Stress control in military operations other than war

A draft doctrine paper entitled "Combat Stress Control in Operations Other Than War" (MCCS HPO, March 1993) has been circulated in pocket booklet form among the Army's mental health and combat stress control unit personnel and to personnel of other Services and Allies. That draft has not yet been formally staffed throughout the Medical Department or the U.S. Army. One major source of inspiration for that draft paper has been a NATO Panel on Psychological Support to Troops. The panel members from allied NATO countries have extensive experience in highly stressful peacekeeping operations. Two shorter booklets ("Stress Dimensions in Operations Other Than War" and "Controlling Stress in Operations Other Than War") have been extracted or distilled from the draft paper. There are also prototype pocket training cards or memory aids. These are referenced on the List of Combat Stress Actions Office Cards and Boolets, at the end of this paper.

STRESSORS IN OPERATION OTHER THAN WAR

Our concern in peace support operations is to help commanders monitor and control several categories of psychological stressors which may threaten accomplishment of the mission or the soldier's current or future well being and usefulness. While these stressors are often also present in war, they may have an especially strong impact on morale and performance in operations or conflicts which do not provide the mobilizing effect of a declared war.
Operations other than war, and peace support operations, cover a wide spectrum and can differ widely in the stressors involved. Some operations have very definite objectives and endpoints, but many are ambiguous and open ended. They can suffer 'mission creep', and require soldiers to do tasks very different from what they were trained for. When conflict or combat is involved, it may be impossible to distinguish "the enemy" from the people we were sent to help. This potentially leads to mistrust and hatred of everyone. The rules of engagement (ROE) may be unclear, or they may be distressingly strict    for example limiting self defense. The ROE may even forbid giving aid to suffering people or intervening to stop ongoing, inhuman atrocities. That strictness may only highlight the ambiguity of the reason for being there. Even the nation's commitment to the value of the operation to which it has committed its troops may be in question.
Peace support operations are often conducted in austere, primitive environments and inhospitable climates. The foreign culture of the local population, or of the multinational allies, may create friction or temptation. Separation from home, isolation from usual comforts, loss of privacy, and boredom can be strong stressors. On the other hand, the unprecedented world wide reach of the news media and the availability of telephones with which to call home can decrease isolation, but create their own unstable mix of benefits and pitfalls. While some peace support operations are no more dangerous or trauma prone than training exercises, others have involved extreme risk of seeing scenes of horror and suffering, individual and mass injustice, and considerable risk of personal injury, disease or death.
STRESS RESPONSES

The stress control mission is concerned with four types of stress responses   one of them positive and three negative or dysfunctional. (TABLE 1). First priority for the stress control mission should go to helping the chain of command and leadership promote the positive stress behaviors. Positive stress behaviors include the development of strong, cohesive bonds among peers and with leaders, all sharing a common unit identity and dedication to the mission. This "unit cohesion" focuses the general stress response to sustain alertness, stamina, and tolerance of discomfort and pain. Unit cohesion can bring out deeds of heroism and self sacrifice in moments of crisis. Positive stress, constrained by the right sense of personal and unit identity, is essential to maintaining discipline, perspective, and restraint in the presence of rising frustration and anger. High quality leadership and training must continually keep the mission in focus, despite the ambiguities of the situation. The danger is that the same psychological processes which give the positive stress behaviors can also result in individual or collective misconduct if they come out in the wrong times and places.
The boredom, tension, frustration or anger generated in the operation can result in various types of misconduct when unit cohesion and mission focus stray. Distainful or domineering behavior towards the local population will turn that population against our well intentioned intervention, and may escalate to brutality and atrocities which disgrace and invalidate the mission in the eyes of the World. Soldiers may have easy access to abusable substances, to relieve their boredom or to self treat their symptoms of distress. Sexual misconduct with the local population or within the unit can cause resentment, disease, and harm unit cohesion. The troops must understand that no amount of stress justifies criminal misconduct. Misconduct behaviors, even when provoked by extreme stress, must be met with appropriate disciplinary action.
Classical wartime cases of severe battle fatigue or combat stress reaction, with disabling exhaustion, anxiety, depression, or dissociative or conversion symptoms, are rare in operations other than war unless heavy casualties occur among our own troops. However, mild cases which can be rested and restored in their own units may be common. The term 'contingency fatigue' can be used when no battles are involved. It is important not to remove stress casualties far from their units, as this often leads to chronic disability instead of rapid return to effective  ness. The traditional principles of treatment for battle fatigue still apply. These are expressed in the memory aids "PIES" and the "4 R's":
Proximity = treat close to or in the soldier's unit;

Immediacy = treat as soon as symptoms are detected;

Expectancy = expressed positive expectation of rapid return to duty;

Simplicity = use simple, mon mysterious, non "medical" methods.

Reassure of normality of the reaction in this abnormal situation;

Rest, briefly, from the heavy stress;

Replenish physiological status (hydration, nutrition, sleep, hygiene).

Restore confidence with debriefings, recreation, and work details.

The most serious concern in some operations other than war is with assuring that the soldiers return home and continue their careers without being haunted or worn out by the memories of what they have done or seen. Post traumatic stress disorder is a recognized clinical condition with strict criteria both for the original terrible event and the recurring symptoms. The symptoms include reexperiencing the event in disruptive memories and dreams, hyperarousal, increasing constriction of activities to avoid the memories, and disturbed interpersonal relationships. The sufferers of post traumatic stress, and of less dramatic post deployment stress, are not always obvious, and often lack insight into the causes. They may present with misconduct behaviors, burnout (performing poorly at or quitting high stress jobs), family violence, or physical illness complaints. The result can end their military careers, loses for the service their hard won experience, and burden Society. Prevention involves talking through the experience, preferably with peers, soon after it occurred. Just as the mechanical equipment needs to be cleaned and oiled after use in corrosive or dirty environments, so the human mind needs to resolve harmful memories before they lock into the deep workings of the brain.
RESPONSIBILITIES AND ASSETS FOR STRESS CONTROL
The U.S. Army stress control field manuals emphasize that control of stress is ultimately the leaders' responsibility at every echelon. The mental health personnel in unit mental health sections and combat stress control units have as their primary mission assisting Command with promotion of positive stress behaviors and prevention of dysfunctional ones. They have the secondary missions of on site case evaluation and far forward treatment for stress and neuropsychiatric casualties.
Currently, each U.S. Army division has a psychiatrist, social worker, clinical psychologist, and 6 or 7 enlisted specialists. The 23 person Combat Stress Control Detachments and 85 person CSC Companies have more of the same specialties, plus psychiatric nursing and occupational therapy expertise. They can tailor smaller teams for specific operations other than war.
The Chaplaincy also has a well defined role in monitoring and sustaining morale and spiritual well being. The chaplains in every maneuver battalion and many headquarters and hospitals play key roles, as can other staff and medical personnel. They should be monitored, mentored, and quality assured by the MH/CSC personnel.
Stress control must be continuous from the site of stress back to the home station, where a number of Department of Army and other governmental agencies are involved. These agencies include the Army Community & Family Support Center in Alexandria, Virginia, and the Family Advocacy, Drug & Alcohol Prevention/Control Program personnel, Army Community Service, and Medical Command activities at Army posts. The Center for Health Promotion and Preventive Medicine in Aberdeen, Maryland, is a recently activated medical general officer command. It can potentially provide valuable technical oversight and support to stress control. The Medical Research & Materiel Command, especially the Walter Reed Army Institute of Research, conducts research into the stressors and stress in military operations. The Department of Veterans' Affairs also conducts research, as well as providing treatment for retirees and some current service members.

STRESS CONTROL ACTIVITIES IN EACH PHASE OF AN OPERATION

The Army Medical Department recommends specific stress control activities be accomplished in each phase of an operation: Preparation and Predeployment, Deployment and In Country Routine, Special Critical events, and Pre Homecoming and Post Homecoming. Critical events (especially terrible experiences) can happen with little or no warning in any phase, but are more likely during the deployment.

PREDEPLOYMENT

The preparation and immediate predeployment phase may be predictable and long, or it may be uncertain and very short. In either case, it provides a crucial opportunity. Soldiers will be less likely to commit cultural blunders and will be better able to cope with cultural differences (and even with horror or injustice) if they have been forewarned and have information with which to moderate their emotional reactions. The intelligence and civil affairs staffs prepare brief talks or handouts for leaders to give to the troops about the area of operation, including something of its history and culture. Because regional expertise is rare and published area studies become obsolete quickly in the modern world, this is an intervention that can be improved by modern information gathering and dissemination technologies.
Preventive medicine booklets have been quickly assembled and distributed for all the recent military operations by Medical Research and Materiel Command institutes or by the Center for Health Promotion and Preventive Medicine. These booklets detail the environmental and disease threats and countermeasures. They have had only general paragraphs on stress, but they can become the vehicle for more historical and cultural information from regional experts. Special Operations Command has many of those experts. The booklets have the advantage of providing reading during transit and in theater. It is still important that the information be briefed orally to the troops. The briefings can be supplemented by audio or video tapes for delivery to large audiences. "Stress inoculation" can be accomplished by showing the troops videos of the actual or expected horrors, similar to what is often being shown on the TV network news. These presentations must always convey the positive expectation that the troops will tolerate the real exposures well. They should teach simple coping techniques.
Many units could benefit from special training. Peacekeeping rules of engagement and negotiating skills for combat arms units have been highlighted in some rotations at the U.S. Army's combat training centers, where a full time cadre play the roles of the local non combatants as well as the partisans to the conflict. Mission rehearsal is great, when time and advanced knowledge of the mission allows it. Special effort may be needed to assure predeployment training is given to the combat service support units, especially those which are added to the task organization from distant Army posts or the Reserves.
The inclusion of all unit families (and the significant others of single soldiers) in strong family support groups is essential to reducing stressful distractions on the deploying soldiers. This is difficult when families live off post or far away. Mental health sections, stress control unit personnel and the unit chaplains should actively assist these groups.
DURING THE DEPLOYMENT
Mental health or stress control teams should deploy relatively early, as they have in Somalia, Haiti and Bosnia. Once in country, they perform the routine duties shown in Table 2. Unit survey interviews are systematic ways of monitoring the perceptions and morale at all echelons and providing useful feedback to the leaders. The teams should advise and mentor the leaders of squads and platoons to conduct their own routine after action debriefings. They can help facilitate the resolution of individual soldiers' homefront concerns.

Telemedicine refers to the use of sophisticated digital, audio and video telecommunications to provide expert consultation and diagnosis from a distance. In the mental health arena, unlike surgery, useful consultation cannot be provided by some unknown, distant "expert." Too much depends on the consultant's specific knowledge of the situation and the unit. In a large operation other than war, telemedicine will help the widely dispersed stress control teams in theater pool their specialty expertises and experiences. It will allow them to provide consultation to line or medical units in many situations without having to risk travel back and forth. For a small, low risk operation, telemedicine will enable an already trusted consultant to provide support without leaving home station unless some especially traumatic event occurs to warrant their deployment.
CRITICAL EVENTS
When some soldiers are subjected to an especially horrifying, terrifying or frustrating critical event, the stress control teams should provide advice and emotional support to the leaders and chaplains They should be called upon to conduct or supervise critical event debriefings for all involved small units. They may assist the chaplains and leaders with planning appropriate memorial activities. Following events such as suicides, they can also provide suicide prevention classes and clinical interventions, as was done in Haiti after the two Army suicides occurred.
PRE  AND POST HOMECOMING
Whether or not there were any critical events, all units should conduct end of tour debriefings. In these, the teams and larger elements review the operation from predeployment to the end, talking about what went well and what did not, the lessons learned, the good and bad times. This fosters a sense of shared completion and closure. The mental health and stress control personnel can facilitate and even conduct these debriefings for units which have suffered critical events. Even more urgently, the stress control teams can assist units which suffered from noncritical but chronic conditions that have eroded cohesion and morale.
There should also be pre homecoming orientation briefings for the soldiers in theater and also for the families back home. These presentations can often be given by unit chaplains. They discuss the expectable minor (and occasionally major) frustrations of reunion, and how to weather those frustrations. The stress control team can give advice regarding these briefings, and also on suitable unit activities following reunion. They can provide followup on request, at either the unit or the individual level. Because of the geography, the home base (whether active or Reserve component) parts of these programs must often be provided by stress control units or medical personnel who did not, themselves, deploy.
The stress control measures recommended by doctrine were begun in the Persian Gulf War and the Somalia operation. Although there were notable successes, the work was limited in the initial months by lack of experience and in the late stages by insufficient resources in theater. Stress control support for the Rwanda humanitarian relief operation was much less than doctrine recommended. The Haiti Operation was the first in which stress control resources and activities came close to what is prescribed by doctrine. While Haiti did not involve significant risk to U.S. troops, it had its own set of frustrations and some truly distressing events. In the 6 months from 15 January to 8 June, the 4 person stress control team supporting the U.S. contingent made 172 base camp visits (including some Special Forces teams in remote villages), and logged about 8,000 miles on its vehicle. It conducted 13 battalion aid station visits, 12 unit ministry team meetings, 20 stress management classes, 7 critical event debriefings, and 33 end of tour debriefings, involving direct contact with a total 3603 soldiers. It also made 82 clinical command consultations, counseled 261 individual U.S. soldiers, plus 31 multinational cases from 16 countries. The team evacuated only 1 soldier from theater. In the much larger, more complex and dangerous Bosnia operation, an 8 person division mental health section, a 23 person combat stress control detachment and a 9 11 person element of a second detachment, have been similarly busy, dividing up unto smaller teams to cover many separated locations.

RESEARCH
It is important to continually assess systematically the stressors and stress reactions in operations other than war, and the effectiveness of our interventions. The Medical Research and Materiel Command's Walter Reed Army Institute of Research (WRAIR) sent Human Dimensions Teams to Operation Desert Shield in Saudi Arabia (which was an expanding operation other than war up until 15 January '91). More recently WRAIR sent teams to Somalia, Haiti, the October '94 Kuwait contingency deployment, and Bosnia.
These 3 to 4 person research teams conduct structured unit interviews and administer survey questionnaires. They are sent to acquire data for the Department of Army Staff, for use in reviewing policy. In theater, they work closely with the medical stress control teams, who provide them assistance in getting into the units and can expand their data collection capability. The Human Dimensions Teams provide immediate feedback to the commanders in theater in the form of outbriefings each time they finish surveying a unit and before departing the theater.
Some of the findings of a WRAIR Survey of units in Haiti are presented here. The mission was to assess soldier psychological and physical well being, unit cohesion, and leadership climate. The objective was to provide information to Army leaders on how to sustain effective performance and prevent casualties in this new and unpredictable type of constabulary operation. Questionnaire surveys were returned by 3210 soldiers, and over 300 soldiers were also interviewed directly.
The soldiers reported "uncertainty of date of return" and "environmental conditions" as their greatest stressors. Other significant stressors included lack of time off, waiting without work to do, lack of morale/welfare/recreation equipment, and fear of getting a disease. The soldiers reported a number of ways they used to manage the stress. The large majority of soldiers in Haiti felt they were coping well. However, four percent were clearly distressed, and two percent reported that they were coping very poorly. It is this two percent who could cause significant harm to the mission, to the commander's ability to stay focused on the mission, or to themselves.
Although only a few soldiers reported they were coping poorly, many reported physical health symptoms, most of a non specific type. Companies differed markedly in the average number of physical symptoms their soldiers reported. The worst had over three times as many as the best. Companies also differed markedly in the average number of psychological distress symptoms their soldiers reported. There was a strong positive correlation between the physical and the psychological symptoms. When physical symptoms were plotted against leadership climate (defined in accordance with Army doctrinal definitions), there was a strong correlation between poor leadership climate and health complaints. There were also more health complaints, on average, when troops lacked belief in the value of the operation. Good leadership climate reduced the health symptoms in the troops, even when there was low belief in the value of the operation.
The findings of the Human Dimensions Teams have proved sufficiently valuable to the Department of Army Staff that the Deputy Chief of Staff for Personnel has requested that they be incorporated into a field Medical unit which will deploy routinely. The Medical Department plans to incorporate an 8 person Human Dimensions Team into each corps level medical command headquarters for Army Force 21.

The Department of Veterans Affairs conducted a questionaire survey of 1907 Army and Marine Corps returnees from Somalia. Dr. Bret Litz, of the National Center for Posttraumatic Stress Disorder, has reported preliminary findings. Four percent reported symptoms sufficient to meet strict criteria for post  traumatic stress Disorder.
Veterans' Affairs also monitors the self referrals of deployment veterans to the Veterans' Outreach and Readjustment Centers. These include retirees, discharged service members, reservists, and a few active duty service members. The active duty mental health sections, clinics and stress control detachments that support units which have returned from operations other than war have provided some memorable anecdotes of soldiers suffering from post traumatic stress problems, but there is no central, systematic collation of their caseloads.
United States Army stress control doctrine, organization and training for peace support operations is making good progress, but has not yet been tested in a highly traumatic scenario such as Bosnia under UNPROFOR, before the Dayton Agreement and NATO intervention. We seek to learn from the experience of our allies who had prolonged experience in that (and other) most unpeaceful of peacekeeping operations. We are also eager to share our experience with new Partners for Peace.
REFERENCES
Field Manual 22 51, Leaders' Manual for Combat Stress Control, HQDA,

Wash DC, 29 September 1994

Field Manual 8 42, Combat Health Support in Operations Other Than War,

HQDA, Wash DC,

Field Manual 8 51, Combat Stress Control in a Theater of Operations  

Tactics, Techniques, Procedures, HQDA, Wash DC, 29 September, 1994.

Field Manual 8 55, Planning for Health Service Support, HQDA, 9 September 1994

   LEADERS' MANUAL FOR COMBAT STRESS CONTROL, BOOKLET 1

(FM 22 51 chapter 1, Appendices B, C)

   COMBAT STRESS BEHAVIORS (FM 22 51 chapters 2, 3, 4, 5, 6)
   STRESS ISSUES IN ARMY OPERATIONS (FM 2 51 chapters 7, 8, 9, 10)
   LEADER ACTIONS TO OFFSET BATTLE FATIGUE RISK FACTORS

(FM 22 51 Appendix A and chapter 11, which reference the following GTA's, and expand on the outline of part of GTA 21 3 6)

o 3 pocket card Graphical Training Aids (official Army, available thru Training and Audiovisual Support Centers (TASC)).
   GTA 21 3 4 BATTLE FATIGUE: NORMAL, COMMON SIGNS; WHAT TO DO FOR SELF AND BUDDY (1986)

   GTA 21 3 5 BATTLE FATIGUE: WARNING SIGNS, LEADER ACTIONS (1995 update)

   GTA 21 3 6 BATTLE FATIGUE: COMPANY LEADER ACTIONS AND PREVENTION (1994 update)

o COMBAT STRESS CONTROL IN A THEATER OF OPERATIONS    TACTICS, TECHNIQUES, PROCEDURES, HQ DA, 29 Sep 1994. A 3 booklet set, extracted by reducing Xerox machine from Field Manual FM 8 51, Combat Stress Control in a Theater of Operations   TTP.

   BOOKLET 1: C0NTROL OF COMBAT STRESS, CSC CONSULTATION, CSC RECONSTITUTION SUPPORT (FM 8 51 chapters 1, 4, 5)
   BOOKLET 2: COMBAT NEUROPSYCHIATRIC TRIAGE; CSC STABILIZATION; CSC RESTORATION, CSC RECONSTITUTION (FM 8 51 chapters 6, 7, 8, 9)
   BOOKLET 3: MENTAL HEALTH & CSC ELEMENTS IN A THEATER OF OPERATIONS; CSC OPERATIONS IN THE COMBAT ZONE (FM chapters 2, 3)
o PLANNING FOR COMBAT STRESS CONTROL (FM 8 55 chapters 1, 2, 12, and appendices B, C). A booklet, extracted by reducing Xerox machine from Army Field Manual FM 8 55, Planning for Health Service Support, HQ DA Sep 1994.

o PLANNING FOR COMBAT STRESS CONTROL IN JOINT OPERATIONS, Draft #3, Oct 1993 (unofficial). A booklet, reduced on the xerox machine from a paper by COL Stokes:

o COMBAT STRESS CONTROL IN OPERATIONS OTHER THAN WAR, March 1994.

A booklet, reduced on the Xerox machine from a draft white paper by COL Stokes, with card annexes.
o STRESS DIMENSIONS IN OPERATIONS OTHER THAN WAR

A booklet, extracted from the "CSC in OOTW" booklet.

o PROVIDING COMBAT STRESS CONTROL IN OPERATIONS OTHER THAN WAR

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