stressors such as light level, temperature, and precipitation.

Recognize that individuals and units react differently to the 

same stress.

Learn the signs of stress in yourself and others.

Recognize that fear is a normal part of combat stress.

Rest minor stress casualties briefly, keeping them with their 

unit.

Be aware of background stress sources prior to combat; e.g., 

family concerns and/or separation, economic problems.

Provide an upward, downward, and lateral information flow to 

minimize stress due to a lack of communication.
Combat Stress _____________________________________________ 19

Table 2-1. Stress Management Techniques (Continued).

l Look out for Service members’ welfare.

l Communicate with Service members personally to learn of

stressors and detect signs of stress.

l Understand that stress in response to threatening or uncertain

situations is normal. 

l Create a spirit to win under stress.

l Act as role model for self-control of stress reactions.

Realistic training is the primary stress-reduction technique. It

assures Service members' maximum confidence in their skills and

belief that their leaders are doing their best for them. Since the

basic necessities of life assume even greater importance on the

battlefield, leaders should:

l Ensure personnel are properly trained.

l Ensure training includes understanding of combat stress and

how to deal with it.

l Place welfare of subordinates before personal welfare, but

keep them capable.

l Ensure Service members get as much rest as possible. 

Practice stress control through cross-training, task allocation, 

tasks matching, and task sharing.

Look for stress signs and a decreased ability to tolerate stress.

Practice and master stress-coping techniques.

Face combat stress; it is unhealthy to deny the stresses of 

combat.
20 _______________________________________________ MCRP 6-11C

l Ensure the best possible shelters are available.

l Keep Service members well supplied with food, water, and

other essentials.

l Provide mail, news, and information avenues.

l Provide the best medical, logistical, and other support.

l Maintain high morale, unit identity, and esprit de corps.

l Keep the same unit members together. 

l Assure that experienced unit members take care of and teach

new members. 

The unit’s encouragement and support of Service members’ efforts

to cope with stress have a decisive effect. Unit actions can determine if Service members will endure combat exposure and accomplish their mission. Stress-coping indoctrination is part of every

unit's combat training and is followed by a program of action. Controlling stress requires practice. Programs are tailored to individual

units and improve with experience. Coping with stress is practiced

under conditions as similar to combat as possible. A unit’s ability

to cope with stress in combat depends primarily on how rigorously

and realistically training has been conducted.

2003. PERFORMANCE DEGRADATION 

PREVENTIVE MEASURES 

Every Service member, team, and unit must learn to effectively

sustain performance in continuous operations. This requirement

applies especially to leaders. While it is an important ingredient,

the determination to endure does not ensure effectiveness. Gaining

the required capability goes beyond a high level of proficiency in

combat skills and technical specialties. It means learning to identify

the adverse conditions of continuous operations, cope with them,
Combat Stress _____________________________________________ 21

and overcome their effects. It also means learning how to slow the

rate of performance degradation. Units, leaders, and personnel

must prepare and execute plans and train to sustain performance.

Adverse conditions progressively degrade Service member effectiveness. Fortunately, long-term remedies exist for slowing the rate

of performance decline. These remedies, which must be introduced

prior to combat, include safety, food intake, combat load, and physical fitness. 

Safety 

Safety, which encompasses such factors as using proper lifting

techniques and staying alert and careful, is influenced by fatigue.

Overtired Service members are more vulnerable to injury than

those who are rested. After 72 hours of continuous combat, the tendency to seek shortcuts is very strong, and accident rates increase

50 percent. Fatigue affects all military systems, but it is especially

hazardous when weapon systems are involved. Catastrophic accidents can occur when fatigued (and under-experienced) crews man

weapon systems. Ways to safeguard Service members include

developing and following safety standing operating procedures and

increasing supervision during extended operations.

Food Intake 

If Service members are too busy, stressed or tired to eat adequate

rations during continuous operations, their caloric intake will be

reduced. This may lead to both physical and mental fatigue and

degraded performance. For example, in accidents judged to

involve aviator fatigue, there is some indication that before the

accidents occurred, the pilots had irregular eating schedules or

missed one or more meals. In field tests done by the U.S. Army

Natick Research, Development, and Evaluation Center, Natick,
22 _______________________________________________ MCRP 6-11C

MA, some personnel subsisting solely on meals, ready to eat

(MREs) lost weight over just a few weeks. Leaders must encourage troops to eat all of the main items in their MREs, not just the

candy, to get balanced nutrition. In various other field tests conducted during continuous operations, it was discovered that meals

were frequently delivered late or missed altogether. Although the

relationship between performance and nutrition is not clear, eating regularly is important in continuous operations, as well as

providing hot meals at assigned times or when the workload has

been sustained boosts morale.

Good nutrition is important. An inadequate diet degrades

performance, reduces resistance to disease, and prolongs

recuperation from illness and injury. When food and water become

available in continuous operations, leaders must provide and

maintain a supply of food that has the nutritional value

commensurate with the physical activity and stress of battle. They

must remind and encourage Service members to eat and drink

properly. The excitement, stress, and rapid pace of events

associated with field preparations can cause Service members to

forget to drink liquids. Thus, they enter the early part of the field

scenario inadequately hydrated. Dehydration may result, especially

if the early scenario calls for assault of a position or rapid air/land

deployment. Contributing to developing dehydration is the relative

lack of moisture in MREs and other packets. In addition, Service

members experiencing dehydration lose their appetite and reduce

their food intake. This, in combination with dehydration, leads to

degraded performance. Leaders must reemphasize drinking

regimens to ensure that Service members are properly hydrated

going into battle. Leaders must remind Service members to drink

liquids in both hot and cold climates and must monitor fluid intake.

If personnel drink only when thirsty, they will become dehydrated.
Combat Stress _____________________________________________ 23

Combat Load

In combat, the load carried by a Service member significantly

exceeds optimum recommended weights. In the case of a light

infantry Service member, the combat load is as much as double the

recommended load. Physical conditioning cannot compensate for

this degree of excess. Service members tire faster and, in continuous combat, recovery from fatigue becomes more time-consuming.

When the Service member must carry excessive amounts of

equipment, the effects of stress and lack of rest are magnified.

Employing a load echelonment concept must be considered to

ease the strain on Service members. In this concept, the unit separates an individual’s equipment into two loads—fighting and

existence. As the unit closes the objective, the heavier existence

load is dropped and the Service member continues with the

lighter fighting load. 

Physical Fitness

Good physical conditioning delays fatigue, builds confidence, and

shortens recovery times from illness and injury. It also prepares

individuals to better cope with the physiological demands of

stress. Service members in top physical condition can better

control their internal physiological functions, which will improve

their overall performance. Physical fitness—including aerobic

fitness, muscular strength, and endurance—must be developed in

all Service members to strengthen their ability to rebound from

exhaustion. Aerobic fitness increases work capacity and the ability

to withstand stress. While feelings of depression and moodiness

accompany tiredness, aerobically fit Service members are affected

less than those unfit. The ability to quickly recover from

physically strenuous workloads is maintained by smart physical

training, performed consistently and routinely. However, there is
24 _______________________________________________ MCRP 6-11C

no evidence that good physical conditioning significantly reduces

normal sleep requirements nor compensates for the deleterious

impact of sleep deprivation on cognitive functioning. Sleep

deprivation is discussed in greater detail in chapter 4.

2004. EFFECTIVE LEADERSHIP

The effective leader in combat is competent and reliable. He

knows his job without question, and he can be counted on to do it

regardless of the situation or circumstances.

Effective small-unit leadership reduces the impact of stress in

several ways. Leaders understand the sources of combat stress

and reactions to them. In addition, leaders manage stress problems to keep them from spreading throughout the organization by

implementing the following actions:

l Continue mission performance; focus on immediate mission.

l Expect Service members to perform assigned duties.

l Remain calm, directive, and in control at all times.

l Let Service members know their reactions are normal and

there is nothing seriously wrong with them.

l Keep Service members productive (when not resting) through

recreational activities, equipment maintenance, and training to

preserve perishable skills.

l Ensure Service members maintain good personal hygiene.

l Ensure Service members eat, drink, and sleep as soon as possible.

l Let the Service members express their thoughts. Do not ignore

or make light of expressions of grief or worry. Give practical

advice and put emotions into perspective.
Combat Stress _____________________________________________ 25

A battalion commander in World War II made the following

address to his Marines just before a new offensive:

I know as well as you do that the going has been tough. Maybe I

sweat it more than you do because I have more to worry about. But

you've done a fine job, and I'm proud of every single man in my

outfit. I assure you that everything possible will be done to give you

the best available support, and I will not order you to attack unless

I'm confident that you have a real chance to succeed . . . . The harder

we fight now, the sooner we can finish this mess and get back to

living the way we want.

That speech demonstrated a common sense approach in dealing

with stress. Had this commander preached about the advantages

of democracy over fascism or the evils of Hitler, his words would

have fallen on deaf ears. Instead, he seized on the strong motivators of his troops: their respect for him as a leader, their desire to

continue to be worthy of his respect, and their desire to share in

the unit's accomplishments.

Generally, confidence is based on the technical and tactical competence exhibited by leaders and Service members. Since confidence is one of the strongest defenses against stress, its

development is a major goal for every military leader. To gain

confidence, Service members must believe in themselves, their

equipment, other unit members, and their training. Above all,

they must believe in their leaders' competence. Each of these

beliefs is instilled and reinforced at every opportunity.

The following comments were made by a Marine colonel reflecting on his experience as a company commander in Vietnam.

A feeling of helplessness will overtake men when they realize that

they have been put in an untenable position. When the situation is so

bad that the men cannot fight back, they are susceptible to fear. The
26 _______________________________________________ MCRP 6-11C

situation can be critical, but as long as the men can fight back, fear

normally will not overtake them. The solution to this problem is:

don’t put your men in untenable positions. Granted, in every battle

some men in a unit will find themselves in a situation where they

can’t fight back. This is inevitable especially in an attack. Proper use

of fire team, squad, platoon, and company formations, as well as

intelligent use of terrain, minimizes the danger of a large portion of

the unit being pinned down to the extent where the men cannot return

fire. If you are tactically and technically proficient, use common

sense, apply the principles of war, and employ the firepower available to your unit, untenable situations can be avoided. Simply stated,

know your job!

Those comments provide an insight and sensitivity to problems

related to combat stress through small-unit leadership. His

instincts told him how important it was to exhibit solid leadership

qualities in order to allow his troops to operate at maximum effiiency. A unit builds confidence, esprit, integrity and cohesion

when the leaders know their jobs. 

2005. COMBAT STRESS MANAGEMENT

BUILDING BLOCKS

Confidence in Leaders

Leaders must demonstrate effective leadership to earn their subordinates’ loyalty and trust. Leaders are responsible for—

l Committing the unit to missions commensurate with abilities.

l Planning operations carefully and thoroughly.

l Preparing the unit to accomplish the mission.

l Leading and guiding the unit to mission accomplishment.
Combat Stress _____________________________________________ 27

l Showing consistent good leadership that convinces subordinates their leaders know best what should be done, how it

should be done, who should do it, and how long the task

should take. Authority accompanies leadership beyond the

automatic authority given by military rank and position.

Authority and respect are earned based on confidence in a

leader's ability to guide the unit to success.

Confidence in Training

Training helps Service members develop the skills required to do

their jobs. Confidence is the result of knowing they have received

the best possible training for combat, and are fully prepared. This

confidence results from the following:

l Realistic training that ends with successful mastery. 

l Relevance of training to survival and success on the integrated

battlefield. 

l Refresher and cross training.

l Systematic individual and collective training.

Confidence in Unit

Each Service member in a unit needs to become confident of the

other unit members’ competence. Individuals must stay and train

together to gain that personal trust. Unless absolutely necessary,

teams should not be disbanded or scrambled. Subunits in the same

larger unit should have the same Standing Operating Procedures

and training standards, so members can fit in quickly if teams have

to be cross-leveled or reorganized after casualties occur. Confidence in the unit leads to feelings of security, which in turn allows

members to sleep and positively focus stress. In combat, the unit
28 _______________________________________________ MCRP 6-11C

must receive each member’s highest commitment to unit loyalty.

Mission accomplishment is the unit's highest priority.

Confidence in Equipment

Service members who learn to operate and maintain assigned

equipment develop confidence in their ability to employ it. This,

in combination with an individual’s belief in his personal capabilities, raises overall confidence in fighting ability. 

Cohesion and Morale

Good unit cohesion and morale offset the negative effects of

combat stress. The foundation for any stress reduction program

includes trust and confidence in the following:

l Fellow Service members.

l Competence and fairness of the unit leaders.

l Unit’s technical abilities and military power.

l Equipment.

l Personal combat ability.

l Sense of support from the civilian community.

l Personal spiritual well-being.

Physical Conditioning

A strong relationship exists between physical stamina and the

ability to resist combat stress. Good physical conditioning has
Combat Stress _____________________________________________ 29

physical and psychological benefits. Rigorous physical conditioning helps protect against the stress of continuous operations. A

regular program of physical fitness to increase aerobic endurance,

muscular strength, and flexibility is essential to combat readiness.

As physical conditioning improves, Service members feel better

about themselves, have greater confidence in each other, and their

stress is reduced.

Unit training includes regular physical conditioning. This

increases the members' tolerance to all types of stressors. The

program is geared to the unit's combat mission, and exercises are

tailored to the environment where the unit operates. The pace,

length, and types of runs, road marches, and other activities are

commensurate with the unit's need. Light infantry units need

more demanding, longer road marches than maintenance units.

Activities also include team athletics, which capitalize on cohesion-building aspects as well as physical benefits. The benefits of

such a program include developing endurance through aerobic

exercises, enhancing strength through weight training, and deprivation/physical stress training.

Family Care

Service members entering combat with financial worries or family problems risk breaking down under the additional stress of

combat. Even positive but unfinished changes on the home front,

such as a recent marriage or parenthood, can distract the Service

members' focus on combat missions with worries that they will

not live to fulfill their new responsibilities at home.

Leaders must be aware of this risk and assist members in handling personal matters before deployment. Pre-deployment and
30 _______________________________________________ MCRP 6-11C

post-deployment family briefings should be conducted, and programs established to assist families before, during, and after

deployment. When Service members know their families are

cared for, they are better able to focus on their combat duties.

Coping with Individual Stress

Stress pushes the body to its limits and causes tension; relaxation

reverses this process. Coping with personal stress is essential.

Stress-coping skills are incorporated into unit training early, and

command emphasis is placed on practicing them. Service members receive a block of instruction on stress-coping techniques,

then are given supervised time each duty day to practice them

quietly. After 3 or 4 weeks of practice, most Service members

relax easily and quickly, even under highly stressful conditions.

They will be able to naturally control stomach fluttering, heart

rate, blood pressure, and stress. 

The stress-coping exercises include deep breathing, muscle

relaxation, and cognitive exercises. Deep breathing is the simplest to learn and practice; the others require longer instruction

and more practice time. On request, the Combat Stress Control

(CSC) team will provide instructional materials and assistance.

Deep-Breathing Exercise

This consists of slow, deep inhaling, which expands the chest and

abdomen, holding it for 2 to 5 seconds, then exhaling slowly and

completely, which pushes out the used air. This can be done for

five breaths as a quick, mind-clearing exercise, or continuously to

promote sleep. Abdominal or diaphragmatic breathing (making

the stomach move the air, rather than the upper chest) is

especially effective for stress control and, with practice, can be

done simultaneously with task that require full attention. 
Combat Stress _____________________________________________ 31

Muscle Relaxation Exercises

These are more complex. They generally consist of concentrating

on various muscle groups and the tensing and relaxing of limbs to

relax the entire body. Quick versions for use in action consist of

tensing all muscles simultaneously, holding for 15 seconds or

more, then letting them relax and “shaking out the tension.” Deep

relaxation versions start in the feet and work up (or start in the

head and work down), body part by body part (muscle group by

muscle group), tensing and then relaxing each in turn, while

noticing how each part feels warm after it relaxes. 

Cognitive Exercises

These consist of self suggestion (positive self-talk); imagery

(imagine being fully immersed in a deeply relaxing setting);

rehearsal (imagine performing the stressful or critical task under

pressure and doing it perfectly); and meditation (clearing the

mind of all other thoughts by focusing on every breath and

silently repeating a single word or phrase). These techniques

involve creating positive mental images that reduce the effects of

stressful surroundings, redirecting mental focus and learning to

detach from stress. Service members are encouraged to practice

stress management techniques and discuss their use in combat. 

CAUTION

It is important not to use deep relaxation techniques at times

when you need to be alert to dangers in your surroundings.

Practice the quick relaxation techniques so you can use them

automatically without distraction from the mission.
32 _______________________________________________ MCRP 6-11C

2006. CRITICAL EVENT DEBRIEF AND UNIT 

LEADER’S AFTER ACTION REVIEW

NOTE: On the subjects of Critical Event Debrief/After-Action

Review, U.S. Army personnel will follow the guidance provided in

FM 22-51, Leaders’ Manual for Combat Stress Control, chapter 6. 

Critical Event Debrief

A Critical Event Debrief (CED) is a structured group process

designed to mitigate the impact of a critical event and to accelerate normal recovery of those personnel involved. The CED is

normally conducted by a team composed of trained members,

(medical officers, chaplains, mental health professionals, trained

unit members). A CED'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 critical event. Ideally, CEDs are

conducted 24 to 72 hours after the occurrence of the event, away

from the scene and separate from any operational debriefing. The

typical CED lasts from 2 to 3 hours. Situations that warrant a

CED include:

l Death of unit member

l Death or suffering of noncombatants (especially women and/

or children)

l Handling of the dead, management of carnage or the sight of

devastation during disaster work

l Serious friendly fire incident 
Combat Stress _____________________________________________ 33

l Situation involving a serious error, injustice or atrocity

l Terrorist attack.

After Action Review

Although a CED would be warranted following such traumatic

events as those listed, if access to CED trained professional team

is not available, small-unit leaders can modify their After Action

Review (AAR) to assist in identifying the level of stress reaction

of unit members. The AAR or “hotwash” is a routine practice

used by leaders to debrief post-mission operations. Accordingly,

it provides a familiar, non-threatening forum for leaders to identify the levels of stress reaction experienced by the unit members

using the information in paragraph 1004. The leader's AAR may

be sufficient to restore unit readiness for further action. It may

also identify personnel who need immediate or later referral for

chaplain or mental health/CSC help for combat stress-related

symptoms. In those instances when access to CED trained facilitators is not available, the unit leader should incorporate the following questions in the AAR: 

Fact Phase 

Ask unit members to describe the event from their individual perspectives. What was each member’s specific role in the event?

Thought Phase 

What were each member’s first thoughts at the scene (or when the

incident was first heard of)? 

Reaction Phase 

What was the worst thing about the event? What was thought

and/or felt?
34 _______________________________________________ MCRP 6-11C

Symptom Phase 

Describe probable thinking, physical, and emotional responses

both at the scene and a few days afterward.

Training Phase 

Relay information regarding stress reactions and what can be

done about them. If prepared handouts are available, distribute

them. Include points of contact within the unit.

Wrap-up Phrase 

Reaffirm positive things. Summarize. Be available and accessible. Debriefing team/unit leaders together decide which individuals need more help or referral.

2007. EFFECTIVE COMBAT STRESS

CONTROL PROGRAM

An effective stress management program starts with early planning, continues during employment, and extends beyond the

return home. The CSC program is comprised of three phases: predeployment, deployment and combat, and post combat.

Phase 1: Predeployment

During pre-deployment, some stressors facing Service members

include long working hours, preparation for training, fear of the

future, family worries, and anxiety about the unit's readiness.

Signs of poor coping include insomnia, increased use of alcohol,

marital problems, increased bickering in the unit, irritability, and

suicidal feelings. The most important preparatory steps to take in

the predeployment phase are to:

l Conduct unit training and mission rehearsals. 

l Prepare for changed sleep schedules and jetlag.
Combat Stress _____________________________________________ 35

l Attend to task assignments and allocations.

l Conduct equipment and supply maintenance checks.

l Attend to personal and family matters. (Call the Family Service Center.)

l Integrate new members into the unit positively and actively. 

l Welcome “significant others” (not just entitled beneficiaries)

in the Family Support network information tree. 

l Brief as much information about the operation as possible,

consistent with operations security measures.

l Actively familiarize the unit members with the stressors and

horrors they may encounter (for example, watch videotapes

from network television showing suffering civilians or atrocities), but always followed immediately with what the unit will

do in those situations.

l Arrange for pre-deployment training and education, especially

for refresher training of stress reduction techniques from local

mental health professionals, a Special Psychiatric Rapid Intervention Team (SPRINT) or CSC team, if available. 

Unit Training

Because unit leaders have combatted the stressors associated with

garrison living and peacetime training, they have learned to know

their Service members and what affects their performance. All

Service members should believe unit training has prepared them

thoroughly for combat. Stress is reduced if the training improves

belief in themselves, and the unit's ability to fight and win. They

are assured training is designed and developed to meet combat

requirements, provides the ability to fight successfully, and that

supporting units receive the same realistic training.
36 _______________________________________________ MCRP 6-11C

Realistic mission rehearsal helps desensitize Service members

against potential combat stressors. For example, wearing and

realistically training in protective gear is important. By doing so

in pre-deployment training, Service members become less distressed in combat. The unit should be exposed to extensive drills

wearing protective gear during live-fire exercises before employment. Such training has the two-fold, stress-reduction benefit of

building confidence and preparing Service members for combat.

Leaders who provide their Service members with advance knowledge about the enemy prepare them for the stress created during

deployment and initial enemy encounter. It is important during

such training to talk realistically about enemy strengths and

weaknesses as well as those of their own units. While inspirational pep talks are also important at this time, they should not

include biased, inaccurate information. Leaders earn trust and

respect if their troops perceive them as accurate, dependable

sources of information.

Physical Fitness Training

In the time-urgent work of preparing for deployment, leaders

assure that physical fitness is sustained, either by the work

involved or by selective unit physical training exercises. New

unit members who are insufficiently fit receive special training. 

Stress-Coping Skills Training

During preparation for deployment, the leaders direct the unit to

practice stress coping and relaxation techniques, and are positive

role models by demonstrating use of these techniques. If necessary, the chaplain and mental health professional personnel available to the units can provide additional training. 

Sleep Discipline

Before deployment, unit leaders must consider fatigue and sleep

loss occurring during combat. The enforcement of work and rest
Combat Stress _____________________________________________ 37

schedules begins early in pre-deployment training. During continuous operations, fatigue caused by lack of sleep is a major source

of stress. Breaks in combat are irregular, infrequent, and unscheduled. Extended sleep is unlikely. Sleep logistics is emphasized

such that sleep and rest are allocated or supplied like rations,

water, equipment, and ammunition. Sleep discipline training

addresses the following points:

l A unit-specific work-rest-sleep plan is developed and practiced.

l The unit leader or commander is included in the allocation of

sleep and rest time, as lack of sleep will impair his judgment and

decision-making skills as much as those of his subordinates.

l The plan allows Service members at least 5 hours of uninterrupted sleep, ideally between 2400 and 0600, every 24 hours.

Persons receiving only 5 hours per 24 hours over a period of

several days will accumulate a significant sleep debt.

l Sleep priority is assigned to those whose judgment and decision-making are critical to mission accomplishment. 

l If received frequently, 1 hour of sleep or even 15-minute naps

help, but “slow mental starting” upon wake up can result. 

l Relaxation exercises complement sleep schedules. These exercises are used as an alternative to regular sleep or as an aid to

help Service members rest under difficult circumstances.

If preparation is made for jetlag, its effects are minimal. The ideal

method is to seclude units up to several weeks before deployment, gradually changing work, eat, and rest cycles to coincide

with the destination’s schedule. Although rapid deployment does

not permit this method, there are ways to help make the transition
38 _______________________________________________ MCRP 6-11C

to a new environment, such as changing to new sleep cycles collectively versus individually; sleeping up to 12 hours before operation start; ensuring leaders receive rest; and adjusting diet to

meet energy needs. If the unit is divided into shifts, make sure

that shift assignments are maintained from day to day, i.e., if a

member is assigned to the 0600-1400 shift, keep him on that

same shift each day.

Task Allocation and Management

Overloading Service members with tasks or responsibilities is

another major source of stress. Allocating tasks fairly among

available Service members improves unit effectiveness as well as

decreases stress. Proper allocation of tasks include: 

Selecting the Right Person for the Job

The right person is fitted to the right task according to the task

requirement and the individual’s talents, abilities, and training.

Duplicating Critical Tasks

Two Service members are assigned to a critical task requiring

mental alertness and complete accuracy. They check each other’s

work by performing the same task independently.

Cross-Training

Each Service member is trained in a secondary duty position to

ensure competently stepping into the position of another.

Developing Performance Supports

Develop standing operating procedures, checklists or other mental aids to simplify critical tasks during periods of low alertness.
Combat Stress _____________________________________________ 39

Equipment Maintenance and Supply

During pre-deployment, the unit maintains its equipment and

manages needed supplies. Once deployed for combat, Service

members require confidence that supplies are ample and equipment is dependable. The following questions are important:

l Does the unit provide ample training in equipment maintenance and troubleshooting?

l Has the unit’s equipment been field-tested under realistic conditions? For example, have Service members fired and

cleaned their weapons while wearing full combat gear or protective clothing?

l Does the unit have sufficient ammunition, food, water, and

other essential supplies?

l Does the unit have contingency plans for procuring and managing critical supplies if normal channels are disrupted?

Personal and Family Matters

Family stress adds to combat-imposed stress and causes distraction, interference with performance of essential duties, and a negative impact on stress-coping ability. This will result in the unit’s

inability to perform at peak. The unit should help the Service

members resolve important family care matters before deployment and develop methods for helping families when Service

members are deployed. Service members are encouraged to:

l Generate or update their wills.

l Finalize power of attorney for spouses.

l Update life insurance policies, including Servicemen’s Group

Life Insurance (SGLI).

l Ensure family automobiles are in good repair.
40 _______________________________________________ MCRP 6-11C

l Develop lists of telephone numbers of reliable points of contact for specific problems (mechanics, emergency transportation, babysitters, sources of emergency money, health

care, etc.).

l Resolve major legal issues such as alimony payments, property

settlements following divorces, and child support payments.

Role of Leaders

Unit commanders should:

l Brief families as a group before deployment or as soon as possible after deployment. Within the bounds of security limits,

explain the mission's nature. Even if a mission is highly confidential, families benefit from such a meeting by being told of

the support available to them while separated. They begin to

solve problems and form support systems with other families.

This includes an opportunity to discuss family questions and

concerns. The Family Services Office, base mental health service or the chaplain's office assist in staging this briefing.

l Establish points of contact (e.g. Key Volunteer Network) to

assist with family problems. These volunteers possess good

working relations with the chaplain and mental health personnel to assist with the management of complex problems.

l Establish key volunteer communication and support networks.

Commanding officers' spouses, or spouses of sergeants major

are often good resources for developing and running such networks; however, the involvement of junior Service members'

spouses is also crucial. Some of the most enthusiastic participants are tasked to make outreach visits and encourage shy or

depressed spouses to participate.

l Have mental health professionals conduct meetings to discuss

post-deployment problems. For example, some children have
Combat Stress _____________________________________________ 41

difficulty adjusting to a parent's absence, and other family

members may experience similar difficulties. Mental health

professionals give families valuable information on these normal reactions and suggest ways to prepare for them.

Phase 2: Deployment and Combat

In addition to the normal stress associated with moving to a combat zone, Service members in this phase start worrying about

their survival and performance under fire. Their thoughts become

centered on fear of the unknown. Leaders should emphasize that

stress under these circumstances and conditions is expected and is

a natural reaction. This will help prevent “normal” stress reactions from escalating into extreme reactions.

Unit leaders should provide as much information as necessary to

their survival and mission success, reinforce the stress control

techniques learned during pre-deployment, and help their subordinates understand what happens to them when stressors occur.

Deployment Vehicle

The deployment vehicle—in most cases, an airplane—is a stressor by itself. If it is a commercial aircraft, in-flight problems are

usually minor. However, if the unit deploys on a military aircraft,

leaders should accomplish the following:

l Designate areas for light exercise and stretching to counter

seating discomfort caused by a buildup of leg fluids.

l Ensure Service members drink enough fluids to prevent dehydration and have access to head/latrine.

l Adopt the activity schedule of the new time zone. If the unit is

in the sleep cycle or is already in or about to enter the sleep
42 _______________________________________________ MCRP 6-11C

cycle, cover windows; reduce lighting; and issue earplugs,

blankets, and pillows.

l Allow uninterrupted sleep. If a stopover occurs during a sleep

cycle, do not waken Service members to eat or partake in

activities. If the stopover occurs during an activity period, take

full advantage of it by having Service members take washcloth baths, stretch, and perform head-and-shoulder rotations. 

l Upon arrival in the area of operations, follow the schedule of

the new time zone. Eat the next meal and go to bed on the new

schedule. Doing so helps the Service members' bodies adjust.

Information Flow

Since uncertainty about the future is a major source of stress,

timely and accurate information becomes vital. Lines of communications are clearly defined and kept open. Issuing warning,

operation, and fragmentary orders is critical to ensuring adequate

information flow. Informational meetings are conducted at regular intervals, even when there is no new information to disseminate. This reinforces the organizational structure and the

importance of unit meetings as the source of current, accurate

information. Reliable sources of information are especially important for countering rumors.

Service members also need information or performance feedback

after mission completion. Merely engaging in a firefight or completing a mission is insufficient. Service members must be told

how they performed as a group. The knowledge of mission

accomplishment and progress builds unit cohesion, develops a

winning attitude, and reduces the effects of stress.
Combat Stress _____________________________________________ 43

Family Support

Marine Corps Family Team Building programs and corresponding programs for other Services provide family support throughout deployments. The Navy-Marine Corps Relief Society, Army

Emergency Relief, American Red Cross, Family Service Centers,

and other community agencies also provide direct assistance to

family members. The Key Volunteer Network and the American

Red Cross continue to function as conduits for emergency information between Service members and their families. Leaders

need to educate Service members about these programs and agencies that are available to serve the needs of the community. Effective communication and caring support networks help to prevent

anxiety while Service members are deployed and/or in combat. 

Religious Ministry Support and Pastoral Care

The Religious Ministry Team is an integrated part of the battalion

or unit. In the Marine Corps, a Religious Ministry Team (RMT)

consists of a chaplain and Religious Program Specialist (RP) or

chaplain’s assistant. RMTs are organic to commands or are

assigned by higher headquarters to provide direct religious ministry support to a command. (NOTE: In the Army, the same teams

are called Unit Ministry Teams (UMT).) During operations, the

RMT often travels with the forward battalion aid station (BAS) in

order to minister to the wounded and to be with the Service members who are most likely to experience combat stress. Using their

professional training, skills, knowledge, and relationship with the

Service members, chaplains provide care focusing on prevention

of mild and moderate combat stress reactions. The RMT’s primary

mission is to provide ministry and pastoral care to the troops,

offering faith, assurance, and hope. Before, during, and after the

mission, the team provides field services, sacraments, and counsel,
44 _______________________________________________ MCRP 6-11C

which bring comfort, assurance, and encouragement to Service

members as they integrate their experiences into their lives.

In addition to being a spiritual/pastoral mentor for Service members, most chaplains are trained in some form of CED process.

Chaplains are effective CED team members as well as trainers of

small-unit leaders (e.g., platoon leaders, noncommissioned officers (NCOs), corpsmen, etc.) in CED team member skills and

stress management techniques. Appendix B explains the roles of

the Religious Ministry Teams.

Physical and Recreational Activities

Service members need an outlet for the anger, frustration, hostility, and grief developed in combat. It is unwise to conduct sports

and recreation activities under observation by the enemy, but

these activities can be conducted further to the rear. Although

makeshift athletic games help relieve stress, they should be conducted with caution. It is interesting to note that the most frequent

medical problem in Operation Desert Shield/Desert Storm was

sports injury. Other activities, such as listening to music, reading

or practicing relaxation exercises are encouraged at rest and recuperation facilities. Time and access to personal hygiene items and

facilities are psychologically valuable in combat.

Humanitarian assistance and community relations’ projects provide excellent opportunities for Service members to constructively engage in meaningful work. Public Affairs Officers, Civil

Affairs Officers, and chaplains are excellent personal resources

for developing working relationships with local nongovernmental

organizations (NGOs) and private voluntary organizations

(PVOs) in the coordination of such projects.
Combat Stress _____________________________________________ 45

Integration of New Unit Members

The arrival of replacements requires small-unit leaders to conduct

continuous training programs. Leaders should be concerned with

the various stressors affecting new Service members, as well as

those Service members who have been around for a while, including seasoned combat veterans. Leaders teach newcomers to use

stress coping skills. Replacements are quickly integrated into their

units and become thoroughly acquainted with all aspects of the new

unit. The unit also becomes thoroughly acquainted with the

replacements. A brief orientation with a sincere welcome, with

NCOs and officer support, eases replacement transition for combat.

It is important Service members adjust to a new unit quickly and

effectively. If they do not feel they are part of the group, unit

cohesion and morale suffer, decreasing unit effectiveness. New

Service members in garrison are assigned sponsors to assist them,

introduce them to the unit, and smooth their families' adjustment.

In combat, replacements are placed with suitable groups of seasoned veterans. New unit members are much more likely to

become battle or stress casualties than are members of a seasoned

and cohesive group. The veterans need to give support and advice

to the newcomers, by example and direct action, if necessary.

Phase 3: Post-Combat

Just as pre-deployment and combat are stressful, the period after

combat is also difficult. Today’s rapid transportation enables Service members to travel from the battlefield to their hometowns in

48 to 72 hours. This short time often does not give them reflection with their comrades. Units should therefore set aside time in

the last few days before leaving the theater to conduct their own

“End of Tour” debriefing in which they start at pre-deployment

and talk about whatever stands out in their memories, good or
46 _______________________________________________ MCRP 6-11C

bad, as they recount the operation up to its end. There should also

be appropriate memorial ceremonies and rituals that formally

bring the operation to a close. Awards, decorations, and other recognition must be allotted fairly by the commanders. 

Unit officers, staff NCOs, and NCOs, assisted by the chaplains

and mental health/CSC teams, prepare the Service members for

problems encountered during family reunion. For example, most

Service members expect to resume roles and responsibilities they

had prior to separation. However, their spouses often resist giving

up their new roles as decision makers and primary home managers. Also, a spouse may feel that his or her sacrifices during the

Service member's absence have gone unrecognized. This feeling

becomes an additional source of tension. If at all possible, the

families should receive the same briefings or written materials.

Families need to be reassured of their contribution. Key Volunteer Networks and other Marine Corps Family Team building

programs, and corresponding organizations for other Services

continue to help manage problems with reunion and adjustment.

Service members are briefed that startle reactions to sudden noise

or movement, combat dreams and nightmares and occasional

problems with sleeping, and feeling bored, frustrated and out of

place are common when first returning from combat to a peacetime, civilian setting. The leaders, chaplains, and the CSC team

emphasize the normalcy of such reactions. Service members are

also advised on resources available to help deal with such symptoms, if they are persistent and become upsetting. 
Chapter 3

Command Leadership Actions 

3001. LEADERSHIP ACTIONS AND INTERVENTIONS

FOR COMBAT STRESS

It is important for military leaders to know something about the

treatment of combat stress reactions. As most cases of initial combat stress symptoms do not require medical treatment, it has been

found that military leaders are often quite adept at treating less

severe cases of combat stress. In most cases, debriefing the mission,

including any traumatic events, coupled with rest, food, and sleep,

is often sufficient to alleviate the symptoms. If the operational

tempo permits the Service member to remain with his unit, and he

responds to simple reassurance (e.g., “You just need rest, you’ll be

okay tomorrow”), he is not a casualty (by definition), and may not

require further referral for specialized care. Military leaders in combat often make such decisions. When a Service member requires

medical attention to rule out a possible serious physical cause for

his symptoms, or because his inability to function endangers himself, the unit, and the mission, he should be transported to the BAS

or equivalent nearest medical support facility. Interventions at the

small-unit level include: 

l If a Service member’s behavior endangers the mission, himself,

or others, the leader should take appropriate measures to control

him.

l If a Service member is upset, let him talk about what is upsetting

him, listen, then try to reassure him.

l If a Service member’s reliability becomes questionable:
48 _______________________________________________ MCRP 6-11C

n Unload the Service member’s weapon. 

n Remove the weapon if there is a serious concern.

n Physically restrain the Service member only when safety is

a concern or during transport.

l Reassure unit members that the signs are probably a normal

combat stress reaction, and will quickly improve.

l If the combat stress reaction signs continue:

n Get the Service member to a safer place.

n Do not leave the Service member alone. Keep someone he

knows with him.

n Notify the senior NCO or officer.

n Have the Service member examined by medical personel.

l If the tactical situation permits, give the Service member simple tasks to do when not sleeping, eating or resting.

l Assure the Service member that he will return to full duty as

soon as possible.

The following quote was taken from an article about fear. It was

written by a Marine who articulated his experiences during his

tours in Vietnam. It provides intricate insight into how many Service members think and bond during combat.

What should be done when men succumb to fear brought on by the

realization that they are going to die? Before discussing this, first let

us look at the men themselves. There are very few men who can be

classified as cowards. Most men have too much self-respect to let

their buddies down. It is the rare man indeed who will willingly violate the trust of his peers. The vast majority of men will give their

lives rather than violate this trust. Proper training of combat troops,

prudent leaders who are technically and tactically sound, and the

reluctance of men to violate the trust of their peers are the foundation
Combat Stress _____________________________________________ 49

of a solid combat unit. In this environment, courage and sacrifice are

the rule, not the exception. At any given moment, anyone can be rendered ineffective by fear if one realizes that he is going to die. When

this happens to a man, do not overreact. He knows he has let his buddies down, and he knows that his buddies and leaders know he has let

them down. This is a very uncomfortable feeling for a combat

Marine. The men around him will not make a big deal about his

actions because they understand the situation. To make an issue of

this situation will destroy the man and usually alienate the rest of

your men. The man will most likely bounce back to his normal performance. The leader must keep in mind that today's coward is

tomorrow’s hero. If a man does not bounce back and continues to

succumb to this type of fear, the Marines in his fire team will let you

know when they have given up on him and no longer consider him

trustworthy. Situations such as this are rare, so there is no need to

make an example of the man. The biggest pitfall to be avoided is to

judge the man's actions as a failure of your leadership as this will

indeed cause you to overreact.

3002. SAFETY CONSIDERATIONS

Confiscation of a Service member's weapon should only be considered when it is clearly apparent that the Service member is

unreliable and a safety hazard to himself or others. Service members identify with other Service members who are trusted and

needed by their comrades. This is one of the strongest factors that

aid in returning battle-fatigued members to effective duty. The

small-unit leader relocates battle-fatigued Service members to a

safer, quieter place to rest and work for several hours up to 1 or 2

days. If the unit cannot wait for the Service members to recover,

it is necessary to evacuate them to the first level supporting medical unit. From there, every effort is made to move the Service

members to a nonmedical unit or area (a tent or building of

opportunity could suffice) for rest, replenishment, and reassur-
50 _______________________________________________ MCRP 6-11C

ance. It should be made clear that the Service members are tired

and in need of an opportunity to talk, to sleep, eat, and replenish

fluids; they are not patients. Some small detachments without

first sergeants or platoon/company organizations are attached to

other units for support and rely on the effectiveness of small-unit

leaders. Each Service member is accounted for and every effort is

made to ensure strong lines of communications are in place and

maintained between Service members and their original unit. Key

to successful treatment is the return of the Service member to his

original unit.

Actions to be taken for severely combat-stressed Service members are the same as those for the moderately combat-stressed,

with one exception: medical personnel at the BAS level should

evaluate severely combat-stressed Service members as soon as

possible. Casualties will be treated and released within hours;

held for rest and replenishment; or evacuated for further restoration. Service members who recover from combat stress reactions;

return to their original units, i.e., same company or platoon; and

are welcomed upon their return are less likely to suffer recurrence. Once rested and returned, they usually become healthy

again. New joins and replacements in the unit are more susceptible to succumb to combat stress. Accordingly, this risk is

reduced when Service members recovering from combat stress

return to the same unit where their combat experience is known

and welcomed. In rare instances, however, it is in the best interest

of the individual to be reassigned to other jobs or units. 
Combat Stress _____________________________________________ 51

3003. COMBAT STRESS CASUALTY 

INTERVENTION MODELS 

Management of combat stress reactions is unlike the treatment of

physical trauma. Severely injured Service members are stabilized

as rapidly as possible and then transferred to the rear. In all wars

since World War I, combat stress casualties treated in the rear

rarely return to full duty. In contrast, when the same casualties are

treated near the front, approximately 75 percent return to full

duty. Of those returned to full duty, only 10 percent experience

continued symptoms requiring further treatment. Some studies

suggest half of those treated at the rear go on to have chronic psychiatric symptoms, and approximately half return to full duty.

Therefore, it is clearly in the Service member's best interest to be

treated at the front and returned to duty. This also serves the best

interest of the unit because it receives a veteran Service member

back to duty, rather than breaking in a replacement. 

Guidelines for dealing with Service members unable to function

because of combat stress reaction are summarized in the memory

aid BICEPS. BICEPS stands for brevity, immediacy, centrality

(Marines)/command contact (Army), expectancy, proximity, and

simplicity.

l Brevity. Critical Event Debriefing should take 2 to 3 hours.

Initial rest and replenishment at medical CSC facilities should

last no more than 3 or 4 days. Those requiring further treatment are moved to the next level of care. Since many require

no further treatment, military commanders expect their Service members to return to duty rapidly.

l Immediacy. CSC should be done as soon as possible when

operations permit. Intervention is provided as soon as symptoms appear.
52 _______________________________________________ MCRP 6-11C

l Centrality (Marines)/Contact (Army). Service members

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 BAS, surgical support company in a central location (Marines) or forward support/division support or area support medical companies (Army)

nearest the service members' unit. It is best to send Service

members who cannot continue their mission and require more

extensive respite to a central facility other than a hospital,

unless no other alternative is possible. The Service member

must be encouraged to continue to think of himself as a warfighter, rather than a patient or a sick person. The chain of

command remains directly involved in the Service member's

recovery and return to duty. The CSC team coordinates with

the unit's leaders to learn whether the overstressed individual

was a good performer prior to the combat stress reaction, or

whether he was always a marginal or problem performer

whom the team would rather see replaced than returned.

Whenever possible, representatives of the unit, or messages

from the unit, tell the casualty that he is needed and wanted

back. The CSC team coordinates with the unit leaders,

through unit medical personnel or chaplains, any special

advice on how to assure quick reintegration when the Service

member returns to his unit. 

l Expectancy. The individual is explicitly told that he is reacting normally to extreme stress and is expected to recover and

return to full duty in a few hours or days. A military leader is

extremely effective in this area of treatment. Of all the things

said to a Service member suffering from combat stress, the

words of his small-unit leader have the greatest impact due to

the positive bonding process that occurs during combat. Simple statements from the small-unit leader to the Service member that he is reacting normally to combat stress and is
Combat Stress _____________________________________________ 53

expected back soon have positive impact. Small-unit leaders

should tell Service members that their comrades need and

expect them to return. When they do return, the unit treats

them as every other Service member and expects them to perform well. Service members suffering and recovering from

combat stress disorder are no more likely to become overloaded again than are those who have not yet been overloaded.

In fact, they are less likely to become overloaded than inexperienced replacements.

l Proximity. In mobile war requiring rapid and frequent movement, treatment of many combat stress cases takes place at

various battalion or regimental headquarters or logistical

units, on light duty, rather than in medical units, whenever

possible. This is a key factor and another area where the

small-unit leader helps in the treatment. CSC and follow-up

care for combat stress casualties are held as close as possible

to and maintain close association with the member’s unit, and

are an integral part of the entire healing process. A visit from a

member of the individual’s unit during restoration is very

effective in keeping a bond with the organization. A Service

member suffering from combat stress reaction is having a crisis, and there are two basic elements to that crisis working in

opposite directions. On the one hand, the Service member is

driven by a strong desire to seek safety and to get out of an

intolerable environment. On the other hand, the Service member does not want to let his comrades down. He wants to

return to his unit. If a Service member starts to lose contact

with his unit when he enters treatment, the impulse to get out

of the war and return to safety takes over. He feels that he has

failed his comrades and they have already rejected him as

unworthy. The potential is for the Service member to become

more and more emotionally invested in keeping his symptoms
54 _______________________________________________ MCRP 6-11C

so he can stay in a safe environment. Much of this is done outside the Service member's conscious awareness, but the result

is the same. The more out of touch the Service member is with

his unit, the less likely he will recover. He is more likely to

develop a chronic psychiatric illness and get evacuated from

the war. This is one of the essential principles of CSC. 

l Simplicity. Treatment is kept very simple. CSC is not therapy.

Psychotherapy is not done. The goal is to rapidly restore the

Service member’s coping skills so that he functions and

returns to duty again. Sleep, food, water, hygiene, encouragement, work details, and confidence-restoring talk are often all

that is needed to restore a Service member to full operational

readiness. This can be done in units in reserve positions, logistical units or at medical companies. Every effort is made to

reinforce Service members’ identity. They are required to

wear their uniforms and to keep their helmets, equipment,

chemical protective gear, and flak jackets with them. When

possible, they are allowed to keep their weapons after the

weapons have been cleared. They may serve on guard duty or

as members of a standby quick reaction force.

If treated near their units, 65 to 85 percent of combat stress casualties treated in medical CSC facilities return to duty within 1 to 3

days. About 15 to 20 percent more return to duty in 1 to 2 weeks.

Only 5 to 10 percent are sent home, and these usually have other

problems in addition to combat stress reactions. If evacuated, few

combat stressed Service members will return to duty. In fact,

many are likely to be permanently disabled.

History shows that it is important to treat combat stress casualties

as close to the front as practicable. Everyone is susceptible to the

effects of combat stress, regardless of past performance, rank or

duty. Most Service members receiving combat stress control in
Combat Stress _____________________________________________ 55

accordance with the principles of BICEPS return to duty quickly.

The chances of later psychiatric problems are also reduced.

Combat stress reactions are inevitable in combat, but high stress

casualties are not. History shows that highly trained and small

cohesive units with good leadership have less than 1 such casualty for every 10 to 15 WIA, even in very heavy fighting. This is

significantly fewer than the usual 1:3 to 1:5 ratio in high-intensity

battle, and the 1:1 or 1:2 ratio in extreme fighting. Knowledge of

factors that increase combat stress disorder in the tactical and

overall situation encourages small-unit leaders, comrades, and the

individual Service member to act towards building unit cohesion,

sharing the burden, and reducing stress. The same measures, plus

positive adherence to discipline and the law of war, also prevent

combat stress-related misconduct that defeats the purpose of the

mission. Tough, realistic training that builds confidence and caring within the unit in combat overcomes many adversities associated with combat stress in a combat environment. However, if a

member fails to adequately respond to actions taken by the unit,

then he should be evacuated for appropriate medical evaluation.
Chapter 4

Sleep Deprivation 

4001. CHALLENGES OF SLEEP DEPRIVATION

People accumulate a “sleep debt” (cumulative loss of sleep over

time) when they perform under limited sleep conditions. The only

corrective measure for satisfying this sleep debt is sleep itself. Military operations, by their demanding nature, create situations where

obtaining needed sleep will be difficult or impossible for more than

short periods.

Continuous operations are military operations with many pulses

of action every day and night, continuing for several days to weeks,

which require careful planning and resource allocation to give

everyone a minimum of 4 hours sleep in 24. (FM 22-51)

Sustained operations are continuous operations or combat with

opportunity for less than 4 hours sleep per 24 hours for significant

personnel, which may be brief or fragmented. (FM 22-51)

Accordingly, service members may have opportunities for only limited or fragmented sleep over an extended period. As a result of

these periods of sleep loss, several combat tasks are likely to show

decreased performance. These tasks include the following:

l Orientation with friendly and enemy forces (knowledge of the

squad’s location and maintaining camouflage, cover, and

concealment).
58 _______________________________________________ MCRP 6-11C

l Coordination and information processing (coordinating firing

with other vehicles and dismounted elements, reporting vehicle readiness, and communicating with the headquarters).

l Combat activity (firing from bounding vehicle, checking the

condition of weapons, observing the terrain for enemy presence).

l Force preservation and regrouping (covering disengaging

squads, marking the routes between locations, and conducting

reconnaissance).

l Command and control activity (directing location repositioning,

directing mounted defense, assigning fire zones and targets).

Continuous operations will potentially be more commonplace on

the battlefield. In offensive operations, darkness is the time to

retain or gain the initiative; while in defensive operations, obstacles can be employed with greater security during darkness.

Forces can disengage undetected and threats to close air support

lessen. The physical environment changes at night. As the air

cools below ground temperature, inversions reduce visibility and

hamper radar and radio signals. Conditions are optimal for using

chemical weapons. Visual changes also occur. Without the aid of

white light, there is no color perception. There is also a decrease

in visual clarity, field of view, and depth perception. Targets take

longer to engage. Preparation time increases two-fold to six-fold.

Simple actions, such as the departure and return of patrols,

become more complex and dangerous. Nighttime planning and

coordination require greater attention. Navigation, adjusting fire,

and munitions and/or target matching are more difficult. Precision is essential, but accuracy has a price. Service members tend

to maintain accuracy at the sacrifice of speed. The adverse conditions associated with or generated by continuous ground combat

at night will degrade the fighting performance of Service members, teams, and units. The almost complete mechanization of
Combat Stress _____________________________________________ 59

land combat forces and technological advances that permit effective movement at night, during poor weather conditions, and

under conditions of limited visibility have largely overcome the

reasons for “traditional” pauses in battle, such as darkness, resupply, and regrouping. New technologies have significantly

increased the range, reduced the time, and changed the conditions

over which battles are fought. For example, day/night-capable

vehicles can operate for extended periods without re-supply, but

they are limited by a crew’s need to sleep. A Service member is

not a machine and is, therefore, the weak link in the chain. The

equipment can operate longer than the Service member who operates it, as the Service member must have sleep. 

Commanders and leaders must ensure that all Service members

obtain enough rest to counteract the effects of rapidly shifting

from daytime to nighttime duty hours, or to extended work schedules. Implementing countermeasures that are designed to help

Service members adapt to continuous operations conditions can

satisfy this requirement. Neither leaders nor their subordinates

can perform without rest or sleep. The Service member, the unit,

and the leader are all affected by continuous operations. Generally at night, the cognitive and physiological resources of Service

members are not at their peak, especially after a rapid shift from

daytime to nighttime duty hours. Fatigue, fear, feelings of isolation, and loss of confidence may increase. 

Non-stop, unrelieved combat operations (sustained operations)

with little or no sleep degrade performance and erode mental abilities more rapidly than physical strength and endurance. Information gained from the Army Unit Resiliency Analysis Model

shows that even healthy young Service members who eat and

drink properly experience a 25 percent loss in mental performance for each successive 24-hour period without sleep. The

mental parameters include decisionmaking, reasoning, memory
60 _______________________________________________ MCRP 6-11C

tasks, and computational tasks. The loss may be greater for Service members who are older, less physically fit, or who do not eat

and drink properly.

The effects of sustained operations are sometimes hidden and difficult to detect. Units are obviously impaired when Service members are killed or wounded in action or become noncombatant

losses. They are further impaired when their troops are too tired

to perform their tasks. Unlike individual performance, unit performance does not deteriorate gradually. Units fail catastrophically, with little warning. 

A priority for fighting units is to assure that commanders and

leaders are rested and able to think clearly. While this is obvious,

it is a most difficult lesson for leaders to learn. During combat,

commanders must focus on the human factor. They must assess

and strengthen their units as they plan and fight battles. They

must accurately decipher which units must lead, which must be

replaced, where the effort must be reinforced, and where tenacity

or audacity and subsequent success can be exploited. When leaders begin to fail, control and direction become ineffective, and the

organization disintegrates. No fighting unit can endure when its

primary objectives are no longer coordinated. Leaders must also

prepare and precondition Service members to survive. It is particularly important that leaders conscientiously plan and implement

effective sleep plans, because activities that are most dependent

on reasoning, thinking, problem solving, and decision-making are

those that suffer most when sleep and rest are neglected.

Some leaders wrongly believe that their round-the-clock presence

during an operation is mandatory; they are unwilling to recognize

that they, too, are subject to the effects of sleep deprivation. If the

unit has been regularly trained according to the mission command

philosophy, two benefits accrue. Not only will a leader be confident that in his absence his subordinates will adhere to his intent,
Combat Stress _____________________________________________ 61

but the trust he shows in his subordinates will continue to maintain unit morale and help ease some of the stress of the situation.

In future operations, the battlefield will become increasingly

lethal. The threat of nuclear, biological, and chemical weapons

will maximize confusion, uncertainty, and stress, which adversely

impact our ability to move, shoot, communicate, and sustain.

Sleep loss in this type of environment increases an already stressful situation. 

4002. EFFECTS OF SUSTAINED

OPERATIONS ON PERFORMANCE

A basic rule for continuous operations is planning ahead to avoid

sustained operations, and provide members 5 to 6 hours sleep in

24. However, missions or enemy actions sometimes require

exceptional exertion for several days with only unpredictable,

fragmented sleep—as required in sustained operations. Sustained

combat leads to exhaustion and reduction in effective task performance. Even during the first night of combat, normal sleeping

habits and routines are abnormal. The Service member feels the

effects of fatigue and the pressure of stress from noise, disrupted

sleep time, and threat to life. While essential for endurance, sheer

determination cannot offset the mounting effects of adverse conditions. Cognitive degradation involving poor decisionmaking

begins during and after the first 24 hours of sleep deprivation.

Individual and unit military effectiveness is dependent upon initiative, motivation, physical strength, endurance, and the ability

to think clearly, accurately, and quickly. The longer a Service

member goes without sleep, the more his thinking slows and

becomes confused. Lapses in attention occur, and speed is sacrificed to maintain accuracy. Continuous work declines more rapidly than intermittent work.
62 _______________________________________________ MCRP 6-11C

Tasks such as requesting fire, integrating range cards, establishing positions, and coordinating squad tactics become more difficult than well-practiced, routine physical tasks, such as loading

magazines and marching. Without sleep, Service members can

perform the simpler and/or clearer tasks—lifting, digging, and

marching—longer than the more complicated or ambiguous tasks

such as a fine hand-eye coordination sequence; i.e., tracking a target through a scope. 

Sleep loss affects memory, reasoning, mental assessments, decision-making, problem-solving, subsequent actions, and overall

effectiveness. While comprehension is accurate, reading speed

slows and recall fails. For example, Service members may understand orders when reading them in documents, yet they are forgotten later when required. Individuals will forget or omit

assigned tasks more often than they will make errors in carrying

them out.

Leaders can expect declining moods, motivation, initiative, planning ability, and preventive maintenance. High motivation will

only increase risk, due to impaired performance. Leaders must

recognize erratic or unreliable task performance in subordinates,

as well as in themselves. Alertness and performance decline gradually with partial sleep deprivation; that is, when sleep is limited

to 4 to 5 hours per night. After 5 to 7 days of partial sleep deprivation, alertness and performance decline to the same low levels

as those following 2 days of total sleep deprivation. After 48 to

72 hours without sleep, personnel become militarily ineffective. 

Adverse Conditions

Continuous combat forces Service members to perform under

adverse conditions that cause degradation in performance. Examples of adverse conditions follow.
Combat Stress _____________________________________________ 63

Low Light Level 

The amount of light available for seeing landmarks, targets, and

maps is greatly reduced at twilight and night.

Limited Visibility 

Smoke, fog, rain, snow, ice, and glare degrade a Service member’s ability to see his environment and objects within it, as

opposed to situations free of such conditions.

Disrupted Sleep Routines

People are accustomed to being awake or asleep during certain

hours of the day or night. Disruption of the normal sleeping

schedule causes degraded performance.

Physical Fatigue

Working the muscles faster than they can be supplied with oxygen and fuel rapidly creates “oxygen debt,” eventually making

these muscles unable to function until the deficits are made up

during brief rests.

Sleep Loss 

The muscles can continue to function adequately without sleep,

but the brain cannot. Increasing sleep debt leads to subtle, but

potentially critical, performance failures.

Sleep Loss Indicators

Indications of degraded performance symptoms become more

prevalent as sleep debt accumulates. Performance is affected by

the hours of wakefulness, tolerance to sleep loss, and the types of

mental or physical work. Both mental and physical changes

occur, with symptoms varying among individuals. Leaders must

observe Service members for the following indications of sleep

loss and degraded performance:
64 _______________________________________________ MCRP 6-11C

l Physical changes in appearance, including vacant stares,

bloodshot eyes, pale skin, and poor personal hygiene. Other

physical signs of sleep loss include the body swaying when

standing, sudden dropping of the chin when sitting, occasional

loss of hand-grip strength, walking into obstacles or ditches,

low body temperature, slowed heart rate, and slurred speech.

l Mood changes, decreased willingness to work, and diminished performance go hand-in-hand. Service members may

experience decreasing levels of energy, alertness, interest in

their surroundings, and cheerfulness with a concurrent

increase in irritability, negativity, and sleepiness. Some

become depressed and apathetic. Others, for a time, can

become energized by sleep loss, talk more, and may be more

assertive without necessarily maintaining good judgment.

Sleepiness and mood changes are not signs of weakness. After

long periods of sleep loss, Service members go from being

irritable and negative to dull and weary.

l Service members may feel more effort is needed to perform a

physical task in the morning than in the afternoon. Exaggerated

feelings of physical exertion may lead to work stoppage, especially between 0400 and 0700. During that time, the tendency

to fall asleep is considerably more noticeable than other times.

l Both bickering and irritability increase with sleep loss. When

Service members argue, it shows that they are still talking to

each other and exchanging orders and messages. When arguments cease, especially after a period of increased bickering,

Service members may be in a state of mental exhaustion.

l Comprehension and perception slow considerably. Individuals

require extended time to understand oral, written or coded

information; to find a location on a map and/or chart coordinates; to interpret changes in enemy fire patterns; and to make

sense of things seen or heard, especially patterns. They may
Combat Stress _____________________________________________ 65

have difficulty with spot status or damage reports, and may be

unable to assess simple tactical situations.

Loss of Concentration

Sleep deprivation causes the attention span to shorten. There is a

loss of concentration on the job as dream-like thoughts cause

lapses in attention. Leaders should watch for the following:

l Decreased vigilance. Personnel are less alert and fail to detect

the appearance of targets, especially in monotonous environments. They may doze off at the wheel of moving vehicles. 

l Distorted attention. Service members may imagine seeing

things that are not there, e.g., “moving” bushes when in reality

there is no such movement. The sleep-deprived brain can also

misperceive bushes, rocks, people, vehicles or anything else

and see them as something different, in very precise detail.

Often the tired brain “sees” what it wishes were there (food, a

bed); at other times, these illusions may be animals or other

more bizarre things. But when the mind is alert for an enemy,

the brain may generate a very convincing, detailed image of

the enemy. Sometimes, but not usually, sounds or other sensations may accompany these illusions. They usually last only

seconds, but can persist for minutes if not challenged, and

rarely have even been “seen” by equally sleep-deprived comrades when told of them. It is essential for sleep-deprived unit

members to check out any questionable things they see with

their comrades, and to faithfully follow reporting and challenge procedures.

l Inability to concentrate; easily confused. Service members

cannot keep their minds on what they are doing. They cannot

follow multiple directions nor perform numerical calculations.
66 _______________________________________________ MCRP 6-11C

l Failure to complete routine tasks. Sleep loss interferes with

completing routine individual tasks, such as drying the feet,

changing socks or filling canteens when water is available.

Tasks such as performing weapons checks may be skipped.

When a Service member cannot recall what he just saw, read,

heard or was told by another individual, he is exhibiting a common sign of sleep loss. His memory loss is limited to recent

events. For example, a sleep-deprived Service member may forget recent target data elements or recall them incorrectly and have

difficulty learning new information.

4003. ACHIEVING SLEEP IN COMBAT 

Sleep deprivation produces stress and, therefore, sleep management is important. Sleep management is a combat multiplier.

Planned sleep routines are important for keeping the unit, the

individual Service members, and the leader himself functioning

as required while reducing sleepiness during continuous combat.

Since leaders are responsible for planning sleep routines, they

need a basic understanding of the physiological and behavioral

aspects of sleep and their impact on performance. The following

paragraphs provide this information.

Rhythmic Variations

There are rhythmic variations in individual performance based on

a predictable physiological and behavioral cycle that comprises

about 24 hours. The 24-hour, day-night/work-rest cycle is called

the circadian rhythm. Because traveling across a half-dozen time

zones disrupts the usual relationship in the day-night/work-rest

cycle, for a few days Service members are not sleepiest at their

usual sleep period of 2400 to 0600, new-locale time. Allowing
Combat Stress _____________________________________________ 67

sleep about 1200 to 1800, new-locale time, will only delay their

adaptation to their new locale. Leaders must instruct troops to go

to bed between 2400 and 0600 new-local time to establish a new

circadian rhythm.

Another example of circadian rhythm is body temperature.

Although one’s “normal” temperature is 98.6 degrees, this is

really an average or midpoint of a daily swing from 96.8 to 100.8

degrees. For someone accustomed to working days and sleeping

nights, body temperature would fluctuate approximately as indicated. There is a well-established link between body temperature

and sleepiness and/or performance slumps. Performance parallels

body temperature. The higher the body temperature, the better the

performance. As body temperature decreases, mood and motivation decline with a concurrent increase in sleepiness and fatigue. 

Impact upon performance is most pronounced during the circadian lull, which is roughly 0200 to 0600 hours. During this time,

performance declines about 10 to 15 percent. In sleep-deprived

Service members, this decline may reach 35 to 40 percent. If the

day-night/work-rest cycle is disrupted, performance suffers

because the Service member is sleepy during the new work

period and awake during the new sleep period. The body needs

several days to adjust to the new schedule. Critical hours for sleep

are between 0200 and 0600 when anchor sleep (the most beneficial sleep) is taken. The body is at its lowest temperature during

this period. This is the best time for sleeping, but not for napping.

To prevent sleep inertia, naps should always be taken at times

other than the lowest point in body temperature. 

Leaders need to calculate the difference in time zones and make

the necessary schedule changes. Leaders will need day-and nightfighting teams. Members acclimated to working days and sleeping nights should be scheduled to work nights and sleep days.
68 _______________________________________________ MCRP 6-11C

Their performance slump/optimal time to sleep would be 2400 to

0600, new-locale time. Deployment, pre-combat, and combat are

not usual circumstances. If certain Service members must have an

offset circadian timing from the rest of the unit, a special effort

must be made to establish their sleeping time. Obviously, troops

must sleep whenever possible. If a planned sleep schedule cannot

be followed, however, performance is enhanced if sleep coincides

with the low point in body temperature. 

Adjusting to new circadian rhythms is a slow process, taking 3 to

6 days to come “in phase” with a new schedule. Leaders should

devise a sleep schedule that provides for sleep at the same time of

day or night every 24 hours. Sleep schedules that provide for

sleep at different times of day or night are less valuable and are

detrimental to quality sleep and optimal performance. 

Sleep Shifts

Staggered work schedules can be set up for two shifts working 4

hours on/4 hours off, 6 hours on/6 hours off, and 12 hours on/12

hours off. See Table 4-1. Each shift follows the same schedule

daily. It is better to maintain regular shift schedules than schedules that continually change.

Sleep/Rest Guidelines

Leaders should use the following sleep and/or rest guidelines in

this section to enhance individual and the unit performance in

continuous operations. 

l Know personal tolerance for sleep loss and those under your

command; major individual differences are not easily

changed. Individuals who are unable to sleep during predeployment and deployment stages should be encouraged to

practice relaxation exercises (see paragraph 2005). 
Combat Stress _____________________________________________ 69

l Ensure that Service members fully use their breaks and other

opportunities for rest. Encourage them to waste no time in getting to sleep. Undisturbed, prolonged sleep is the most desirable use of rest opportunities. When there has been sleep loss

but little physical exertion (e.g., manning communications,

operating a radio), mild physical exercise such as walking

around when conditions permit, can help maintain alertness.

l Encourage Service members to sleep, not just rest, by creating

the most conducive environment possible for sleep: quiet,

without interruptions (or earplugs); dimness or darkness (or

with eye cover); not overly warm or cold. 

Table 4-1. Sleep Shifts.

4 HOURS ON/4 HOURS OFF

Shift 2400-

0400

0400-

0800

0800-

1200

1200-

1600

1600-

2000

2000-

2400

1 SLEEP DUTY SLEEP DUTY SLEEP DUTY

2 DUTY SLEEP DUTY SLEEP DUTY SLEEP

6 HOURS ON/6 HOURS OFF

Shift 2400-

0600

0600-

1200

1200-

1800

1800-

2400

1 SLEEP DUTY SLEEP DUTY

2 DUTY SLEEP DUTY SLEEP

12 HOURS ON/

12 HOURS OFF

Shift 2400-

1200

1200-

2400

1 SLEEP DUTY

2 DUTY SLEEP
70 _______________________________________________ MCRP 6-11C

l Do not allow personnel to sleep in unsafe conditions. Enforce

strict rules designating sleep areas and requiring perimeter

guards. Require day and night guides for all vehicles to prevent Service members from being accidentally run over. 

l Ensure that Service members follow sleep schedules or routines. The field commander who does not enforce a sleep

schedule or routine leads his troops into an environment that

increases the opportunity for hazardous conditions to be

encountered while in continuous combat. Taking naps is not a

sign of low fighting spirit or weakness; it is a sign of foresight.

Measuring Sleep Loss

Sleep loss can be measured by:

l Keeping a sleep and/or activity log. From pre-deployment to

post-deployment, log sleep and nap periods. Service members

need 4 to 5 hours per 24-hour period; 6 or 7 hours is optimum.

If they receive less, the first chance for a long rest period must

be used for sleep.

l Observing performance and asking questions. Look for the

indications of sleep loss—such as increase in error occurrence, irritability, difficulty understanding information, and

attention lapses—with concurrent decreases in initiative,

short-term memory, and attention to personal hygiene. Confirm sleep loss by asking the obvious question: “When did you

sleep last and how long did you sleep?”

Sleep Loss Alternatives

Ways to overcome performance degradation include:

l Upon signs of diminished performance, find time for members

to nap, change routines or rotate jobs (if cross-trained).
Combat Stress _____________________________________________ 71

l Have the Service members most affected by sleep loss execute

a self-paced task.

l Have Service members execute a task as a team, using the

buddy system.

l Do not allow Service members to be awakened for meals

while in flight to a new location, especially if the time zone of

the destination is several hours different than that of point of

departure.

l Insist that Service members empty their bladder before going

to bed. Awakening to urinate interrupts sleep, and getting in

and out of bed may disturb others and interrupt their sleep.

l Allocate sleep by priority. Leaders, on whose decisions mission success and unit survival depend, must get the highest

priority and largest allocation of sleep. Second priority is

given to Service members that have guard duty and to those

whose jobs require them to perform calculations, make judgments, sustain attention, evaluate information, and perform

tasks that require a degree of precision and alertness.

4004. SLEEP/REST PLANNING 

Sleep/rest planning applies to the pre-deployment, deployment,

pre-combat, combat, and post-combat stages of battle.

Pre-Deployment Stage

Using mission-scenario operation guidelines, determine periods

available for sleep and the total number of sleep hours possible.

Because continuous operations requirements may change, alternate sleep routines should be planned. Become familiar with the

area where the combat unit will sleep; For example, some may
72 _______________________________________________ MCRP 6-11C

have to sleep in mission-oriented protective posture (MOPP) IV.

If sleeping in MOPP IV is anticipated in combat, practice it during the pre-deployment stage. Prior experience reduces stress, so

practice anticipated sleep routines before continuous operations. 

Deployment Stage

Since sleep will be reduced during deployment, follow preplanned sleep routines. The prudent commander will choose a 4-

hour on/4-hour off, 6-hour on/6-hour off, or 12-hour on/12-hour

off shifts from the start. Take into account that Service members

on night duty will need to sleep during the daytime. Provide

night-shift personnel with separate sleeping quarters to avoid disruption of their sleep period. 

Pre-Combat Stage

In general, people are most effective during the afternoon and are

least effective just before dawn. Without prior adjustment to the

new time zone, which naturally occurs in 3 to 5 days, leaders can

expect degraded daytime performance. The reason is that 0200 to

0600 hours home-base time is the low point in performance efficiency and should be considered when planning workloads.

Combat Stage

Every effort should be made to avoid situations where all personnel are physically and mentally exhausted simultaneously. Make

the most of any lull during the combat phase by sleeping briefly.

Complete recovery from sleep loss may not be possible during

intense combat, but limited sleep is helpful. Uninterrupted short

sleeps of 15 minutes or longer are beneficial to partially recovering alertness. Sleep during the combat stage may be risky, how-
Combat Stress _____________________________________________ 73

ever, because a Service member may wake up feeling groggy,

confused, sluggish, and uncoordinated. It may take his brain from

several seconds to 15 minutes to “warm up.” Individuals differ in

how quickly they take to wake up, but it tends to be worse when

the body expected to go into deep sleep, and to get worse with

increasing sleep loss. Activities that increase circulation of warm

blood to the brain, like moderate exercise or drinking a hot beverage, may shorten the start-up time.

Post-Combat Stage

It is important to make up sleep debt, but experts disagree about

the amount of recovery time needed. Some say the hours of sleep

needed for recovery after sleep deprivation are less than the

amount lost. It is well known and documented that lost sleep is

not made up hour-for-hour. Most experts agree that immediately

following continuous combat, Service members should be

allowed to sleep up to 10 hours. Longer sleep periods are not

desirable because they cause “sleep drunkenness” and delay in

getting back to a normal schedule. After the first sleep period of

up to 10 hours, Service members should return to the regular

sleep routine. Sleep inertia lasting longer than 5 to 15 minutes

and increased sleepiness may occur for as long as a week following sustained combat. Some experts recommend that 4 of the first

8 hours of recovery sleep should be at the 0200 to 0600 sleep

time, and they suggest the following guidelines for complete

recovery from the effects of sleep loss:

l 12 hours for sleep and rest after 36 to 48 hours of complete

sleep loss with light to moderate work load (fatigue may linger for 3 days).

l 24 hours for sleep and rest after 36 to 48 hours of sleep loss

with high workload (12 to 16 hours per day).
74 _______________________________________________ MCRP 6-11C

l 2 to 3 days time off after 72 hours or more of acute sleep loss.

l As much as 5 days for sleep and rest following 96 hours or

more of complete sleep loss.

Most experts agree that 10 hours of sleep is the maximum

needed, with the additional 2 hours used for rest. It is doubtful

that a Service member could continue past 72 hours of wakefulness. Should this occur, a couple of nights with 10 hours of sleep

are more beneficial than an excess of 10 hours during one sleep

period. If Service members have not slept for 36 to 48 hours or

more, they should avoid sleep of less than 2 hours, especially

between 0400 and 0600. A too-short sleep period at the wrong

time may cause a long period of sleep inertia. After 96 hours of

total wakefulness, 4 hours of sleep may provide substantial

recovery for the simpler, less-vulnerable tasks. Recovery continues with additional days of 4 hours of sleep per 24 hours. Complex leadership tasks may require longer recovery sleep, but sleep

until fully satisfied is not necessary. 

Sleep loss alone does not cause permanent health problems, nor

does it cause mentally healthy people to become mentally ill.

Reduced sleep (from 8 to 4 hours) does not cause physical harm.

Hallucinations may occur, but they disappear after recovery

sleep. Clinical laboratory tests show that total sleep loss of over a

week does not pose serious health problems. It is doubtful that

Service members could stay awake for such an extended period,

and it is not suggested that Service members try to endure long

periods without rest. However, the effects of sleep loss, such as

inattentiveness and poor judgment, may be harmful (such as falling asleep at the wheel of a vehicle). 

Sleep cannot be stored in our bodies for emergency use. Sleep of

more than 7 to 8 hours before deployment does not “store up”
Combat Stress _____________________________________________ 75

excess sleep, but sleep taken immediately before a deployment

can prolong activity. Therefore, it is important to begin continuous operations in a rested state. During daytime or early morning

naps, many Service members experience vivid dreams as they fall

asleep and often wake up frightened. Leaders should inform their

troops that this occurrence is both common and normal during

daytime sleep. If a single, unbroken period of 4 to 5 hours is not

available for sleep, “power naps” of 15 to 30 minutes, although

less recuperative, can be taken. Leaders must capitalize on every

opportunity for a “power nap.” Merely resting by stretching out

does not take the place of sleep. Only sleep can satisfy the need

for sleep.
Appendix A

Suicide Awareness Information

SIGNS OF SUICIDE

A person contemplating suicide—

l Believes he or she is in a hopeless situation.

l Appears depressed, sad, tearful; may have changes in patterns of

sleep and/or appetite.

l May talk about or actually threaten suicide, or may talk about

death and dying in a way that strikes the listener as odd.

l May show changes in behavior, appearance or mood.

l May increase or start drug or alcohol use.

l May injure self or engage in risky behavior.

l Abandons planning for the future.

l May start withdrawing from others, including family and close

friends.

l May give away possessions.

l May appear apathetic, unmotivated, indifferent.

PREVENTION KEYS

The small-unit leader may be the first to identify the “signals” of a

potential suicide-risk Service member. The keys to prevention are
A-2 _____________________________________________ MCRP 6-11C

to provide aid to persons at suspected risk and follow the acronym AID LIFE.

A Ask: “Are you thinking about hurting yourself?” 

I Intervene immediately.

D Do not keep a secret concerning a person at risk.

L Locate help (NCO, chaplain, corpsman, doctor, nurse, 

friend, family, crisis line, hospital emergency room).

I Inform your chain of command of the situation.

F Find someone to say with the person. Do not leave the 

person alone.

E Expedite! Get help immediately. A suicidal person 

needs the immediate attention of helpers.
Appendix B

Religious Ministry Team’s Role

(Adapted from Army Field Manual (FM) 22-51, A Leader’s Manual for Combat Stress Control.)

This appendix addresses the general role of the ministry team in the

commander’s program of combat stress control and in battle fatigue

ministry. In the Marine Corps ministry teams are called Religious

Ministry Teams (RMTs) and consist of chaplains and Religious

Program Specialists (RPs) or chaplain’s assistants (In the Army

they are called Unit Ministry Teams). The RMT is assigned to a

command or designated by higher headquarters to be responsible

for the direct religious ministry support to the command. RMTs

provide professional ministry support to leaders in fulfilling their

combat stress identification and intervention responsibilities. RMTs

can also assist in training leaders to recognize combat stress symptoms.

EFFECTS OF STRESS

Negative effects of stress can be lessened when members are prepared physically, emotionally, and spiritually prior to combat/operations. RMTs can assist in preparing Service members to manage

combat stress with training before and during deployment. This

training helps Service members draw upon their personal religious

faith, spiritual strength, and values as well as to share strength and

confidence during any operation.
B-2 _____________________________________________ MCRP 6-11C

RELIGIOUS MINISTRY TEAM RELATIONSHIP

The RMT’s established relationship with the command promotes

trust with the troops. As integral members of their commands,

RMTs are trained and ready to respond to the needs of Service

members experiencing combat stress. A person-oriented resource,

the chaplain and RP team minister to combat stress casualties,

especially Service members having less severe difficulties who

have rapid replenishment potential.

SPIRITUAL VALUES

Service members’ inner resources are often based on their personal faith, religious beliefs and spiritual values. In combat, Service members may show more interest in their religious beliefs.

When religious and spiritual values are challenged during the

chaos of combat, Service members may lose sight of inner

resources that sustain them. Service members can then become

targets of fear, despair, hopelessness, and eventually, combat

stress casualties. They are also at risk for committing misconduct

stress behaviors. Chaplains are a source of direction and stability

to Service members experiencing these dilemmas and seeking to

refocus their personal beliefs and spiritual values.

RELIGIOUS MINISTRY TEAM SUPPORT

Ministry teams can provide preventive, immediate, and replenishing spiritual and emotional support and care to Service members

experiencing combat stress.
Combat Stress ____________________________________________ B-3

Preventive 

The RMT’s religious ministry support assists in preventing combat and misconduct stress behaviors through establishment of a

presence within the unit. It is important for the RMT to be present

with Service members when the unit trains and when it deploys.

The chaplain and RP can be a calming influence on members and

can help Service members strengthen or regain values important

to them. Chaplains can help prevent combat stress and misconduct by:

l Being present with the Service members and deploying with

the unit.

l Providing opportunities for private and group prayer and worship.

l Supplying personal religious articles and materials.

l Reading the scriptures with Service members.

l Providing sacraments as the situation allows.

l Counseling Service members, allowing them to work through

stress, fear, anxiety, anger, and frustration.

l Visiting Service members in work and living areas.

l Assisting Service members and families prior to deployment

with preparation for geographical separation and an uncertain

future through Marine Corps Family Team Building

(MCFTB) programs that emphasize family strengths. This

helps Service members to know that their families are cared

for during deployment.
B-4 _____________________________________________ MCRP 6-11C

Immediate

RMTs can assist commanders in the identification of Service

members experiencing combat stress. Chaplains often work

closely with the medical officer and are trained to recognize the

signs of combat stress and provide religious support to Service

members experiencing combat stress. Chaplains assess spiritual

needs and provide the appropriate religious ministry. This may

include such things as:

l Presence with the Service member.

l Conversation and counseling, providing opportunities to share

fears, hopes, and other thoughts.

l General prayers; prayers for the individual or fallen comrades.

l Rites, sacraments, and ordinances as appropriate.

l Reading from scriptures.

Replenishing

Following an engagement, the unit may require reconstitution

through the addition of new personnel. The RMT can assist surviving Service members rebuild their emotional, psychological,

and spiritual strength. During this time, RMTs continue their

ongoing direct religious ministry that includes: 

l Coordinating the availability of worship services, sacraments,

rites, and services and/or ceremonies honoring the dead.

l Assisting with the integration of personnel replacements.

l Enabling the grief process through personal counseling and

memorial services.
Combat Stress ____________________________________________ B-5

l Reinforcing the Service member’s sense of self-worth and

hope.

l Assisting with CEDs to provide opportunities for Service

members to talk about their combat experiences and to facilitate integration of the combat experience into their lives.

l Providing leadership training and supervision of CEDs.

l Providing personal religious articles and materials.

l Providing or arranging faith group coverage in the command

or for other units.

l A chaplain’s ability to relate the spiritual aspects of life to the

Service member’s situation is an essential element in the

replenishment process. Religious ministry can assist Service

members in achieving emotional and spiritual wholeness.

Reintegration

After deployments and operations, RMTs can assist reintegration

of the individual Service member into family relationships and

society at large. Many religious ministry support programs

remain the same. Expanded ministry may also include providing

the following:

l Worship events for the entire unit.

l Worship events for varied faith groups.

l Briefings that help Service members recognize, prepare for,

and master the stressors of reunion with family.

l Structured events to assist Service members returning to family and civilian life.

l Opportunities for Service members to experience and understand the forgiving and unchanging love of God.
Appendix C

Glossary

Section I. Acronyms

AAR ................................................................. after action review

BAS.................................................................battalion aid station

BICEPS .....................brevity, immediacy, centrality, expectancy,

proximity, and simplicity

CED............................................................... critical event debrief

CSC .............................................................. combat stress control

MCFTB ...............................Marine Corps Family Team Building

MCRP...................................Marine Corps Reference Publication

MOPP.................................... mission-oriented protective posture

MRE................................................................. meals, ready to eat

NCO ...................................................... noncommissioned officer

NGO .............................................. nongovernmental organization

PVO................................................private voluntary organization

RMT..........................................................religious ministry team

RP.......................................................religious program specialist

SGLI......................................Servicemen’s Group Life Insurance

SPRINT.................. Special Psychiatric Rapid Intervention Team

UMT..................................................................unit ministry team

WIA...................................................................wounded in action
C-2 _____________________________________________ MCRP 6-11C

Section II. Definitions

circadian rhythm—Rhythmic variations in individuals; predictable physiological and behavioral cycle of about 24 hours.

combat stress—The mental, emotional, or physical tension,

strain, or distress resulting from exposure to combat-related conditions. Combat stress is the net result of many stressors (e.g.,

fear of death, fear of failure, other intensive painful emotions

[like grief], uncertainty, boredom, worry about what is happening

back home, and the many physical and mental demands of combat duties) at any given time.

combat stress behaviors—The generic term that covers the

entire range, from highly positive to totally negative behaviors

which can be elicited by combat stress.

combat stress reaction—The common, predictable, negative,

emotional and physical reactions of normal people to the “abnormally high” stressors of combat, which by definition interfere with

mission performance or well-being, but which can be treated

according to the BICEPS principles, with reassurance of normality

and recovery, with rest, replenishment, and activities to restore

confidence. The combat stress reactions do not include the misconduct stress behaviors, since the latter require disciplinary action.

continuous operations—military operations with many pulses of

action every day and night, continuing for several days to weeks,

which require careful planning and resource allocation to give

everyone a minimum of 4 hours sleep in 24. 

stress—An internal process of an individual for preparation in

dealing with, or reacting to stressors. Stress involves physiological stress reflexes, which ready the body for fight or flight, such
Combat Stress ____________________________________________ C-3

as increased release of adrenaline, heart rate, and blood flow to

brain and muscles, with subsequent increase in alertness. Stress

also involves the accompanying emotions (stress responses) such

as anxiety, anger, or guilt. Stress may or may not involve conscious awareness of the threat, but the stressor must be perceived

at some level of awareness. The amount of stress experienced

depends on the appraisal of the stressor and its context by the

individual, even if that perception is incorrect. The stress process

includes psychological defenses which may shield the individual

from perceiving more threat than he can tolerate.

stress behaviors—Stress behaviors are the observable behaviors

that an individual exhibits as a result of internal stress. They may

be intended to overcome and turn off the stressor, escape it, adapt

to an inescapable stressor, or make the uncomfortable stress

symptoms more tolerable. A stress behavior may simply be a side

effect of the tension, which is part of stress. Any of these different

types of stress reactions may be successful, unsuccessful, adaptive, or maladaptive. They may make the situation better, worse,

or not influence it at all. They may resolve one stressor but create

new ones. 

stressor—Any event or situation that requires a non-routine

adaptation or behavior change, creates conflicting motives within

the individual, or is perceived by the individual as a threat to his

well-being or self-esteem. Combat stressors are any that occur in

the context of performing the combat mission (whether under fire

or not).

sustained operations—Continuous operations or combat with

opportunity for less than 4 hours sleep per 24 hours for significant

personnel, which may be brief or fragmented.
Appendix D

References

DoD Directive

6490.5, Combat Stress Control (CSC) Programs

Army Field Manual (FM)

8-51, Combat Stress Control in a Theater of Operations, Tactics,

Techniques, and Procedures

22-9, Soldier Performance in Continuous Operations

22-51, Leaders’ Manual for Combat Stress Control

22-100, Army Leadership

90-22, (Night) Multiservice Night and Adverse Weather Combat

Operations

Miscellaneous

U.S. Army Aeromedical Research Laboratory and U.S. Army

Safety Center, Leader’s Guide to Crew Endurance

http://www.mcu.usmc.mil/TbsNew/Coverpag.htm, Human Factors in Combat: Topics in Combat Leadership that Help Preserve

the Fighting Spirit and Prevent Psychiatric Casualties