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APPENDIX D. THE GENEVA CONVENTIONS AND COMBAT STRESS-RELATED CASUALTIES ........................................................ D-1

D-1. Special Relevance to Medical Combat Stress Control ........................... D-1D-2. Special Considerations for Medical Combat Stress Control Activities ........ D-1D-3. The Law of War ........................................................................ D-5D-4. Protection of the Wounded and Sick ................................................ D-6D-5. Protection and Identification of Medical Personnel ............................... D-9D-6. Protection and Identification of Medical Units and Establishments,

Buildings and Material, and Medical Transports ............................... D-10D-7. Loss of Protection of Medical Units and Establishments ........................ D-12D-8. Conditions Not Compromising Medical Units and Establishments of

Protection.............................................................................. D-13

APPENDIX E. MEDICAL REENGINEERING INITIATIVE FOR MENTAL HEALTHAND COMBAT STRESS CONTROL ELEMENTS IN THETHEATER OF OPERATIONS ................................................. E-1

Section I. Overview of Changes ................................................................. E-1E-1. Unit Mental Health Sections .......................................................... E-1E-2. Combat Stress Control Units ......................................................... E-2

Section II. Unit Mental Health Sections in the Theater of Operations .................. E-5E-3. Location and Assignment of Unit Mental Health Sections ...................... E-5E-4. Utilization in Garrison ................................................................. E-5E-5. Division Mental Health Sections ..................................................... E-6E-6. Area Support Medical Battalion Mental Health Sections ........................ E-11E-7. Mental Health Personnel in the Armored Cavalry Regiments and

Separate Brigades .................................................................... E-15

Section III. Combat Stress Control Company ................................................. E-15E-8. Medical Company, Combat Stress Control (TOE 08467A000) ................ E-15E-9. Headquarters Section .................................................................. E-17

E-10. Combat Stress Control Preventive Section ......................................... E-22E-11. Combat Stress Control Fitness Section ............................................. E-25

Section IV. Combat Stress Control Detachment .............................................. E-30E-12. Medical Detachment, Combat Stress Control (TOE 08567AA00) ............. E-30E-13. Detachment Headquarters ............................................................. E-31E-14. Preventive Section ...................................................................... E-34E-15. Combat Stress Control Fitness Section ............................................. E-36

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GLOSSARY ..................................................................................................... Glossary-1

REFERENCES ................................................................................................. References-1

INDEX ............................................................................................................ Index-1

PREFACE

This field manual (FM) establishes medical doctrine and provides principles for conducting combat stresscontrol (CSC) support operations from forward areas to the continental United States- (CONUS) based medicalfacilities. This manual sets forth tactics, techniques, and procedures (TTP) for CSC units and elements operatingwithin the theater of operations (TO). This TTP is applicable to operations across the operational continuum. Itis important that the users of this manual be familiar with FM 22-51. This manual supports the Army MedicalDepartments (AMEDD) keystone manual, FM 8-10. Readers should have a fundamental understanding of FMs8-10-3, 8-10-5, 8-10-6, 8-10-8, 8-10-14, 8-10-24, 8-42, 8-55, 63-20, 63-21, 100-5, and 100-10.

The staffing and organizational structure presented in this publication reflects information in the most currentliving tables of organization and equipment (TOE) as of calendar year 1993. However, staffing is subject to changeto comply with manpower requirements criteria outlined in AR 570-2. Your TOE can be subsequently modified.

The Medical Reengineering Initiative (MRI) update has been added to this publication as Change 1,Appendix E. Organizational changes to CSC elements as a result of MRI were incorporated into the A-series TOE.CSC elements will convert from the L-series to the A-series TOE in the near future based on Department of theArmy (DA) timelines.

This publication is in agreement with the American, British, Canadian, and Australian (ABCA) QuadripartiteStandardization Agreement (QSTAG) 909, Principles of Prevention and Management of Combat Stress Reaction,Edition 1.

The proponent of this publication is the United States (US) Army Medical Department Center and School(AMEDDC&S). Send comments and recommendations on DA Form 2028 directly to Commander, AMEDDC&S,ATTN: MCCS-FCD-L, 1400 East Grayson, Fort Sam Houston, Texas 78234-6175.

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

Use of trade or brand names or trademarks in this publication is for illustrative purpose only, and does not implyendorsement by the Department of Defense (DOD).

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PREFACE

This field manual (FM) establishes medical doctrine and provides principles for conducting combatstress control (CSC) support operations from forward areas to the continental United States- ( CONUS)based medical facilities. This manual sets forth tactics, techniques, and procedures (TTP) for CSC unitsand elements operating within the theater of operations (TO). This TTP is applicable to operations acrossthe operational continuum. It is important that the users of this manual be familiar with FM 22-51. Thismanual supports the Army Medical Departments (AMEDD) keystone manual, FM 8-10. Readers shouldhave a fundamental understanding of FMs 8-10-3,8-10-5,8-10-6, 8-10-8,8-10-14,8-10-24, 8-42,8-55,63-20, 63-21, 100-5, and 100-10.

The staffing and organization structure presented in this publication reflects information in the mostcurrent living tables of organization and equipment (TOE) as of calendar year 1993. However, staffing issubject to change to comply with manpower requirements criteria outlined in AR 570-2. Your TOE canbe subsequently modified.

This publication is in agreement with the American, British, Canadian, and Australian (ABCA)Quadripartite Standardization Agreement (QSTAG) 909, Principles of Prevention and Management ofCombat Stress Reaction, Edition 1.

The proponent of this publication is the United States (US) Army Medical Department Center andSchool (AMEDDC&S). Send comments and recommendations on Department of Army (DA) Form 2028directly to Commander, AMEDDC&S, ATTN: HSMC-FCD, Fort Sam Houston, Texas 78234-6123.

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

Use of trade or brand names or trademarks in this publication is for illustrative purpose only, and doesnot imply endorsement by the Department of Defense (DOD).

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CONTROL

1-1. Stress Control

CHAPTER 1

OF COMBAT STRESS

a. Control of Stress. In ones ownsoldiers and in the soldiers of the enemy, controlof stress is often the decisive difference betweenvictory and defeat across the operational con-tinuum. Battles and wars are won more bycontrolling the will to fight than by killing all ofthe enemy. Soldiers that are properly focused bytraining, unit cohesion, and leadership are mostlikely to have the strength, endurance, and alert-ness to perform their combat mission. In thesesoldiers, combat stress is controlled and positivecombat stress reactions, such as loyalty, self-lessness, and acts of bravery, are more likely tooccur. However, uncontrolled combat stresscauses erratic or harmful behavior, impairsmission performance, and results in disaster anddefeat.

b. Responsibility For Stress Control.Control of stress is the commanders responsibility(see FM 22-51) at all echelons. The commanderis aided in this responsibility by the noncom-missioned officer (NCO) chain of support; thechaplaincy; unit medical personnel; general,principal, and special staff, and by specializedArmy CSC units and mental health personnel.

c. Control or Management. The wordcontrol is used with combat stress (rather thanthe word management) to emphasize the activesteps which leaders, supporting medical per-sonnel, and individual soldiers must take to keepstress within an acceptable range. This does notmean that control and management are mutuallyexclusive terms. Management is by definitionthe exercise of control. Within common usage,however, and especially within Army usage,management has the connotation of being asomewhat detached, number-driven, higherechelon process rather than a direct, inspi-rational, and leadership-oriented process. Controlof stress does not imply elimination of stress.

Stress is one of the bodys processes for dealingwith uncertain changes and danger. Eliminationof stress is both impossible and undesirable inthe Armys peacetime or combat mission.

1-2. Combat Stress Threat

a. Stressors in Combat. Many stres-sors in a combat situation are due to deliberateenemy actions aimed at killing, wounding, ordemoralizing our soldiers and our allies. Otherstressors are due to the natural environment.Some of these stressors can be avoided orcounteracted by wise command actions. Stillother stressors are due to our own calculated ormiscalculated choice, accepted in order to exertgreater stress on the enemy. Sound leadershipworks to keep these within tolerable limits andprepares the troops mentally and physically toendure them. Some of the most potent stressorscan be due to personal or organizational problemsin the unit or on the home front. These, too,must be identified and, when possible, correctedor controlled. See FMs 8-10, 8-10-8, and 22-51for additional information on the overall threat,medical threat, and combat stress threat.

b. Stress Casualties. The combat stressthreat includes all those stressors (risk factors)which can cause soldiers to become stresscasualties. Stress casualties include

Battle fatigue (BF) cases whichare held for treatment at medical treatmentfacilities (MTFs) for more than a day.

Misconduct stress behaviorscases that have committed breaches of disciplinewhich require disciplinary confinement.

Post-traumatic stress disorder(PTSD) cases which disable the soldier for monthsor years after the battle.

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The combat stress threat also includes somewounded in action (WIA) or disease and nonbattleinjury (DNBI) casualties whose

Disabilities are a direct con-sequence of carelessness or inefficiency due tostress.

Recovery and return to duty(RTD) is complicated by unresolved stress issues.

In a broader sense, the combat stress threat alsoincludes the missed opportunities and increasedcasualties (killed, wounded, and/or takenprisoner) that come from impaired decisionmaking or faulty execution of mission due toexcessive stress.

c. Mental Stressors and PhysicalStressors. A rough distinction can be madebetween those stressors which are mental andthose which are physical.

(1) A mental stressor would be onein which information is sent to the brain, withonly indirect physical impact on the body. Thisinformation may place demands on and evokereactions from either the perceptual and cognitivesystem, or the emotional systems in the brain, orfrom both.

(2) A physical stressor is one whichhas a direct, potentially harmful effect on thebody. These stressors may be external environ-mental conditions or the internal physical/physiologic demands required by or placed uponthe human body.

(3) Table 1-1, Combat Stressors,gives examples for the two types of mentalstressors (cognitive and emotional) and the twotypes for physical stressors (environmental andphysiological).

(4) The physical stressors evokespecific stress reflexes, such as shivering andvasoconstriction (for cold), sweating andvasodilation (for heat), or tension of the eardrum(for noise), and so forth. A soldiers stress reflexescan counteract the damaging impact of thestressors up to a point but may be overwhelmed.

(5) The distinction between mentaland physical stressors is rarely obvious.

(a) Mental stressors can alsoproduce some of the same stress reflexesnonspecifically (such as vasoconstriction,sweating, adrenaline release). These stressreflexes can markedly increase or decrease anindividuals vulnerability to specific physicalstressors. Mental stressors presumably causechanges in the electrochemical (neurotransmitter)systems in the brain.

(b) Physical stressors canresult in mental stress because they causediscomfort, impair performance, and provideinformation which poses a threat.

(c) Physical stressors caninterfere directly with brain functioning andtherefore with perceptual and cognitive mentalabilities, thus increasing the stresses.

(d) Light, noise, discomfort,and anxiety-provoking information may interferewith sleep, which is essential to maintain brainefficiency and mental performance.

(6) Because of this intermeshing ofphysical and mental stressors and stressresponses, no great effort needs to be invested indistinguishing them until the physical stressorsreach the degree where they require specific (andperhaps emergency) protective measures and/ortreatment. Prior to that point, medical andmental health personnel should assume that bothphysical and mental stressors are usually present

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and interacting. They should treat both types ofstressors simultaneously as standard procedure.

d. Positive Stress. Positive stress isthat degree of stress which is necessary to sustainand improve tolerance to stress withoutoverstraining and disrupting the human system.Some level of stress is helpful and even necessaryto health. Insufficient stress leads to physicaland/or mental weakness. A moderate responseto stress actually improves performance. Soldierswho have been trained to manage their responsesto a stressful situation by maintaining neithertoo low nor too high a level of activation performtasks better. Progressively greater exposure to a

physical stressor, sufficient to produce more thanroutine stress reflexes, is often required toachieve greater tolerance or acclimatization tothat stressor. Well-known examples arecardiovascular and muscle fitness and heat andcold acclimatization. Stressors which overstrainthe human system can clearly retardacclimatization and even permanently impair it.For instance, in the physical stress examplegiven, excessive physical work can causetemporary or permanent damage to muscles,bones, and heart, while extreme heat and coldcan cause heatstroke or frostbite withpermanently reduced tolerance to heat or cold.The same may be true of emotional or mental

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stress, although the mechanism is less clear. Upto a point, mental stress (even uncomfortable orpainful mental stress) may increase tolerance tofuture stress without any current impairment. Ahigher level may cause temporary overtrain butmay heal as strong or stronger than ever withrest and restorative processing. More severeoverstrain, however, may severely weakentolerance to future stress. There is reason tobelieve that immediate treatment can greatlyreduce the potential for chronic disability, evenfor impairing emotional overstrain.

1-3. Stress Behaviors in Combat

a. Combat Stress Behaviors. Combatstress behavior is the generic term which coversthe full range of behaviors in combat, from highlypositive to totally negative. Table 1-2 provides alisting of positive stress responses and behaviors,plus two types of dysfunctional combat stressbehaviorsthose which are misconduct stressbehaviors and those which are labeled BF.

b. Positive Combat Stress Behaviors.Positive combat stress behaviors includeheightened alertness, strength, endurance, andtolerance to discomfort. Both the fight or flightstress response and the stage of resistance canproduce positive combat stress behaviors whenproperly in tune. Examples of positive combatstress behaviors include

The strong personal trust,loyalty, and cohesiveness (called horizontalbonding) which develops among peers in a smallmilitary unit.

The personal trust, loyalty, andcohesiveness (called vertical bonding) thatdevelops between leaders and subordinates.

The sense of pride and sharedidentity which soldiers develop with the units

history and mission (this sense is called unitesprit de corps or simply esprit).

The above positive combat stress behaviorscombine to form unit cohesionthe binding forcethat keeps soldiers together and performing themission in spite of danger and death. Theultimate positive combat stress behaviors are actsof extreme courage and almost unbelievablestrength. They may even involve deliberate self-sacrifice. Positive combat stress behaviors can bebrought forth by sound military training, wisepersonnel policies, and good leadership. Theresults are behaviors which are often rewardedwith praise and individual and/or unit recog-nition. For additional information on positivecombat stress behaviors, see FM 22-51.

c. Misconduct Stress Behaviors.Examples of misconduct stress behaviors arelisted in the center column of Table 1-2. Theserange from minor breaches of unit orders orregulations to serious violations of the UniformCode of Military Justice (UCMJ) and the Law ofLand Warfare. As misconduct stress behaviors,they are most likely to occur in poorly trained,undisciplined soldiers. However, misconduct canalso be committed by good and even heroicsoldiers under extreme combat stress. In fact,misconduct stress behaviors can become thesecond edge of the double-edged sword of highlycohesive and proud units. Such units may cometo consider themselves entitled to special priv-ileges and as a result, relieve tension unlawfullywhen they stand-down from their combat mission.They may lapse into illegal revenge when a unitmember is lost in combat. Such misconduct stressbehaviors can be prevented by stress controlmeasures, but once serious misconduct hasoccurred, soldiers must be punished to preventfurther erosion of discipline. Combat stress, evenwith heroic combat performance, cannot justifycriminal misconduct. Combat stress may, how-ever, constitute extenuating circumstances forminor (noncriminal) infractions in determining

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nonjudicial punishment under Article 15, UCMJ.Combat stress may also constitute an extenuatingcircumstance in the sentencing proceedings of acourt-martial. See FM 22-51 for additional infor-mation on misconduct stress behaviors.

d. Battle Fatigue. Battle fatigue is alsocalled combat stress reaction or combat fatigue.Fatigue by definition is the distress and impairedperformance that comes from doing something(anything) too hard and/or too long. The termbattle fatigue is applied to any combat stressreaction which is treated. All BF is treated (asall types of fatigue) with the four Rs

Reassure of normality.

Rest (respite from the work).

Replenish physiologic status.

Restore confidence with activi-ties.

See Table 1-2 for examples of BF. The BF behav-iors which are listed near the top may accompanyexcellent combat performance, and are oftenfound to some degree in all soldiers. These arenormal, common signs of BF. Those behaviorsthat follow are listed in descending order toindicate progressively more serious warningsigns. Warning signs deserve immediate atten-tion by the leader, medic, or buddy to preventpotential harm to the soldier, others, or the mis-sion. If the soldier responds quickly to helpingactions, warning signs do not necessarily meanhe must be relieved of duty or evacuated.However, he may require further evaluation atan MTF to rule out other physical or mentalillness. If the symptoms of BF persist and makethe soldier unable to perform duties reliably,then MTFs, such as clearing stations andspecialized CSC teams, can provide restorativetreatment. At this point, the soldier is a BFcasualty. For those cases, prompt treatment

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close to the soldiers unit provides the best poten-tial for returning the soldier to duty. RecoveredBF casualties who are accepted back in their unitsare at no more risk of recurrence than their fellowsoldiers.

e. Overlapping of Combat Stress Be-haviors. The distinction between positive combatstress behaviors, misconduct stress behaviors,and BF is not always clear. Indeed, the threecategories of combat stress behaviors mayoverlap. Soldiers with BF may show misconductstress behaviors and Vice versa. Soldiers whoexemplify the positive combat stress behaviorsmay suffer symptoms of BF and may even be BFcasualties before or after their performance ofduty. Excellent combat soldiers may commitmisconduct stress behaviors in reaction to thestressors of combat before, after, or during theirotherwise exemplary performance. However,combat stress, even with good combat behaviors,does not excuse criminal acts.

f. Post-Traumatic Stress Disorders.Symptoms of post-traumatic stress are persistentor recurring stress responses after exposure toextremely distressing events. As with BF, post-traumatic stress symptoms can be normal/common signs or warning signs. These signs andsymptoms do not necessarily make the soldier acasualty nor does the condition warrant the labelof a disorder. This becomes PTSD only when itinterferes with occupational or personal life goals.These signs and symptoms sometime occurmonths or years after the event and mayinclude

Painful memories.

Actions taken to escape painfulmemories such as

Substance abuse.

Avoidance of remindersthe traumatic event.

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Social estrangement.

Withdrawal.

Post-traumatic stress disorder often follows inade-quately treated BF. It often follows misconductstress behaviors in those who committed mis-conduct under stress, as well as in the victims,reluctant participants, caregivers, and observers.Post-traumatic stress disorder can occur insoldiers who showed no maladaptive stress behav-iors at the time of the trauma. Post-traumaticstress disorders can occur or recur years after theevent, usually at times of excessive stress. Inaddition to their primary mission during war,leaders, chaplains, and medical and CSC per-sonnel have the additional responsibility ofpreventing or minimizing subsequent PTSD. Themost important preventive measure for PTSD isroutine after-action debriefing in small groups.If properly debriefed, soldiers will often notdevelop clinical PTSD or misconduct stressbehaviors. Experiences of excessive stress can beaccepted and diverted into positive growth. Foradditional information on PTSD, its prevention,and treatment, see FM 22-51.

1-4. Stressors and Stress in Army Opera-tions

a. The Changing Focus. The emergingconcept for Army operations in the post-cold warera has reoriented the nations military capabilityaway from a primary focus on potential large scalewar against Soviet forces in Europe. The focushas shifted towards a more ambiguous threatfrom current or future regional powers aroundthe world.

(1) High technology weapons areavailable from a number of sources throughoutthe world. The dissolution of the Soviet empiremay disperse quantities of high technologyweapons (and weapons design expertise) to

ambitious countries who are hostile toward theUS or toward nations important to the US.Consequently, the danger of regional armor-heavy battles at the high-intensity end of thecontinuum of conflict, and even of regionalnuclear, biological, and chemical (NBC) war, mayparadoxically increase over the next decades.

(2) Alternatively, hostile states (orethnic/religious factions encouraged by them)may attempt to overthrow friendly nations orattack the US interest by conducting terrorist orinsurgency operations. These attacks mayrequire counteractions by US combat forces. Inoperations other than war (OOTW), contingencyoperations may be needed to protect US lives,property, and international standards of humaneconduct in third world countries which areotherwise of little concern to the US. Theseoperations will likely be conducted on shortnotice, under conditions of high operationalsecurity. They will also be subject to intense andnear-instantaneous media coverage.

b. High-Technology Joint and Coa-lition Operations. Most combat and contingencyoperations will be joint operations. Many willinvolve working in coalition with countries whosecustoms and culture are quite different from ourown. The US will make maximal use of ourtechnological superiority in intelligence-gatheringand weapons systems to mobilize overwhelmingforces at the decisive point for quick and certainvictory. However, those systems can only be aseffective as the stress tolerance of the humancommanders and soldier/operators make them.The combining of highly lethal weapons systemsfrom different branches, services, and alliescreates an intrinsic risk of friendly fire casualties.This risk, too, must be calculated and the stressconsequences controlled.

c. Brigade Task Force Operations. TheArmy operations concept makes the brigade thecritical unit for CSC prevention and immediate

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intervention, more so than in previous wars.Divisional and separate brigades and armoredcavalry regiments (ACRs) will be combined intotask forces for rapid-deployment contingencyoperations. Within campaigns, brigade taskforces will be rapidly organized for specific, brief,violent battles. During battles, the task forcescan cover great distances quickly, concentrate fordecisive action, and perhaps reconstitute atdifferent tactical support areas than the ones fromwhere they started. Between battles, brigadesmay remain widely dispersed. A brigade whichis armed with modern weapons systems has morefirepower and covers a larger area of responsi-bility than a World War I (WWI) or WWIIdivision. At the small unit level, the importanceof individual soldiers to the units combat poweris also greatly increased for weapons operatorsand leaders. It is equally true for critical combatsupport (CS) and combat service support (CSS)specialists. Rear battle, in the form of long-rangeartillery fire, enemy airborne/air assault units,guerrilla activity, air interdiction, and terroristor missile attacks, may strike far behind thebattle area. Army mental health/CSC organi-zation and doctrine were first designed to supportWWI and WWII divisions. Our new mentalhealth/CSC doctrine and units must adapt tothese changing conditions by assuring integralCSC support at brigade level while improvingcoverage throughout the supported area.

d. Military Operations Other ThanWar. In addition to war, there will be manyother Army missions which are prolonged. TheNational Command Authority may commit USArmy units to military OOTW including

Conflict.

Nation assistance.

Security assistance.

Humanitarian assistance anddisaster relief.

tions.

erations.

Support to counter drug opera-

Peacekeeping operations.

Arms control.

Combatting terrorism.

Show of force.

Attacks and raids.

Noncombatant evacuation op-

Peace enforcement.

Support for insurgences andcounterinsurgencies.

Support to domestic civil au-thorities.

The rules of engagement for each of the aboveoperations are unique to that situation. Require-ments to maintain neutrality provide a show offorce only, engage in constructive humanitarian,or other such actions may require that only defen-sive actions be taken once attacked. In conflict,however, the opponents may deliberately seek toprovoke our forces into committing misconductstress behaviors. By committing criminal acts,the role of the US Forces would be degraded inthe eyes of local, US, and world populations. Inlight of this, the CSC role in the prevention ofmisconduct stress behaviors is extremely impor-tant. For definitive information pertaining toOOTW, see FM 100-5.

e. Neuropsychiatric Disorders. Thefocus of CSC is on the prevention and treatmentof stress-induced disability in otherwise normalsoldiers. Mental health/CSC personnel, by virtueof their professional training and experience, are

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also best qualified to diagnose, treat, and recom-mend RTD or disposition for the endemicneuropsychiatric (NP) disorders. These NPdisorders include the schizophrenic-type psychoticdisorders, mood disorders, anxiety disorders,organic mental disorders, personality disorders,and substance abuse disorders. These NP dis-orders are significant impediments to combatreadiness and also to peacetime training. Soundprevention and screening programs as identifiedin Army Regulation (AR) 40-216, as well as earlyrecognition and treatment, assist the commandin maintaining the fighting strength.

1-5. Army Combat Stress Control

a. Focus of Army Combat Stress Con-trol. The focus of Army CSC is toward

Promotion of positive mission-oriented motivation.

Prevention of stress-relatedcasualties.

Treatment and early RTD ofsoldiers suffering from BF.

Prevention of harmful combatstress reactions such as misconduct stressbehaviors and PTSD.

b. Implementation. The CSC programis implemented by mental health/CSC person-nel organic to the divisions, the medicalcompanies of separate brigades, and the areasupport medical battalions (ASMBS) in the corpsand communications zone (COMMZ) (seeChapters 2 and 3). These mental health/CSCpersonnel are augmented by the CSC company ordetachment. Combat stress control companiesand detachments are assigned to the corps and inthe COMMZ (see Chapters 2 and 3). Primarygoals of mental health/CSC personnel whenimplementing this program are to

Monitor stressors and stress inunits.

Advise command on measuresto reduce or control stress and stressors beforethey cause dysfunction.

Reduce combat stress-relatedcasualties by training leaders, medical person-nel, chaplains, and soldiers on stress-copingtechniques.

Promote positive combat stressbehavior and progressively increase stress toler-ance to meet the extreme stress of combat.

Recognize and treat BF andother stress reactions as early and as far forwardas possible.

Accomplish the earliest RTDof most soldiers who become stress-relatedcasualties.

Facilitate the correct disposi-tion of soldiers whose BF, misconduct stressbehaviors, and NP disorders do not allow RTD.

Reduce PTSD, chiefly by train-ing and assisting after-action debriefings and byleading critical event debriefings.

1-6. Historical Experience

The AMEDD identified "CSC as a separatefunctional mission area in 1984, but CSC is notnew. Historical experience in the Civil War,WWI, WWII, Korea, Vietnam, the Arab-Israeli,and other wars has demonstrated the basicprinciples of combat psychiatry and combatmental health. The goal is to preserve thefighting strength by minimizing losses due to BFand NP disorders.

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a. World War I. In 1917, before sendingthe American Expeditionary Force to Europe, theUS Army sent a medical team to see what ournew allies had learned from hard experienceabout casualty care. Based on the finding of thisteam in the combat psychiatry area, The SurgeonGeneral of the Army recommended that we adopta three-echelon system similar to that of theBritish Army. He also recommended that weimplement their policies to return soldiers withwar neurosis (commonly mislabeled shell shock)to duty. Accordingly, in WWI, we assigned apsychiatrist to each division (first echelon) to trainthe unit leader and medical personnel. Thepsychiatrist trained unit leaders and medicalpersonnel to recognize and treat simple fatiguecases in their own units. Many US stresscasualties were returned to duty after resting afew days in the 150-cot field hospital which waslocated in the division rear. By direction of TheSurgeon Generals NP consultant, the officialdiagnostic label for these types of cases while thesoldier was still in the division area was Not YetDiagnosed, Nervous, (also adapted from theBritish and abbreviated NYDN). The psychiatristscreened out and evacuated soldiers with seriousNP disorders. Behind the division (secondechelon), we had special neurological hospitals(150-bed facilities with psychiatrist supervisors).They treated the relatively few NYDN cases whodid not RTD within the division in a few days.They also treated some soldiers with gas mania,who believed they had been gassed when in factthey had not been. Further to the rear, we hadBase Hospital 117 (third echelon), staffed bypsychiatrists, nurses, specially trained medics,and occupational therapists. These medicalprofessionals salvaged many soldiers who did notfully recover in the neurological hospitals. Thisthree-echelon system worked well. However, onoccasions when the tactical situation interferedwith forward treatment, it clearly showed theimportance of treating the soldiers close to theirunits. Overall, a large percent of WWI warneurosis cases were RTD.

b. World War II. During the timebetween WWI and WWII, CSC insights and theprinciples learned were forgotten. It was believedthat prior screening could identify and excludemost of the soldiers who would be prone to psycho-neurosis and breakdown in combat. Thatscreening was glaringly unsuccessful. The WWIsystem was reinstituted during the Tunisia cam-paign, and the condition formerly identified aswar neurosis was officially labeled combatexhaustion. By late in the war, the Mediter-ranean and European theaters again hadpsychiatrists assigned to each division. Mostmaneuver battalions had rest centers in theirkitchen trains (where recovering soldiers weremonitored by the battalion surgeon). There wereexhaustion centers in the regimental or combatteam trains area, monitored by the regimentalsurgeon. The division psychiatrist trained theregimental and battalion surgeons in combatpsychiatry. During combat, the psychiatristtriaged and treated combat exhaustion cases atthe division clearing company and supervisedtheir further rehabilitation for 3 to 5 days at thedivisions training and rehabilitation center.There were also (once again) Army NP centers(clearing companies with psychiatric supervisorsand specially trained staff) behind the divisions,Psychiatric consultants were at Army level, andspecialized base hospitals were located in theCOMMZ. In heavy fighting during WWII, somedivisions had one BF casualty for every five,three, even two WIAs. However, highly trainedand cohesive units rarely had more than one BFcasualty for ten WIA. That ratio illustrated thevalue of strong leadership in preventing BF evenunder conditions of extreme stress.

c. Korea. In each division, the divisionpsychiatrist was assisted by a social workspecialist and a clinical psychologist specialist(initially, enlisted specialists; later officers).These professionals functioned very effectively intreating combat exhaustion (what is now referredto as BF). It should be stated that there was

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some confusion during the initial hasty mobili-zation and deployment and many combatexhaustion cases were inadvertently evacuatedto Japan. The lessons of WWII were institu-tionalized in a specialized unit, the "KO Team"(medical detachment, psychiatric). The primarymission of this mobile unit was to augment amedical clearing company and make it into anNP center. Late in the conflict, 85 percent of theBF cases returned to combat within 3 days. Anadditional 10 percent returned to limited duty inseveral weeks, and only 5 percent were evacuatedto CONUS.

d. Vietnam. In Vietnam, division men-tal health sections were located and worked atthe main base camp areas. They sometimes sentconsultation teams or enlisted behavioral sciencespecialists to visit base camps and fire bases.Many of these draftee mental health personnelwere professionals with masters- or doctorate-level degrees. Traditional combat exhaustionwas rarely seen, and most cases of BF werehandled within the units. Substance abuse, thelack of discipline, and even commission ofatrocities were significant problems but were notclearly recognized as misconduct stress behav-iors. By mid-1971, 61 percent of all medicalevacuations from Vietnam were NP patients(mostly substance abuse). Two KO Teams servedwith distinction in Vietnam, but because ofthe different nature of war, functioned mostlyas psychiatric augmentation to an evacuationhospital and as mobile consultation teams. In1972, based on the Vietnam experience, the KOTeam was redesigned into the OM Team.

e. Operation Desert Shield/Storm. Be-ginning in September of 1990, stress assessmentteams from the US Army Medical Research andDevelopment Command were deployed in supportof Operation Desert Shield. These teams con-ducted surveys of many combat, CS, and CSSunits in the TO. These stress assessment teamsused small group interviews and questionnaire

surveys to assess the soldiers level of unit cohe-sion and their self-perceived readiness for combat.The stress assessment teams provided feedbackto units and to the Army Central Command onhow to control stress and enhance morale andreadiness. They also provided training to leadersand troops on stress control. Corps- and theater-level OM Teams reached the theater in lateOctober and December. The mobile teamsactively undertook the command consultation andtraining mission to corps and echelon above corpsunits. They reinforced the activities of the divi-sion mental health sections. During OperationDesert Storm, division mental health/CSC teamswere deployed forward. These teams worked withunits who had suffered casualties. Combat stresscontrol teams from the corps were deployedbehind the brigades. These teams saw few stresscasualties during the ground offensive because ofits rapid and highly victorious pace which lastedonly 100 hours. During demobilization afterOperation Desert Storm, a systematic effort wasconducted by chaplains and mental health per-sonnel to prepare soldiers and their families forthe changes and stressors of reunion. Some unitswhich had especially difficult experiences receivedspecial debriefings.

1-7. Principles of Combat Psychiatry

The basic precepts of combat psychiatry havebeen documented in every US war in this century.Our allies through similar experiences havefurther documented these basic precepts. Theprinciples of combat psychiatry are

a. Maximize Prevention.

(1) Achieve primary prevention.Control (and when feasible, reduce) stressorswhich are known to increase BF and misconductstress behaviors. Some of the factors whichincrease stress and stress casualties include

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Being a new soldier (firsttime in combat) in a unit.

Home front worries.

Intense battle with manykilled in action (KIA) and WIA.

Insufficient tough, realis-tic training.

Lack of unit cohesion.

Lack of trust in leaders,equipment, and supporting arms.

Sleep loss.

Poor physical condition-ing (dehydration, malnutrition).

Debilitating environmen-tal exposure.

Inadequate information.

High degree of uncer-tainty and ambiguity.

Absence of an achievableend of the mission in sight.

Inadequate sense of pur-pose.

(2) Achieve secondary prevention.Minimize acute disability (morbidity) by trainingleaders, chaplains, and medical personnel to

Identify early warningsigns and symptoms of BF/combat stress or mis-conduct stress.

Intervene immediatelywith the soldiers to treat the warning symptomsand control the relevant stressors.

Prevent contagion by rap-idly segregating and treating dramatic BFcasualties and disciplining minor misconductstress behaviors.

Reintegrate recovered BFcasualties back into their units.

Taking and publicizingappropriate disciplinary actions for criminalmisconduct stress behaviors.

(3) Achieve tertiary prevention.Minimize the potential for chronic disability(PTSD), both in soldiers who show BF and thosewho do not. This is done by

Having an active pre-ventive program (debriefings) during andimmediately after combat and/or traumaticincident.

Conducting end of tourdebriefings for units and unit members families.

Remaining sensitive todelayed or covert post-traumatic stress signs andsymptoms and providing positive intervention.(This is primarily the role of leaders, chaplains,and health care providers. )

b. Treat Battle Fatigue. Proximity, im-mediacy, expectancy, and simplicity (PIES) areall extremely important in the treatment of BF.

(1) Proximity. Proximity refers tothe need of treating soldiers as close to their unitsand the battle as possible. It is a reminder thatoverevacuation should be prevented.

(2) Immediacy. Immediacy indi-cates that BF requires treatment immediately.

(3) Expectancy. Expectancy re-lates to the positive expectation provided to BFcasualties for their full recovery and early RTD.

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(4) Simplicity. Simplicity indi-cates the need for using simple, brief,straightforward methods to restore physical well-being and self-confidence by using nonmedicalterminology and techniques.

c. Make Differential Diagnosis, ButDefer Psychiatric Diagnosis. Distinguish life- orfunction-threatening medical or surgical con-ditions as soon as possible and provide thosepatients emergency treatment. Treat all othersusing PIES to the safest maximum extentpossible. Let the response to treatment sort outthe true NP disorders. The nonresponders shouldbe evacuated to the echelon of care appropriatefor their treatment (either COMMZ or CONUSfacilities) where treatment continues and the finaldiagnosis is determined.

1-8. Generic Treatment Principles forBattle Fatigue

The generic treatment principles provided belowapply at all echelons throughout the TO. Theirapplications may differ based on a particularechelon and other factors pertaining to themission, enemy, terrain, troops, and timeavailable (METT-T).

a. Initial Assessment. In the initialassessment, a brief but adequate medical andmental status examination is performed. Thisexamination should be appropriate to the echelonof care and should rule out any serious physicalmental illness or injury. Always consider thepossibility of trauma to the head or trunk. Othersurgical, medical, NP, and drug and alcoholmisuse disorders may resemble BF, but theyrequire emergency treatment. It is important torecognize symptoms to avoid performing un-necessary tests. Often it is best to treat for BFwhile covertly observing for other more seriousconditions.

b. Reassure. At every echelon, giveimmediate, explicit reassurance to the soldier.Explain to him that he has BF and this is atemporary condition which will improve quickly.Actively reassure everyone that it is neithercowardice nor sickness but rather a normalreaction to terribly severe conditions. Providethese soldiers with the expectation that they willbe RTD after a short period of rest and physicalreplenishment and involve them in usefulactivities, as appropriate.

c. Separate. Keep BF soldiers sepa-rated from those patients with serious medical,surgical, or NP conditions. This is done becauseassociation with serious medical, surgical, orpsychiatric patients often worsens symptoms anddelays recovery. Those few BF casualties whoshow overly dramatic symptoms of panic anxiety,depression, and/or physical or memory problemsneed to be kept separate from all other types ofpatients (including other BF casualties). This isdone until those symptoms cease so as not toadversely affect other BF soldiers.

NOTE

Association of recovering BF casualtieswith hold for treatment (patientsexpected to RTD within 72 hours) caseswho have minor injury or illness is notharmful.

No sharp distinction should be made betweenother convalescent soldiers and those recoveringfrom BF. Indeed, many of the soldiers with minorwounds or illnesses also have BF and should betreated with the principles of PIES. Thesesoldiers can be treated together provided they arenot in their "contagious stage and RTD for bothis imminent.

d. Simple Treatment with Rest and Re-plenishment. Keep treatment for BF deliberately

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simple. Provide relative relief from danger butmaintain a tactical atmosphere which is not toocomfortable. Provide rehydration, sleep, andhygiene.

Restore Confidence. Restore confi-dence by structured military work details,physical exercise, and recreation. Get the soldierto talk about what happened to him. Providesupportive counseling as needed to clarify memo-ries, to provide the opportunity to expressfeelings, and to regain perspective. Reinforce thesoldiers identity as a soldier and a member of hisunit, not as a patient.

e.

f. Avoid Sedatives and TranquilizingMedications. Avoid sedative or tranquilizingmedication unless essential to manage sleep oragitated behavior. The BF soldier needs to main-tain a normal state of alertness, coordination, andunderstanding. If the BF soldier is not medi-cated, he can take care of himself and can respondto and accept his treatment.

g. Evacuation and Hospitalization. Donot evacuate or hospitalize BF casualties unlessabsolutely necessary. Evacuation and hospital-ization delay recovery and significantly increasechronic morbidity, regardless of the severityof the initial symptoms. It is better to transportBF casualties in general-purpose vehicles, notambulances (and especially not air ambulances),unless no other means of transportation isfeasible. Evacuation should be approved by asingle qualified authority (for example, if thesoldier is to leave the division, by the divisionpsychiatrist, in accordance with AR 40-216).

h. Unrnanageable Cases. Soldiers whoseBF (or psychiatric} symptoms make them toodisruptive to manage at a given echelon shouldbe evacuated only to the next higher echelon withthe expressed positive expectation of improve-ment. The next higher echelon will reevaluatethe soldier for manageability. However, be

careful not to let "unmanageability become well-known as the criteria for escape by evacuation,since that could lead others to follow the badexample.

i. Manageable Battle Fatigue, but Un-responsive to Initial Treatment. Those man-ageable BF casualties who (after initialtreatment) do not improve sufficiently within theallotted time to RTD are also sent unobtrusivelyback to the next higher echelon, with expressedpositive expectations for further treatment. Thissustains the positive expectation of rapid recoveryfor BF casualties who are just arriving.

j. Hospitalization. As stated above, donot hospitalize a BF casualty unless absolutelynecessary for safety. Those BF casualties who dorequire brief hospitalization for differentialdiagnosis or acute management should betransferred to a nonhospital treatment setting assoon as their conditions permit. Those who reachhospitals as an inappropriate evacuee should betold they are only experiencing BF; they shouldbe returned to their unit area or other forwardarea as soon as possible to recover in a non-hospital facility.

k . Restoration and Reconditioning.Ideally, BF casualties are not evacuated toCONUS without having had an adequaterestoration and/or reconditioning trial in boththe combat zone (CZ) and the COMMZ. Thetreatment strategies of these programs assistrecovering BF soldiers in regaining skills andabilities needed for combat duty. These skillsand abilities include concentration, team work,work tolerance, psychological endurance, andphysical fitness. Restoration is a 1- to 3-dayprogram which is conducted in both the divisionand the corps areas. Restoration is normallyconducted by the medical detachment, CSC and/or the mental health section in the division. Inthe corps area, restoration is conducted by themedical detachment, CSC and/or the mental

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health section of the ASMB. Reconditioning is a7- to 14-day program that requires hospitaladmission for accountability of BF cases. It isconducted in a nonhospital setting by the medicalcompany, CSC in both the corps and COMMZ.

1-9. Combat Stress Control FunctionalMission Areas

a. Functional Roles. The principles ofcombat psychiatry and the methods for pre-vention and treatment of BF are exercised in sixfunctional mission areas for mental health/CSCpersonnel and units. These functional missionareas have differing priorities depending on thesituation. They are defined below and areanalyzed in detail in subsequent chapters of thismanual.

(1) Consultation. Consultation in-volves the liaison and preventive advice andassistance to commanders and staff of supportedunits (see Chapter 4).

(2) Reconstitution support. Re-constitution support is that assistance providedto attrited units at field locations. Reconstitutionis an extraordinary action that commanders planand implement to restore units to a desired levelof combat effectiveness commensurate withmission requirements and available resourcesaccording to FM 100-9. Reconstitution is a totalprocess which involves the sequence of reor-ganization, assessment, and regeneration. Men-tal health/CSC personnel support reconstitutionas a part of a consolidated team (see Chapter 5).

(3) Combat neuropschiatric tri-age. Combat NP triage (as distinguished fromsurgical triage) is the process of sorting combatstress-related casualties and NP patients intocategories based on how far forward they can betreated. These categories are DUTY (RTDimmediately), REST (light duty for 1 to 2 days in

their units own CSS elements), HOLD (requiresmedical holding at this echelon for treatment),and REFER (requires evacuation to the nexthigher echelon for further evaluation and treat-ment) (see Chapter 6).

(4) Stabilization. This functionprovides stabilization of severely disturbed BFand NP patients. They are evaluated for RTDpotential or prepared for further treatment orevacuation, if required (see Chapter 7).

(5) Restoration. Restoration in-volves treatment with rest, food, water, hygiene,and activities to restore confidence within 1 to 3days at forward medical facilities. Between 55and 85 percent of BF casualties should RTD withrestoration treatment (see Chapter 8).

(6) Reconditioning. Recondition-ing involves treatment with physical training andan intensive program of psychotherapy and mili-tary activities. Reconditioning programs are con-ducted for 7 or more days in a nonhospital settingin the corps area. Additional reconditioning maybe provided in the COMMZ (see Chapter 9). Nomore than 5 to 10 percent of BF casualties shouldeventually be evacuated to CONUS.

NOTE

All CSC functions since WWII exceptreconstitution support were suc-cessfully demonstrated repeatedly.Although the terminology has changed,the functions remain the same. Recon-stitution support has been identified asa separate mission to meet the specialhazards and requirements of war.

b. Priority of Functional MissionAreas. The six functional mission areas listedabove are in the usual order of their doctrinal

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priority for allocation of assets when workloads upon the total situation. Subsequent chapters ofexceed resources. However, the functions have this manual will discuss each of the functionaldifferent relative importance in different sce- areas and provide basic TTP for accomplishingnarios or phases of the operation. The CSC com- them. These chapters will also address how CSCmander must set priorities and allocate resources functional areas interface with other functionalto accomplish missions in each program based areas.

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CHAPTER 2

MENTAL HEALTH AND COMBAT STRESS CONTROLELEMENTS IN THE THEATER OF OPERATIONS

Section I. UNIT MENTAL HEALTH SECTIONS IN THE THEATER

2-1. Locations and Assignments of UnitMental Health Sections

Mental health sections are located in thedivisions, the corps, and the COMMZ. In thedivisions, they are assigned to the medicalcompany of the main support battalion (MSB).In the corps and COMMZ, they are assigned tothe ASMB headquarters. In separate brigades,they are assigned to the medical company.

2-2. Division Mental Health Section

The division mental health section is assigned tothe main support medical company (MSMC),which is a division support command (DISCOM)asset (see FMs 8-10-1, 8-10-3, and 63-21).

NOTE

The responsibilities of the divisionmental health section extend to alldivision elements and require a mentalhealth/CSC presence at the combatmaneuver brigades.

The division mental health section is the medicalelement in the division with primary respon-sibility for assisting the command in control-ling combat stress. Combat stress is controlledthrough sound leadership, assisted by CSCtraining, consultation, and restoration programsconducted by this section. The division mentalhealth section enhances unit effectiveness andminimizes losses due to BF, misconduct stressbehaviors, and NP disorders. Under the directionof the division psychiatrist, the division mental

health section provides mental heath/CSCservices throughout the division. This section,acting for the division surgeon, has staff respon-sibility for establishing policy and guidance forthe prevention, diagnosis, treatment, and man-agement of NP, BF, and misconduct stressbehavior cases within the division area of opera-tions (AO). It has technical responsibility for thepsychological aspect of surety programs. The staffof this section provides training to unit leadersand their staffs, chaplains, medical personnel, andtroops. They monitor morale, cohesion, andmental fitness of supported units. Other respon-sibilities for the division mental health sectionstaff include

Monitoring indicators of dysfunc-tional stress in units.

Evaluating NP, Bl, and misconductstress behavior cases.

Providing consultation and triage asrequested for medical/surgical patients exhibitingsigns of combat stress or NP disorders.

Supervising selective short-termrestoration for HOLD category BF casualties ( 1to 3 days).

Coordinating support activities ofattached corps-level CSC elements.

The division mental health section normallycollocates with the MSMC clearing station. Fora listing of major equipment assigned, seeAppendix A. The staffing of the division mentalhealth section allows for this section to be splitinto teams which deploy forward to provide CSCsupport, as required, to brigades in the division.

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Normally, each brigade is supported by a brigadeCSC team. This team consists of a mental healthofficer who is designated the brigade mentalhealth officer and a behavioral science NCO thatis designated the brigade CSC coordinator. If nomental health officer is available, the seniorbehavioral science noncommissioned officer incharge (NCOIC) substitutes as the brigade CSCteam leader. The division psychiatrist overseesall brigade CSC teams and provides consultationas necessary.

a. Mental Health/Combat Stress Con-trol Support. The division psychiatrist providesinput to the division surgeon on CSC-relatedmatters. He works with the division medicaloperations center (DMOC) to monitor andprioritize mental health support missions inaccordance with the division combat healthsupport (CHS) operation plans (OPLANs) oroperation orders (OPORDs). Coordination formental health personnel augmentation isaccomplished through the MSB Operations andTraining Officer (US Army) (S3) and the DMOC.

b. Division Mental Health SectionStaff. The division mental health section isstaffed as shown in Figure 2-1. The consolidationof assigned mental health officers and behavioralscience specialists in one division mental healthsection provides unity of CSC support for alldivision prevention, training, and treatmentresponsibilities of the section. It providesmultidisciplinary mental health professionalexpertise to

behavioral

commands

Supervise and train thescience NCOs and specialists.

Provide staff input to thewithin the division AO.

Assure clinical evaluation andsupervision of treatment for all NP and problem-atic BF cases before they leave the division.

2-2

Maintain communications andunity of efforts when division mental health sec-tion personnel are dispersed to the brigades.

Provide the points of contact tointegrate reinforcing CSC teams throughout thedivision.

(1) Psychiatrist. The division psy-chiatrist (Major [MAJ], Medical Corps [MC], areaof concentration [AOC] 60WOO) is the officer incharge of the division mental health section. Thepsychiatrist is also a working physician whoapplies the knowledge and principles of psychi-atry and medicine in the treatment of all patients.He examines, diagnoses, and treats, or recom-mends courses of treatment for personnel suffer-ing from emotional or mental illness, situationalmaladjustment, BF (combat stress reactions), andmisconduct stress behaviors. His specific func-tions include

Directing the divisionsmental health (combat mental fitness) program.

Being a staff consultantfor the division surgeon on matters having psy-chiatric aspects, which include

Personnel reliabilityprogram.

Security clearances.

FM 8-51

Alcohol and drugabuse prevention and control programs (ADAPCPs).

Planning CSC support forsupported units.

Conducting mental health/CSC Operations.

Providing staff consulta-tion for the MSMC commander and for supportedcommands within the division.

Being responsible for as-suring the diagnosis, treatment, restoration, anddisposition of all NP and problematic BF cases.

Participating in the diag-nosis and treatment of the sick, injured, andwounded, especially those who can RTD quickly.

Providing consultation andtraining to physicians, physicians assistants, unitleaders, chaplains, and other medical personnelregarding diagnosis, treatment, and managementof BF, misconduct stress behavior, and NPdisorders.

Prescribing treatment anddisposition for soldiers with NP conditions.

Providing supervision andtraining of assigned and attached mental healthpersonnel.

(2) Clinical psychologist. Theclinical psychologist (Captain [CPT], MedicalService Corps [MS], AOC 73B67) assists in thedevelopment, management, and supervision ofthe divisions mental health (combat mental fit-ness) program. His special responsibilities applyto the knowledge and principles of psychology toinclude

Evaluating the psycholog-ical functioning of soldiers.

Conducting surveys andevaluating data to assess unit cohesion and otherfactors related to prediction and prevention ofboth BF casualties and misconduct stressbehaviors.

Performing psychologicaland neuropsychological testing to evaluate psy-chological problems, psychiatric and organic men-tal disorders, and to screen misconduct stressbehaviors and unsuitable soldiers.

Apprising unit leaders,primary care physicians, and other clinical per-sonnel regarding the assessment of individual andunit mental health fitness program.

Providing consultation forunit commander and CSC coordinators (mentalhealth NCOs working at the brigade level) re-garding problem cases.

Counseling and providingtherapy or referral for soldiers with psychologicalproblems.

Serving as the brigademental officer for one maneuver brigade (nor-mally teamed with a behavioral science NCO).

(3) Social work officer. The socialwork officer (CPT, MS, AOC 73A67) assists in thedevelopment, management, and supervision ofthe divisions mental health (combat mental fit-ness) program. He applies the mental healthprinciples and his knowledge of social work inthe performance of his duties. His responsibilitiesinclude

Evaluating the social in-tegration of BF and misconduct stress behaviorsoldiers in their units and families.

Coordinating and ensuringthe return of recovered stress casualties to dutyand their reintegration into their original or newunits.

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Identifying and resolvingorganizational and social environmental factorswhich interfere with combat readiness.

Ensuring support for sol-diers and their families from Army and civiliancommunity support agencies.

Apprising unit leaders,primary care physicians, and other clinical per-sonnel of available social service resources.

Providing consultation tounit commanders and to division mental healthsection personnel regarding problem cases.

Counseling and providingtherapy or referral for soldiers with emotionalpsychological problems.

Serving as brigade mentalhealth officer for one maneuver brigade, teamedwith one of the behavioral science NCOs.

(4) Senior behavioral science non-commissioned officer. The senior behavioral sci-ence NCO (E-7, military occupational specialty[MOS] 91G40) is the section sergeant for thedivision mental health section. This senior NCOassists the division psychiatrist and mental healthofficers in accomplishing their duties. He pro-vides assistance with management of both thetechnical and tactical operations of the sectionand supervises subordinate members. His specificduties include

Keeping the division psy-chiatrist and mental health officers informed.

Monitoring, facilitating,and supervising the training activities of thedivision mental health section.

Monitoring and coordinat-ing situation reports from division mental healthsection personnel deployed within the BSAs.

Coordinating additionalmental health support with the supporting medi-cal detachment, CSC, or other corps-level CSCelements supporting the division.

Supervising restoration ofBF casualties at the MSMC by the patient-holdingsquad and division mental health section subordi-nate personnel.

Serving as leader of abrigade CSC team when no mental health officeris available.

Conducting classes onselected mental health topics for senior NCOswithin the division.

(5) Behavioral science noncom-missioned officers. There are three behavioralscience NCOs (E-6, MOS 91G30 and E-5 [two],91G20) assigned to the division mental healthsection. These three NCOs are brigade CSCcoordinators and are deployed to the forwardsupport medical companies (FSMCs) located inthe brigade support areas (BSAs) of the division.They assist the brigade surgeons with matterspertaining to mental health/CSC. As required,the brigade CSC coordinators participate in staffplanning to represent and coordinate mentalhealth/CSC activities throughout the brigade.They are especially concerned with assisting andtraining

Small unit leaders.

Unit ministry teams.

Battalion medical platoons.

Patient-holding squad andtreatment squad personnel of the FSMC.

They provide training and advice in the controlof stressors, the promotion of positive combat

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stress behaviors, and the identification, handling,and management of misconduct stress behaviorand BF soldiers. They coordinate training andsupport to the brigade by the mental healthofficers of the division mental health section. Thebehavioral science NCOs collect and record socialand psychological data and counsel personnelwith personal, behavioral, or psychologicalproblems. Their general duties include

Assisting in a wide rangeof psychological and social services.

Compiling caseload data.

Providing counseling tosoldiers experiencing emotional or social problems.

Referring soldiers to spe-cific mental health officers, physicians, oragencies when indicated.

Assisting with group de-briefings, counseling, and therapy sessions, andleading group discussions.

Providing individual caseconsultation to commanders, NCOs, chaplains,battalion surgeons, and physician assistantswithin the supported brigade.

Collecting informationfrom units regarding unit cohesion and moralewhich include

Obtaining data ondisciplinary actions.

Collecting informa-tion with questionnaires.

Conducting struc-tured interviews.

Collecting information onindividual BF cases pertaining to the prior

effectiveness of the soldier, precipitating factorscausing the soldier to have BF, and RTDpotential.

When the brigades are tactically deployed, thebrigade CSC coordinators use the divisionclearing stations operated by the FSMCs as thecenters of their operations but are mobilethroughout the AO. Their priority functions areto prevent unnecessary evacuations and to coordi-nate RTD, not to treat cases. Through the brigadesurgeons they keep abreast of the tactical situ-ation and plan and project requirements for CSCsupport when units are pulled back for rest andrecuperation.

(6) Behavioral science specialist.There are three behavioral science specialists(E-4 and E-3, MOS 91 G1O). These specialistsassist division mental health section officers andNCOs in gathering social and psychological datato support patient evaluation. Under the super-vision of the mental health officer and NCOs, theyprovide initial screening of patients suffering emo-tional disorders. Their specific duties include-

Providing supportive coun-seling for patients experiencing emotional orsocial problems.

Assisting in the evalu-ation of emotionally and mentally impairedsoldiers.

Assessing a patientsmental status (level of functioning capacity), andhis need for professional services.

Deploying to an FSMC toassist an NCO brigade CSC coordinator or mentalhealth oficer.

Serving as squad leaderfor up to 12 junior enlisted grade BF soldiers in arestoration program.

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Collecting informationfrom units, including questionnaires, surveys,and data regarding soldiers/patients. One ofthese behavioral science specialists will beassigned as the CSC coordinator for the divisionsupport, area (DSA).

In addition to the above duties, they operate andmaintain assigned vehicles.

2-3. Area Support Medical Battalion Men-tal Health Section

The mental health section is the medical elementwith primary responsibility for assisting units inthe corps support area in controlling combat stress.Combat stress is controlled through vigorous pre-vention, consultation, and restoration programs.These programs are designed to maximize theRTD rate of BF soldiers by identifying combatstress reactions and providing rest/restorationwithin or near their unit areas. Under the direc-tion of the ASMB psychiatrist, the mental healthsection provides mental health/CSC servicesthroughout the ASMBs AO. The mental healthsection collocates with the headquarters and sup-port company (HSC) clearing station and deploysmental health/CSC personnel within the ASMBsAO (see FM 8-10-24). This section has staffresponsibility for establishing policy and guidancefor the prevention, diagnosis, and managementof NP, BF, and misconduct stress behavior caseswithin the ASMB. It has technical responsibilityfor the psychological aspect of surety programs.The staff of this section provides training to unitleaders and their staffs, chaplains, medical per-sonnel, and troops. They monitor morale, cohe-sion, and mental fitness of supported units. Otherresponsibilities for the mental health section staffinclude

Providing command consultationand making recommendations for reducingstressors.

Evaluating NP, BF, and misconductstress behavior cases.

Providing consultation and triage asrequested for patients exhibiting signs of combatstress reactions.

Providing selective short-termrestoration for HOLD category BF cases.

Coordinating support activities withmedical company, CSC elements, when attachedor in support of the ASMB.

a. Mental Health Support. The ASMBS3 and the mental health section monitor andprioritize mental health support missions in coor-dination with the medical brigade/group head-quarters.

b. Mental Health Section Staff. TheASMB mental health section is staffed as shownin Figure 2-2, For a listing of major items ofequipment assigned, see Appendix A. The consoli-dation of assigned mental health officers andbehavioral science specialists under one sectionin the HSC of the ASMB assures unity of theCSC support throughout the AO for preventiontraining and treatment responsibilities. Itassures multidisciplinary mental health profes-sional expertise to

Train and supervise the behav-ioral science NCOs and specialists.

Provide staff input to supportedcommands.

Provide clinical evaluation andsupervision of treatment for all NP and problem-atic BF cases at a central location.

Maintainthe medical brigade/group

communications withand corps resources.

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Provide selected officer exper-tise for brief intervention where required through-out the AO.

(1) Psychiatrist. The psychiatrist(MAJ, MC, AOC 60W00) is the section leader.The psychiatrist is also a working physician whoapplies the knowledge and principles of psychia-try and medicine in the treatment of all patients.He examines, diagnoses, and treats, or recom-mends courses of treatment for personnel suf-fering from emotional or mental illness, situa-tional maladjustment, combat stress reaction, BF,and misconduct stress behaviors. His areas ofresponsibility include

Implementing CSC sup-port according to the CHS plan.

Conducting mental healthCSC operations.

Providing staff consulta-tion for the ASMB commander and for supportedcommands within the supported AO. This in-cludes the personnel reliability program, securityclearances, and ADAPCPs.

Diagnosing, treating, anddetermining disposition of NP, BF, and miscon-duct stress behavior cases.

Participating in the diag-nosis and treatment of the sick, injured, andwounded, especially of those who can RTDquickly.

Providing consultationand training to unit leaders, chaplains, andmedical personnel regarding identification andmanagement of BF (combat stress reaction), mis-conduct stress behaviors, and NP disorders.

Providing therapy or re-ferral for soldiers with NP conditions.

Providing supervision andtraining of assigned and attached mental healthand CSC personnel.

(2) Social work officer. The socialwork officer (CPT, MS, 68R00) performs socialwork functions of providing direct services, teach-ing, and training. He provides consultation ser-vices for soldiers assigned to units within theASMBs AO. The social work officer assists inthe development, management, and supervisionof the battalions mental health (combat mentalfitness) program for the AO. His responsibilitiesare to apply the knowledge and principles of socialwork to

Evaluate the social rela-tedness of BF and misconduct stress behaviorsoldiers in their units and families.

Identify and resolve orga-nizational and social environmental factors whichinterfere with combat readiness.

Ensure support forsoldiers and their families from Army and civiliancommunity support agencies.

Apprise unit leaders, pri-mary care physicians, and other clinical person-nel of available social service resources.

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Provide consultation tounit commanders and to mental health sectionpersonnel regarding problem cases.

Counsel and provide ther-apy or referral for soldiers with psychologicalproblems.

Coordinate and ensure thereturn of BF and NP soldiers to duty and theirreintegration into their original or new units.

(3) Senior behavioral science non-commissioned officer. The senior behavioralscience NCO (E-7, MOS 91G40) is the sectionsergeant for the battalion mental health section.This senior NCO assists the mental health officersin accomplishing their duties. He provides assist-ance with management of both the technical andtactical operations of the section and supervisessubordinate members. His specific duties include-

Keeping the ASMB psy-chiatrist and mental health officers informed.

Monitoring, facilitating,and supervising the training activities of themental health section.

Monitoring and coordinat-ing situation reports from mental health sectionpersonnel deployed within the battalions AO.

Coordinating additionalmental health support for the battalions AO asdirected with the medical brigade/group.

Conducting classes onselected mental health topics for senior NCOswithin the AO.

(4) Behavioral science noncommis-sioned officers. There are four behavioral scienceNCOs assigned to the section (one E-6, MOS91G30, and three E-5, MOS 91 G20). The E-6 is

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the assistant section sergeant and aids the sectionsergeant with the accomplishment of his duties.Behavioral science NCOs collect and record socialand psychological data and counsel personnelwith personal, behavioral, or psychological prob-lems. All these NCOs assist with the manage-ment of the mental health section. These NCOsmay be deployed with area support medical com-panies (ASMCs) as CSC coordinators to providemental health/CSC support. They assist theASMCs with matters pertaining to mental health/CSC. As required, the CSC coordinators partici-pate in staff planning to represent and coordinatemental health/CSC activities throughout theASMCs AO. They are especially concerned withassisting and training

Small unit leaders.

Unit ministry teams.

Battalion medical platoons.

Patient-holding squad andtreatment squad personnel of the ASMC.

They provide training and advice in the controlof stressors, the promotion of positive combatstress behaviors, and the identification, handling,and management of misconduct stress behaviorsand BF soldiers. They coordinate training andsupport to the supported units by the mentalhealth officers of the ASMB mental healthsection. The behavioral science NCOs collect andrecord social and psychological data and counselpersonnel with personal, behavioral, or psycho-logical problems. Their general duties include-

Assisting in a wide rangeof psychological and social services.

Compiling caseload data.

Providingsoldiers experiencing emotionallems.

counseling toor social prob-

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Referring soldiers tospecific mental health officers, physicians, oragencies when indicated.

Assisting with group de-briefings, counseling and therapy sessions, andleading group discussions.

Providing individual caseconsultation to commanders, NCOs, chaplains,battalion surgeons, and physician assistantswithin the supported brigade.

Collecting informationfrom units regarding unit cohesion and moralewhich include

Obtaining data ondisciplinary actions.

Collecting informa-tion with questionnaires.

Conducting struc-tured interviews.

Collecting information onindividual BF soldier cases pertaining to

Prior effectiveness ofthe soldier.

Precipitating factorscausing BF.

Potential for RTD

When the supported units are tactically deployed,the behavioral science NCOs use the clearingstations operated by the ASMCs as the centers oftheir operations, but the NCOs are mobilethroughout the AO. Their priority functions areto prevent unnecessary evacuations and tocoordinate RTD, not to treat cases. Through theASMC commanders, they keep abreast of the

tactical situation and plan and project require-ments for CSC support when units are pulledback for rest and recuperation.

(5) Behavioral science specialist.There are three behavioral science specialists(E-4 and E-3, MOS 91 G1O). These specialistsassist mental health officers and NCOs ingathering social and psychological data to supportpatient evaluation. They provide initial screeningof patients suffering emotional disorders. In addi-tion to their duties, they operate and maintainassigned vehicles. Under the supervision of amental health officer or an NCO, their specificduties include

Providing supportive coun-seling for patients experiencing emotional orsocial problems.

Assisting in the evalua-tion of the emotionally disturbed or mentally ill.

Assessing a patients men-tal status (level of functioning capacity) and hisneed for professional services.

Deploying to an ASMC toassist an NCO CSC coordinator or mental healthofficer.

Serving as squad leaderfor up to 12 junior enlisted grade BF soldiers in arestoration program.

2-4. Mental Health Personnel in theSeparate Brigades

In the separate brigades, both light and heavy,mental health personnel are assigned to themedical company, separate brigade. In the lightseparate brigade, one behavioral science NCOis assigned to the medical company clearingsection. He functions as a brigade CSC

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coordinator and advises the commander on identified for the brigade CSC coordinator. Whenmental health/CSC issues. In the heavy separate a separate brigade is attached to a division,brigade, the medical company has a mental the mental health personnel assigned to thathealth section which consist of a behavioral sci- brigade work with and come under the tech-ence NCO and two behavioral science specialists. nical supervision of the division mental healthThe NCOs duties are also consistent with those section.

Section II. COMBAT STRESS CONTROL COMPANY

2-5. Medical Company, Combat StressControl (TOE 08-467L000)

The medical company, CSC is employed in theCOMMZ and the CZ. In the corps areas, it sendsteams forward, as required, to reinforce CSCelements operating in the divisions. The medicalcompanies, CSC and medical detachments, CSC(TOE 08-567 LA00) are replacing the medical de-tachments, psychiatric (OM Teams), which areunder the H-series TOE.

a. Mission. A medical company, CSC(Figure 2-3) provides comprehensive CSC supportfor two or more divisions and their corps slices(combat, CS, and CSS units). This comprehensivesupport involves all six CSC functions that werediscussed in Chapter 1 to a varying degree basedon the threat and tactical operations support re-quirements.

b. Basis of Allocation. The basis ofallocation for the medical company, CSC is 0.4unit per division supported. One medical com-pany, CSC will normally support two divisionsand their corps slice in a high-intensity conflict.In a mid-intensity conflict, because of the reducedlikelihood of BF casualties, a medical company,CSC may be able to support up to five divisions,The medical company, CSC is supplemented byallocation of a variable number of CSC medicaldetachments. The basis of allocation for CSCmedical detachments is one unit per division, andone unit per two or three separate brigades or

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regiments in the corps. The medical detachment,CSC will be discussed in Section III of this chapter.

c. Assignment. The medical company,CSC may be assigned to a medical command(MEDCOM), medical brigade or medical group.It may be further attached to an ASMB. For alisting of major items of equipment assigned, seeAppendix A.

d. Organization. The medical company,CSC is organized into a headquarters section, apreventive section, and a restoration section. Thecompany is dependent on appropriate elementsof the MEDCOM, medical brigade, or medicalgroup for administrative and medical logisticalsupport, medical regulating, BF casualty deliv-ery, and medical evacuation. The company isdependent on appropriate elements of the corpsor COMMZ for finance, legal, personnel and ad-ministrative services, food service, supply andfield services, supplemental transportation, andlocal security support services. When conductinga large restoration or reconditioning program,the medical company, CSC is dependent on themedical-holding company for attachment of amedical-holding platoon to support the program.When medical company, CSC elements or teamsare deployed to division areas, they are dependenton the division medical companies (such as theMSB medical company or the forward supportbattalion [FSB] medical company) for patientaccounting, transportation, food service, and fieldservice support.

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e. Employment in the Theater. Themedical company, CSC operates in the corpsarea and deploys its assets forward, as required,in support of operations for supported divi-sions and separate brigades. In the corps area,it provides CSC support on an area basis andconducts CSC consultation, restoration, and re-conditioning programs. The medical company,CSC normally operates from the medical brigadeor group headquarters. The medical company,

CSC may be attached to ASMBs, combat sup-port hospitals (CSHs), or other corps medicalunits. The task-organized CSC element is alsodeployed into the supported division areas,as required, to augment the medical detach-ment, CSC and organic division mental healthsection/CSC personnel. The medical company,CSC provides advice and assistance to itshigher headquarters on combat stress and NPissues.

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2-6. Headquarters Section

The headquarters section provides command andcontrol (C2) and unit-level administrative andmaintenance support to its subordinate sectionswhen they are collocated with the company. Theheadquarters section may also provide assistanceto detached elements by making site visits if theelements are within a feasible distance for groundtransportation. The medical company, CSC ele-ments normally deploy with limited maintenanceand are without administrative support. Whenthese CSC elements deploy, they are dependenton the supported units for patient accounting,transportation, food service, and field services.The personnel assigned to the headquarters sec-tion include

cal NCO.

al science NCO.

clerk.

(two).

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Company commander.

Chaplain.

Medical operations officer.

First sergeant.

Supply sergeant.

Nuclear, biological, and chemi-

Unit clerk.

Commanders driver/behavior-

Prescribed load list (PLL)

Armorer.

Motor sergeant.

Light-wheeled vehicle mechanic

Power generation equipmentrepairman.

Cook (three).

Personnel from the headquarters section aredeployed with teams or task-organized CSC ele-ments as required.

a. Company Commander. The medicalcompany, CSC commander (Lieutenant Colonel[LTC], MC, AOC 60W00) plans, directs, andsupervises the operations of the company. Thecommander is also responsible for the training,discipline, billeting, and security of the company.He provides daily reports to his higher head-quarters as established by the tactical standingoperating procedures (TSOPs) and corps reportingprocedures. He serves as the NP consultant onthe staff of the medical group. As a psychiatrist,he coordinates with command and unit physiciansregarding care and disposition of BF casualtiesand NP patients. He exercises clinical super-vision over all treatment provided by the CSCsections and detachments. He performs physicaland mental status evaluations in emergency orcommand evaluation situations; this includesdiagnosing, prescribing initial treatment, anddetermining disposition. The commander inter-faces with higher and supported headquartersand with supported CSC medical detachments,ASMB mental health sections, and division men-tal health sections. He keeps informed on CSCoperations through daily reports and by frequentvisits to task-organized CSC elements deployedfrom his company.

b. Chaplain. The chaplain ( CPT,Chaplain [CH], AOC 56AOO) provides religious/ethical education and perspective to the dispersedsections for the prevention and treatment of BFand misconduct stress behaviors. He interfacesCSC activities with unit ministry teams inmaneuver units, hospital chaplains, and withstaff chaplains at each headquarters level. The

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chaplain usually accompanies the medical com-pany, CSC commander when he visits supportedunits and task-organized CSC elements deployedin support of those units. The chaplain has achaplains kit to conduct services but is without achaplains assistant. The chaplains primary roleis to aid CSC personnel in preventive stress con-trol and in working with BF casualties and mis-conduct stress behaviors. In addition to his coor-dination, liaison, and training duties, he providesreligious support to BF casualties and to staff asavailable time and support requirements permit.

Medical Operations Officer. Themedical operations officer (CPT, MS, AOC 70B67)is the principal assistant to the company com-mander on all matters pertaining to the tacticalemployment of company assets. He is responsiblefor overseeing operations and administrative,supply, and maintenance activities within thecompany. His responsibilities also include

Coordinating administrativeactivities with the staff of the higher medicalheadquarters.

Ensuring unit operations andcommunications security.

Keeping the commandercurrent on the corps and supported divisionstactical situations.

Assisting the commander withdevelopment of CSC support estimates and plans.

Training.

Coordinating movement ordersand logistical support for deployed companyelements.

d. First Sergeant. The first sergeant(E8, MOS 91B50) serves as the principal enlistedassistant to the company commander. He

manages the administrative activities of the com-pany command post (CP). He supervises thecompany activities of the unit clerk and maintainsliaison between the commander and assignedNCOs. He provides guidance to enlisted membersof the company and represents them to the com-mander. He plans, coordinates, supervises, andparticipates in activities pertaining to organi-zation, training, and combat operations for thecompany. He assists the company commander inthe performance of his duties. The first sergeantalso assists the medical operations officer andperforms the duties of an operations NCO.

e. Supply Sergeant. The supplysergeant (E6, MOS 76Y30) requests, receives,stores, safeguards, and issues general suppliesand salvages equipment authorized to the com-pany. He maintains the company supply records,supervises unit supply operations, and maintainsaccountability for all equipment organic to thecompany.

f Nuclear, Biological, and ChemicalNoncommissioned Officer. The NBC NCO (E5,MOS 54B20) coordinates NBC defense operationsfor the company. He supervises training pertain-ing to procedures and techniques of NBC defense.He predicts the effects of weather and terrain onchemical operations. His responsibilities alsoinclude preparing predictions on nuclear falloutand on nuclear, chemical, and biological down-wind hazards. He prepares and evaluates NBCreports and computes expected radiation effectsaffecting personnel, equipment, and operations.This NCO is the technical advisor to the unitcommander on matters pertaining to NBC func-tions. He provides expertise and training in theoperations and maintenance of NBC equipmentand supervises decontamination of unit equip-ment, supplies, and personnel (not patients). Attime of heavy caseloads (unless the unit is in anactive NBC environment), he serves as squadleader for up to ten BF casualties in recondition-ing or restoration.

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g . Unit Clerk. The unit clerk (E4, MOS75B10) provides and coordinates personnel andadministrative support to company personnel andmaintains unit administrative records. He alsoadvises on and coordinates personnel actions forrecovering BF casualties or RTD soldiers thatrequire other administrative actions.

h. Commanders Driver/BehavioralScience Noncommissioned Officer. The com-manders driver/behavioral science NCO (E5, MOS91G20) assists the commander and chaplain as avehicle driver. He performs surveys and collectsinformation on stress and stressors in units whichthe commander visits. He also checks the statusof recovered stress casualties.

Prescribed Load List Clerk. Thelogistic automation specialist (PLL clerk [E5,MOS 92A20]) also serves as the maintenance shopclerk. He performs duties involving supply ofrepair parts and maintenance of equipmentrecords. He initiates and maintains records onequipment use, operation