United States Army Fm 8-51-30 January 1998

8/14/2019 United States Army Fm 8-51-30 January 1998

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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-1

D-2. Special Considerations for Medical Combat Stress Control Activities ........ D-1

D-3. The Law of War ........................................................................ D-5

D-4. Protection of the Wounded and Sick ................................................ D-6

D-5. Protection and Identification of Medical Personnel ............................... D-9

D-6. Protection and Identification of Medical Units and Establishments,

Buildings and Material, and Medical Transports ............................... D-10

D-7. Loss of Protection of Medical Units and Establishments ........................ D-12

D-8. Conditions Not Compromising Medical Units and Establishments ofProtection.............................................................................. D-13

APPENDIX E. MEDICAL REENGINEERING INITIATIVE FOR MENTAL HEALTH

AND COMBAT STRESS CONTROL ELEMENTS IN THE

THEATER OF OPERATIONS ................................................. E-1

Section I. Overview of Changes ................................................................. E-1

E-1. Unit Mental Health Sections .......................................................... E-1

E-2. Combat Stress Control Units ......................................................... E-2

Section II. Unit Mental Health Sections in the Theater of Operations .................. E-5

E-3. Location and Assignment of Unit Mental Health Sections ...................... E-5

E-4. Utilization in Garrison ................................................................. E-5

E-5. Division Mental Health Sections..................................................... E-6

E-6. Area Support Medical Battalion Mental Health Sections ........................ E-11

E-7. Mental Health Personnel in the Armored Cavalry Regiments and

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

Section III. Combat Stress Control Company ................................................. E-15

E-8. Medical Company, Combat Stress Control (TOE 08467A000) ................ E-15

E-9. Headquarters Section .................................................................. E-17

E-10. Combat Stress Control Preventive Section ......................................... E-22

E-11. Combat Stress Control Fitness Section ............................................. E-25

Section IV. Combat Stress Control Detachment .............................................. E-30

E-12. Medical Detachment, Combat Stress Control (TOE 08567AA00) ............. E-30

E-13. Detachment Headquarters ............................................................. E-31

E-14. Preventive Section ...................................................................... E-34

E-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 stress

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 units and elements operating

within the theater of operations (TO). This TTP is applicable to operations across the operational continuum. It

is important that the users of this manual be familiar with FM 22-51. This manual supports the Army Medical

Departments (AMEDD) keystone manual, FM 8-10. Readers should have 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 organizational structure presented in this publication reflects information in the most current

living tables of organization and equipment (TOE) as of calendar year 1993. However, staffing is subject to change

to 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 the

Army (DA) timelines.

This publication is in agreement with the American, British, Canadian, and Australian (ABCA) Quadripartite

Standardization 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 imply

endorsement 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 med ical facilities. This manu al sets forth tactics, techniqu es, and procedures (TTP) for CSC un itsand 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 shouldha ve a fun d am ental u nd ersta nd ing 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 commen ts and recommend ations on Dep artm ent 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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C O N TR O L

1-1. Stress Control

CHAPTER 1

OF COMBAT STRESS

a. Control of Stress. In ones ownsoldiers and in the soldiers of the enem y, controlof stress is often the decisive difference betweenvictory and defeat across the op erational con-t inuum. Battles and wars are won more bycontrolling the will to fight than by killing all ofthe enem y. Soldiers that are p roperly focused bytraining, unit cohesion, and leadership are mostlikely to have the strength, endu rance, and alert-ness to perform their combat m ission. In these

soldiers, combat stress is controlled and positivecomb at stress reactions, such a s loyalty, self-lessness, and acts of brav ery, are more likely tooccur. However, uncontrolled combat stresscauses erratic or harmful behavior, impairsmission performance, and results in d isaster anddefeat.

b. Responsibility For Stress Control.Control of stress is the command ers respon sibility(see FM 22-51) at all echelons. The com mand eris aided in this responsibility by th e noncom -missioned officer (NCO) chain of support; thechaplaincy; un it med ical personn el; general,principal, and special staff, and by specializedArmy CSC units and m ental health personnel.

c. Control or M anagement . The wordcontrol is used with combat stress (rather thanthe word management) to emp hasize the activesteps wh ich leaders, sup porting m edical per-sonnel, and individual soldiers must take to keepstress within an acceptable range. This does notmean that control and management are mu tuallyexclusive terms. Managem ent is by d efinition

the exercise of control. Within common usage,however, and especially within Army usage,management has the connotation of being asomewhat detached, num ber-driven, higherechelon process rather than a direct, inspi-rational, and leadership-oriented process. Controlof stress d oes not im ply elimination of stress.

Stress is one of the bod ys processes for dea lingwith 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 d ue to d eliberateenem y actions aimed at killing, wou nd ing, ordem oralizing our soldiers and our allies. Other

stressors are du e to the natu ral environm ent.Some of these stressors can be avoided orcounteracted by wise command actions. Stillother stressors are due to our own calculated ormiscalculated choice, accepted in ord er to exertgreater stress on th e enemy. Sound leadershipwor ks to keep th ese within tolerable limits andprep ares the troops mentally and p hysically toendure them. Some of the most potent stressorscan be du e to personal or organizational problemsin the unit or on the home front. These, too,mu st be identified a nd , when possible, correctedor con tro lled . See FM s 8-10, 8-10-8, an d 22-51for additional information on the overall threat,med ical 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 th an a day.

Miscond uct stress behaviorscases that have comm itted breaches of disciplinewh ich require d isciplinary 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 includ es somewoun ded in action (WIA) or disease and nonbattleinjury (DNBI) casualties whose

Disabilities are a direct con-sequen ce of carelessness or inefficiency d ue tostress.

Recovery and return to d uty(RTD) is complicated by unresolved str ess issues.

In a broad er sense, the combat stress threat also

includes the missed opportunities and increasedcasualties (killed, wounded, and / or takenprisoner) that come from impaired decisionm aking or faulty execution of mission du e toexcessive stress.

c. Mental Stressors and PhysicalStressors. A rou gh d istinction can be m adebetween those stressors which are mental andthose which are physical.

(1) A mental stressor would be one

in which information is sent to the brain, withonly ind irect ph ysical imp act on the bod y. Thisinformation may place dem and s on and evokereactions from either th e perceptua l and cognitivesystem, or the emotional systems in the br ain, orfrom both.

(2) A physical stressor is one whichhas a direct, poten tially harm ful effect on th ebod y. 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 ph ysical stressors (environ men tal andphysiological).

(4) The physical stressors evokespecific stress reflexes, such as shivering andvasoconstriction (for cold), sweating an dvasodilation (for heat), or tension of the eard rum(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 d istinction between m entaland ph ysical stressors is rarely obvious.

(a) Mental stressors can alsoproduce some of the sam e stress reflexes

nonspecifically (such as vasoconstriction,sweating, ad renaline release). These stressreflexes can m arked ly increase or d ecrease anind ividu als vuln erability to specific p hy sicalstressors. Mental stressors presu mably causechanges in the electrochemical (neurotransmitter)systems in the brain.

(b) Physical stressors canresult in mental stress because they causediscomfort , imp air performance, and provideinformation wh ich p oses a threat.

(c) Physical stressors caninterfere d irectly with brain fun ctioning an dtherefore with p erceptual and cognitive mentalabilities, thus increasing the stresses.

(d) Light, noise, discomfort,and anxiety-provoking information may interferewith sleep, w hich is essential to maintain brainefficiency an d mental performan ce.

(6) Because of this in termesh ing ofphysical and mental stressors and stressresponses, no great effort need s to be invested indistinguishing them until the physical stressorsreach the d egree wh ere they r equire specific (andperhaps emergency) protective measures and/ ortreatment. Prior to that point, med ical andmental health personnel should assum e that bothphy sical and m ental stressors are usually present

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and interacting. They should treat both types ofstressors simu ltaneously 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 necessary

to hea lth. Insu fficient stress leads to p hysicaland/ or mental weakness. A moderate responseto stress actually improves p erformance. Soldierswho have been trained to manage their responsesto a stressful situation by m aintaining n eithertoo low nor too high a level of activation p erformtasks better. Progressively greater exposure to a

physical stressor, sufficient to p rodu ce 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 perm anently impair it.

For instan ce, in the p hysical stress examp legiven, excessive physical work can causetemporary or perm anent dam age to muscles,bones, and h eart, w hile extreme h eat and coldcan cause heatstroke or frostbite withperm anently redu ced tolerance to heat or cold.The same may be tru e of emotional or mental

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stress, although the mechanism is less clear. Upto a p oint, 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 p rocessing. More severeoverstrain, how ever, may severely weakentolerance to future stress. There is reason tobelieve that imm ediate treatment can greatlyred uce the p otential for chron ic disability, evenfor impairing emotional overstrain.

1-3. Stress Behaviors in Combat

a. Combat Stress Behaviors. Combatstress behavior is the generic term w hich coversthe full range of behaviors in combat, from highlypositive to totally negative. Table 1-2 provides alisting of positive stress responses and behaviors,plus tw o types of d ysfunctional combat stressbehaviorsthose w hich are m iscondu ct stressbehaviors and those wh ich are labeled BF.

b. Positive Combat Stress Behaviors.

Positive combat stress behaviors includeheightened alertness, strength, endu rance, andtolerance to d iscom fort. Both t he fight or flightstress response and the stage of resistance canproduce positive combat stress behaviors whenproperly in tune. Examples of positive combatstress behaviors includ e

The strong personal trust,loyalty, and cohesiveness (called horizontalbonding) wh ich develops am ong peers in a smallmilitary unit.

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

The sense of pride and sharedidentity wh ich soldiers develop with the un its

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 an d almost un believablestrength. They may even involve d eliberate self-sacrifice. Positive combat stress behaviors can bebrought forth by soun d military training, wisepersonn el policies, and good leadership. The

results are behaviors which are often rew ardedwith praise and individu al and/ or unit recog-nition. For add itional information on p ositivecombat stress beh aviors, see FM 22-51.

c. Misconduct Stress Behaviors.Examp les of miscond uct stress behaviors arelisted in th e center column ofTable 1-2. Theserange from m inor 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 m ost likely to occur in poorly trained,

undisciplined soldiers. However, misconduct canalso be committed by good and even heroicsoldiers un der extreme combat stress. In fact,miscondu ct stress behaviors can b ecome thesecond edge of the double-edged sword of highlycohesive and proud units. Such units may cometo consider them selves entitled to special priv-ileges and as a resu lt, relieve tension u nlawfullywhen 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 preven ted by stress controlmeasures, but once serious misconduct has

occurred , soldiers mu st be pun ished to preventfurther erosion of discipline. Combat stress, evenw ith heroic comb at perform ance, cann ot justifycriminal m iscondu ct. Combat stress ma y, how-ever, constitute extenuating circumstances forminor (noncriminal) infractions in determining

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nonjudicial pu nishment und er Article 15, UCMJ.Combat stress may also constitute an extenuatingcircumstance in the sentencing p roceedings of acourt-martial. See FM 22-51 for additional infor-mation on misconduct stress behaviors.

d. Battle Fatigue. Battle fatigu e is alsocalled combat stress reaction or combat fatigue.Fatigue by d efinition is the distress and imp airedperformance that comes from doing someth ing(anything) too hard and / or too long. The termbatt le fatigue is applied to any combat stressreaction wh ich is treated . All BF is treated (as

all 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 accompany

excellent combat performance, and are oftenfound to some degree in all soldiers. These arenormal, common signs of BF. Those behaviorsthat follow are listed in d escend ing ord er toindicate progressively more serious w arningsigns. Warning signs deserve immediate atten-tion by the leader, med ic, or bud dy to p reventpotential harm to the soldier, others, or the mis-sion. If the soldier respond s quickly to helpingactions, w arning signs d o not necessarily meanhe mu st be relieved of du ty or evacuated .How ever, he may requ ire furth er evaluation atan MTF to rule out other physical or mental

illness. If the symp tom s of BF persist and m akethe soldier unable to perform d uties reliably,then MTFs, such as clearing sta tions andspecialized CSC team s, can provid e restorativetreatment. At this point, the soldier is a BFcasualty. For those cases, prompt treatment

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close to the soldiers un it provides th e 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 betw een p ositive 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 wh o

exemplify the positive combat stress behaviorsmay su ffer symp toms of BF and may even be BFcasualties before or after their perform ance ofdu ty. Excellent combat soldiers m ay com mitmisconduct stress behaviors in reaction to thestressors of combat before, after, or during theirotherwise exemplary p erforman ce. However,combat stress, even w ith good combat behaviors,does not excuse criminal acts.

f. Post-Traumatic Stress Disorders.Symp toms of p ost-traum atic stress are p ersistentor recurring stress responses after exposure to

extremely d istressing events. As with BF, post-traumatic stress symptoms can be normal/common signs or w arning signs. These signs andsymptoms do not necessarily make the soldier acasualty nor does the condition warran t the labelof a disord er. This becomes PTSD only wh en 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 painfulmem ories such as

Substance a buse.

Avoidance of remindersthe traumatic event.

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Social estrangement.

Withdrawal.

Post-traumatic stress disorder often follows inade-qu ately treated BF. It often follows miscond uctstress behaviors in those who committed mis-condu ct und er stress, as well as in th e victims,reluctant p articipants, caregivers, and observers.Post-traumatic stress disorder can occur insoldiers who show ed no m aladaptive stress behav-iors at the tim e of the trau m a. Post-traum aticstress disorders can occur or recur years after theevent, usually at times of excessive stress. Inadd ition to their p rimary mission d uring w ar,leaders, chaplains, and m edical and CSC per-sonnel have the additional responsibility ofpreventing or minimizing subsequ ent PTSD. Themost important preventive measure for PTSD isroutine after-action d ebriefing in small group s.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. Theemergingconcept for Army operations in the post-cold warera has reoriented the nations m ilitary capabilityaway from a primary focus on potential large scalewar against Soviet forces in Europe. The focushas shifted toward s a more am biguous threatfrom current or future regional pow ers around

the world.

(1) High technology weap ons areavailable from a n um ber of sources throu ghou tthe w orld. The dissolution of the Soviet empiremay disperse quantities of high technologyweapons (and weapons design expertise) to

amb itious countries who are hostile toward theUS or toward nations important to the US.Consequ ently, the da nger of regional arm or-heavy battles at the h igh-intensity end of thecontinuum of conflict, and even of regionalnuclear, biological, and chemical (NBC) war, maypara doxically increase over the next decades.

(2) Alterna tively, hostile states (orethnic/ religious factions encouraged by them )m ay attemp t to overthrow friend ly nations orattack the US interest by conducting terrorist orinsurgency operations. These attacks mayrequire counteractions by US combat forces. Inoperations other th an w ar (OOTW), contingencyoperations m ay be need ed to p rotect 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 med ia 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. How ever, those systems can on ly be aseffective as the stress tolerance of the hu m ancomm anders and soldier/ operators make them.The combining of highly lethal weapons systemsfrom different branches, services, and allies

creates an in trinsic risk of friend ly fire casualties.This risk, too, must be calcu lated an d th e stressconsequences controlled.

c. Brigade Task Force Operations. TheArmy operations concept makes the brigade thecritical un it for CSC prevention an d imm ediate

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intervention, more so than in p revious wars.Divisional and separate brigades and armoredcavalry regiments (ACRs) will be combined intotask forces for rapid-deployment contingencyoperations. Within camp aigns, brigade taskforces will be rapidly organized for specific, brief,violent battles. During battles, the task forcescan cover great distances quickly, concentrate fordecisive action, and perhap s 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 more

firepow er and covers a larger area of responsi-bility than a World War I (WWI) or WWIIdivision. At th e small un it level, the imp ortanceof ind ividu al soldiers to the u nits combat pow eris also greatly increased for w eapons op eratorsand leaders. It is equally true for critical combatsup por t (CS) and comba t service sup port (CSS)specialists. Rear batt le, in th e 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 d octrine were first designed to sup port

WWI and WWII divisions. Our new mentalhealth/ CSC doctrine and units must adapt tothese changing conditions by assuring integralCSC sup port at brigad e level while imp rovingcoverage throughout the supported area.

d. Military Operations Other ThanWar. In add ition to war, there will be manyother Army missions which are prolonged. TheNational Comm and Authority may comm it 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.

Sup port for insurgences andcounterinsurgencies.

Sup port to d omestic civil au-thorities.

The rules of engagement for each of the aboveoperations are u nique to that situation. Require-

ments to ma intain 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 opp onents may d eliberately seek toprovoke our forces into committing misconductstress behaviors. By comm itting criminal acts,the role of the US Forces wou ld be d egraded inthe eyes of local, US, and world populations. Inlight o f this, the CSC role in th e pr evention o fmisconduct stress behaviors is extremely impor-tant. For definitive information pertaining toOOTW, see FM 100-5.

e. Neuropsychiatric Disorders.Thefocus of CSC is on the p revention and treatmentof stress-ind uced disability in oth erwise norm alsoldiers. Mental health/ CSC personnel, by virtueof their professional training and experience, are

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also best qualified to d iagnose, treat, and recom-mend RTD or disposition for the endemicneuropsychiatric (NP) disorders. These NPdisorders include the schizophrenic-type psychoticdisord ers, m ood d isorders, anxiety disorders,organic mental disorders, personality disorders,and substance abuse disorders. These N P dis-orders are significant imp edim ents to com batreadiness and also to peacetime training. Soundprevention and screening program s as identifiedin Army Regulation (AR) 40-216, as w ell as earlyrecognition and treatment, assist the comman d

in 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 an d early RTD ofsoldiers su ffering from BF.

Prevention of harmful combatstress reactions such as m iscond uct stressbehaviors and PTSD.

b. Implementation. The CSC p rogramis imp lemented by mental health/ CSC person-nel organic to the d ivisions, the med icalcompa nies of separate brigades, and th e areasup port med ical battalions (ASMBS) in the corpsand comm unication s zone (COMMZ) (see

Chapters 2 and 3). These mental health/ CSCpersonnel are augmented by the CSC company ordetachment. Combat stress control compan iesand detachments are assigned to the corps and inthe COMM Z (see Chapters 2 and 3). Prim arygoals of men tal health/ CSC personnel whenimplementing this program ar e to

Monitor stressors and stress inunits.

Advise command on measuresto redu ce 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.

Accomp lish th e earliest RTDof most soldiers who become stress-relatedcasualties.

Facilitate the correct d isposi-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 Experien ce

The AMEDD identified "CSC as a separatefunctional m ission area in 1984, but CSC is not

new. Historical experience in the Civil War,WWI, WWII, Korea, Vietnam , the Arab -Israeli,and other wars has demonstrated the basicprinciples of combat psychiatry and combatm ental 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 Am erican Expeditionary Force to Europ e, theUS Army sent a med ical team to see wh at ournew allies had learned from hard experienceabout casualty care. Based on the finding of thisteam in th e combat psychiatry area, The SurgeonGeneral of the Army recommended that we adopta three-echelon system similar to that of theBritish Arm y. He also recomm ended that weimplement their policies to return soldiers withwar neurosis (commonly mislabeled shell shock)to d uty. Accord ingly, in WWI, we assigned apsychiatrist to each division (first echelon) to train

the unit leader and medical personnel. Thepsychiatrist trained un it leaders and m edicalpersonnel to recognize and treat simple fatiguecases in their own un its. Many US stresscasualties w ere returned to du ty after resting afew d ays in th e 150-cot field hosp ital which w aslocated in the d ivision r ear. By d irection of TheSurgeon Gener als NP con sultan t, the officialdiagnostic label for these typ es of cases wh ile thesoldier was still in the d ivision area w as N ot YetDiagnosed, Nervous, (also adap ted from theBritish and abbreviated NYDN). The psychiatristscreened out and evacuated soldiers with serious

NP disorders. Behind the division (secondechelon), we h ad special neurological hosp itals(150-bed facilities with psychiatrist supervisors).They treated the r elatively few NYDN cases whodid not RTD w ithin the d ivision in a few d ays.They also treated some soldiers with ga s man ia,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 occup ational therap ists. These medicalprofessionals salvaged many soldiers who did notfully recover in th e neu rological hosp itals. Thisthree-echelon system w orked well. How ever, onoccasions w hen the tactical situation inter feredwith forward treatment, it clearly showed theimportance of treating the soldiers close to theirunits. Overall, a large p ercent of WW I warneurosis cases were RTD.

b. World War II. During the timebetween W WI and WW II, 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 neu rosis was officially labeled combatexhaustion. By late in the war, the Mediter-ranean and European theaters again hadpsychiatrists assigned to each division. Most

man euver battalions h ad rest centers in theirkitchen trains (where recovering soldiers w eremon itored 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. Dur ing combat, the p sychiatristtriaged and treated combat exhaustion cases atthe d ivision clearing comp any an d sup ervisedtheir furth er rehabilitation for 3 to 5 d ays at thedivisions training and rehabilitation center.There were also (once again) Army NP centers

(clearing companies w ith p sychiatric supervisorsand specially trained staff) behind the d ivisions,Psychiatric consultants w ere at Ar my level, andspecialized base hosp itals w ere located in theCOMMZ. In heavy fighting during WWII, somed ivisions had one BF casua lty 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 pr eventing BF evenun der conditions of extreme stress.

c. Korea. In each d ivision, the d ivisionpsychiatrist 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 d uring the initial hasty m obili-zation and deployment and many combatexhaustion cases w ere inadverten tly evacuatedto Japan. The lessons of WWII were inst itu-tionalized in a specialized unit, the "KO Team"(medical detachment, psychiatric). The primarym ission of this mobile un it was to augm ent amed ical clearing comp any an d m ake it into anNP center. Late in the conflict, 85 percent of theBF cases returned to combat w ithin 3 days. Anadd itional 10 percent returned to limited d uty inseveral weeks, and only 5 percent were evacuatedto CON US.

d. Vietnam. In Vietnam, division men-tal health sections were located an d w orked atthe main base camp areas. They sometimes sentconsultation teams or enlisted beh avioral sciencespecialists to visit base cam ps and fire bases.Many of these draftee men tal health p ersonnelwere p rofessionals with m asters- or d octorate-level degrees. Traditional combat exhaustionwas rarely seen, and most cases of BF werehan dled w ithin the u nits. Substance abuse, thelack of discipline, and even commission ofatrocities were significant problems but were notclearly recognized as m iscond uct 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 augm entation to an evacuationhosp ital and as m obile consultation team s. In1972, based on th e Vietna m exp erience, the KOTeam was red esigned 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 D esert 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 und ertook the command consultation andtraining mission to corps and echelon above corpsun its. They reinforced t he activities of the d ivi-sion mental health sections. During Operation

Desert Storm, division menta l health/ CSC teamswere d eployed forward . These teams w orked w ithunits w ho had suffered casualties. Combat stresscontrol teams from the corps were deployedbehind th e brigades. These teams saw few stresscasualties during the ground offensive because ofits rapid an d h ighly victorious pace which lastedonly 100 hou rs. During dem obilization afterOperation Desert Storm, a systematic effort w ascondu cted by chaplains and m ental health per-sonnel to prepare soldiers and their families forthe changes and stressors of reunion. Some u nitswhich had especially d ifficult experiences receivedspecial debriefings.

1-7. Principles of Combat Psychiatry

The basic precepts of com bat p sychiatry havebeen documented in every US war in th is century.Our allies through similar experiences havefurther d ocum ented th ese basic precepts. Theprinciples of combat psychiatry are

a. Maximize Prevention.

(1) A chieve primary prevent ion.Control (and w hen feasible, redu ce) stressorswh ich are know n to increase BF and m iscondu ctstress behaviors. Some of the factors whichincrease stress and stress casualties include

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Being a new soldier (firsttime in combat) in a u nit.

Home front worries.

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

Insufficient tough, realis-tic training.

Lack of unit cohesion.

Lack of tru st in lead ers,equipment, and supporting arms.

Sleep loss.

Poor physical condition-ing (dehydr ation, malnutrition).

Debilitating environmen-tal exposure.

Inadequate information.

High d egree of uncer-tainty and ambiguity.

Absence of an achievableend of the mission in sight.

Inadequate sense of pu r-pose.

(2)Achieve secondary prevention.Minimize acute d isability (mor bidity) by trainingleaders, chap lains, and med ical personnel to

Identify early warning

signs and symp toms 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 m inor m iscondu ctstress behaviors.

Reintegrate recovered BFcasualties back into their units.

Taking and publicizingapp rop riate disciplinary actions for crim inalmisconduct stress behaviors.

(3)Achieve tertiary prevention.Minimize the potential for chronic disability(PTSD), both in soldiers who show BF and thosewh o do n ot. This is don e by

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

Condu cting end of tourdebriefings for u nits and un it mem bers families.

Remaining sensitive todelayed or covert p ost-traum atic stress signs andsymptoms and providing positive intervention.(This is prim arily the role of leaders, chaplains,and health care providers. )

b. Treat Battle Fatigue. Proximity, im-mediacy, expectancy, and simplicity (PIES) areall extremely imp ortant 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 immed iately.

(3)Expectancy. Expectancy re-lates to the positive expectation pr ovided 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 ph ysical w ell-being and self-confidence by u sing non med icalterminology and techniques.

c. Make Differential Diagnosis, ButDefer Psychiatric Diagnosis. Distingu ish life- orfunction-threatening m edical or su rgical con-ditions as soon as possible and p rovide thosepatients emergen cy treatment. Treat all othersusing PIES to the safest maximum extentpossible. Let the respon se to treatment sort outthe true NP disorders. The nonresponders shouldbe evacuated to th e echelon of care approp riatefor their treatment (either COMM Z or CON USfacilities) where treatment continues and the finaldiagnosis is determined.

1-8. Gen eric Treatment Principles forBattle Fatigu e

The generic treatment principles provided belowapp ly at all echelons throu ghou t the TO. Their

app lications m ay d iffer based on a pa rticularechelon and other factors pertaining to them ission, enem y, terrain, troops, and timeava ilable (METT-T).

a. Initial Assessment. In the initialassessment, a brief but adequate medical andm ental status examination is performed. Thisexamination should be app ropriate to the echelonof care and should ru le out any serious ph ysicalmen tal illness or injury. Alw ays consider th epossibility of trauma to th e head or tru nk. Other

surgical, medical, NP, and drug and alcoholmisuse d isord ers may resem ble BF, but th eyrequire emergency treatment. It is impor tant 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 neithercoward ice nor sickness but rather a normalreaction to terribly severe conditions. Providethese soldiers with th e expectation that th ey willbe RTD after a short p eriod of rest and physicalreplenishment and involve them in usefulactivities, as app ropriate.

c. Separate. Keep BF soldiers sepa-

rated from th ose patients with serious med ical,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 d ramatic symptoms of pan ic anxiety,depression, and/ or physical or memory problemsneed to be kep t separate from all other typ es ofpatients (includ ing oth er BF casu alties). This isdon e un til those symp toms cease so as not toadversely affect other BF soldiers.

NOTE

Association of recovering BF casualtieswith hold for treatment (patientsexpected to RTD within 72 hours) caseswh o have m inor injury or illness is notharmful.

No sharp distinction should be made betweenother convalescent soldiers and those recoveringfrom BF. Indeed, many of the soldiers with minorwou nd s or illnesses also have BF and should be

treated with the principles of PIES. Thesesoldiers can be treated together provided they arenot in their "contagious stage and RTD for bothis imminent.

d. Simple Treatm ent with Rest and Re-plenishment. Keep treatm ent for BF deliberately

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simple. Provide relative relief from danger butmaintain a tactical atmosph ere wh ich 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 wh at happ ened to him. Providesupportive counseling as needed to clarify memo-ries, to provide the opportun ity to expressfeelings, and to regain perspective. Reinforce thesoldiers identity as a soldier an d a mem ber of his

unit, not as a patient.

e.

f. Avoid Sedatives and TranquilizingMedications. Avoid sed ative or tranqu ilizingmedication unless essential to manage sleep oragitated beh avior. The BF soldier needs t o m ain-tain a normal state of alertness, coordination, andunderstanding. If the BF soldier is not m ed i-cated, he can take care of himself and can respondto and accept his treatment.

g. Evacuation and Hospitalization. Donot evacuate or hospitalize BF casualties unless

absolutely necessary. Evacuation and hospital-ization delay r ecovery an d significantly increasechronic morbidity, regardless of the severityof the initial symp tom s. It is better to transp ortBF casualties in general-pu rp ose veh icles, notambu lances (and especially not air am bulances),un less no other means of transportation isfeasible. Evacuation shou ld be ap proved by asingle qua lified au thority (for exam ple, if thesoldier is to leave the division, by the divisionpsychiat rist, in accordance w ith AR 40-216).

h. Unrnanageable Cases. Soldiers whose

BF (or psy chiatric} sym pto m s ma ke 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-know n as th e 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) d o not imp rove sufficiently within theallotted time to RTD are also sent u nobtru sivelyback to the next higher echelon, with expr essedpositive expectations for further treatment. Thissustains the positive expectation of rapid recovery

for BF casualties who are just arriving.

j. Hospitalization. As stated above, donot h ospitalize a BF casu alty un less 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 perm it. Those who reachhospitals as an inappropriate evacuee should betold th ey are only exp eriencing BF; they sh ou ldbe returned to their un it area or other forw ardarea 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 recond itioning trial in boththe combat zone (CZ) and the COMMZ. Thetreatment strategies of these program s assistrecovering BF soldiers in reg aining sk ills andabilities need ed for comb at d ut y. These skillsand abilities include concentration, team work,work tolerance, psychological endurance, andphysical fitness. Restoration is a 1- to 3-day

progr am w hich is condu cted in both th e 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 cond ucted by themedical detachm ent, CSC and / or the mental

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

1-9. Combat Stress Control Fun ctionalM ission Areas

a. Functional R oles. The p rinciples ofcombat p sychiatry and the m ethods 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 d etail in subsequen t chapters of thismanual.

(1) Consultation. Consultation in-volves the liaison and prev entive advice andassistance to comm and ers and staff of sup portedunits (see Chapter 4).

(2)Reconstitution support. Re-constitution support is that assistance providedto attrited units at field locations. Reconstitutionis an extraordinary action that comman ders planand implem ent to restore units to a desired levelof combat effectiveness commensurate withmission requirements and available resourcesaccording to FM 100-9. Reconstitution is a totalprocess wh ich involves the sequ ence of reor-ganization, assessment, and regeneration. Men-tal health/ CSC personnel supp ort reconstitutionas a pa rt of a consolidated team (see Chapter 5).

(3) Combat neuropschiatric tri-age. Com bat NP triage (as distingu ished fromsurgical triage) is the p rocess of sorting com batstress-related casualties and NP pa tients intocategories based on how far forward they can betreated. These categories are DUTY (RTDimm ediately), REST (light du ty for 1 to 2 days in

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

(4) Stabilization. This functionprov ides stabilization of severely d isturb ed BFand NP patients. They are evalua ted for RTDpoten tial or prepa red for further treatment orevacuation, if required (see Chapt er 7).

(5)Restoration. Restoration in-volves treatment w ith rest, food, wa ter, hygiene,and activities to restore confidence within 1 to 3days at forward medical facilities. Between 55and 85 percent of BF casualties shou ld RTD w ithrestoration tr eatment (see Chapter 8).

(6)Reconditioning. Recondition-ing involves treatment with physical training andan intensive program of psychotherapy and mili-tary activities. Reconditioning program s are con-du cted for 7 or more d ays in a nonh ospital settingin the corps area. Add itional reconditioning may

be provided in the COMMZ (see Chapter 9). Nomor e than 5 to 10 percent of BF casualties shou ldeventually 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 as

a separate mission to meet the specialhazards and requirements of war.

b. Priority of Functional MissionAreas. The six functional mission areas listedabove are in the usu al 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 functionald ifferent relative im p ortan ce in different sce- areas and pr ovide basic TTP for accomp lishingnarios or phases of the operation. The CSC com- them. These chap ters will also ad dress how CSCman der m ust set pr iorities and allocate resources functional areas interface with o ther fun ctionalto accomplish missions in each program based areas.

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CHAPTER 2

MENTAL HEALTH AND COMBAT STRESS CONTROL

ELEMENTS IN THE THEATER OF OPERATIONS

Section I. UNIT M ENTAL HEALTH SECTION S IN THE THEATER

2-1. Locations and Assignments of UnitMental Health Sections

Mental health sections are located in thedivisions, the corps, and the COM MZ. In thedivisions, they are assigned to the medicalcompan y of the m ain sup port battalion (MSB).

In the corps and COMMZ, they are assigned tothe ASMB head quar ters. In separate brigad es,they are assigned to the medical company.

2-2. Division Mental Health Section

The division m ental health section is assigned tothe main sup port m edical comp any (MSMC),wh ich is a d ivision supp ort comman d (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 m ental health section is the m edicalelem ent in the division with prima ry respon-sibility for assisting th e com m an d in control-ling combat stress. Combat stress is controlled

through sound leadership, assisted by CSCtraining, consultation, and restoration programscondu cted by this section. The d ivision 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 gu idan ce forthe preven tion, diagnosis, treatment, and m an-agement of NP, BF, and misconduct stressbehavior cases within th e division area of opera-

tions (AO). It has technical responsibility for thepsychological aspect of surety programs. The staffof this section pr ovides training to u nit 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 misconduct

stress behavior cases.

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

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

Coordinating support activities ofattached corps-level CSC elements.

The division m ental health section n orma llycollocates with the M SMC clearing station . Fora listing ofmajor equipment assigned, seeAppendix A. The staffing of the division mentalhealth section allows for th is section to be sp litinto teams which deploy forward to provide CSCsupp ort, as required, to brigades in the division.

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Norm ally, each brigade is sup ported by a brigadeCSC team. This team consists of a mental healthofficer wh o is designated the brigade m entalhealth officer and a behavioral science NCO thatis designated th e brigade CSC coordinator. If nomental health officer is available, the seniorbehav ioral science noncom missioned 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 p rovidesinpu t to the d ivision su rgeon on CSC-relatedma tters. He w orks with the division m edicaloperat ions center (DMOC) to mon itor andprioritize mental health support missions inaccordance with the division combat healthsup port (CHS) operation plans (OPLANs) oroperation ord ers (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 d ivision mental health section isstaffed as show n in Figure 2-1. The consolida tionof assigned mental h ealth officers and behavioralscience specialists in one division mental healthsection provid es un ity of CSC sup port for alldivision p revention, training, and treatmentresponsibilities of the section. It providesmu ltidisciplinary m ental health p rofessionalexpertise 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 comm unications 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 p sy-chiatrist (Major [MAJ], Medical Corps [MC], areaof concentration [AOC] 60WOO) is the officer incharge of the division mental health section. Thepsychiatrist is also a w orking ph ysician w ho

applies the knowledge and principles of psychi-atry and medicine in the treatment of all patients.He exam ines, diagnoses, and treats, or recom-mends courses of treatment for personnel suffer-ing from em otional or m ental illness, situationalmalad justm ent, BF (combat stress reactions), andmisconduct stress behaviors. His specific func-tions include

Directing the divisionsmental h ealth (combat m ental fitness) program.

Being a staff consultant

for the division surgeon on matters having psy-chiatric aspects, which include

Personnel reliabilityprogram.

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Alcohol and dru gabuse pr evention and control programs (ADAPCPs).

Planning CSC sup port forsupported u nits.

Conducting mental health/CSC Operations.

Provid ing staff consulta-tion for the MSMC comman der an d for sup portedcommands within the division.

Being resp onsible for as-suring the d iagnosis, 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 NP

disorders.Prescribing treatment and

disposition for soldiers w ith N P conditions.

Providing su pervision a ndtraining of assigned and attached mental healthpersonnel.

(2) Clinical psychologist. Theclinical psychologist (Cap tain [CPT], Med icalService Corps [MS], AOC 73B67) assists in thedevelopment, managem ent, and su pervision ofthe d ivisions m ental health (combat mental fit-ness) program. His special responsibilities applyto the knowledge and principles of psychology toinclude

Evaluating the psycholog-ical functioning of soldiers.

Condu cting surveys andevaluating data to assess unit cohesion and otherfactors related to pred iction an d 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 m iscond uct stressbehaviors and unsuitable soldiers.

Apprising unit leaders,

pr imary care ph ysicians, and oth er clinical per-sonnel regarding the assessment of individual andunit mental health fitness program.

Providing consultation forun it comm and er and CSC coordinators (mentalhealth NCO s w orking at the brigade level) re-garding problem cases.

Counseling and providingtherapy or referral for soldiers with psychologicalproblems.

Serving as the brigade

mental 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, managem ent, and sup ervision ofthe divisions mental health (combat mental fit-ness) program. H e app lies the mental healthpr inciples and his know ledge of social work inthe performance of his duties. His responsibilitiesinclude

Evaluating the social in-

tegration of BF and m iscond uct stress behaviorsoldiers in th eir units and families.

Coordinating and ensuringthe retur n of recovered str ess casua lties to du tyand their reintegration into their original or newunits.

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

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

Apprising unit leaders,pr imary care ph ysicians, and other clinical per -sonnel of available social service resources.

Providing consultation to

unit commanders and to division mental healthsection personnel regarding problem cases.

Counseling and providingtherapy or referral for soldiers with em otionalpsychological problems.

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

(4) Senior behavioral science non-commissioned officer. The senior behavioral sci-

ence NCO (E-7, military occup ational sp ecialty[MOS] 91G40) is the section serg ean t for th edivision 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 th e d ivision psy-chiatrist and mental health officers informed.

Monitoring, facilitating,and sup ervising the training activities of thedivision m ental health section.

Monitoring and coordinat-ing situation reports from d ivision mental h ealthsection personnel deployed within the BSAs.

Coordinating additionalmental health sup port with the supporting medi-cal detachm ent, CSC, or oth er corp s-level CSCelements supporting the division.

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

Serving as leader of abrigade CSC team w hen n o menta l health officeris available.

Conducting classes onselected men tal health topics for senior NCO swithin 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 brigad e CSCcoordinators and are deployed to the forwardsup po rt med ical com pa nies (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 pa rticipate in staffplanning to represent and coordinate mentalhealth/ CSC activities through out the brigade.They are especially concerned with assisting andtraining

Small un it leaders.

Unit ministry teams.

Battalion medical platoons.

Patient-holding squad andtreatment squad personnel of the FSMC.

They provide training and adv ice in the controlof stressors, the p rom otion of po sitive comba t

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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 d ivision men tal health section. Thebehavioral science NCOs collect and record socialand psychological data an d counsel personnelwith personal, behavioral, or psychologicalproblem s. Their general du ties include

Assisting in a wide rangeof psychological and social services.

Compiling caseload data.Providing counseling to

soldiers experiencing emotional or social problems.

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

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

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

Collecting informationfrom un its regarding u nit cohesion and moralewhich include

Obtaining data ondisciplinary actions.

Collecting informa-tion with qu estionnaires.

Conducting struc-tured interviews.

Collecting information onindividu al BF cases pertaining to the pr ior

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

When the brigades are tactically deployed, thebrigade CSC coordinators u se the d ivisionclearing 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. Throu gh th e brigadesurgeons they keep abreast of the tactical situ-ation and plan an d p roject requirem ents for CSC

supp ort when units are pulled back for rest andrecuperation.

(6)Behavioral science specialist.There are th ree beh avioral science specialists(E-4 and E-3, MOS 91 G1O). These sp ecialistsassist division mental health section officers andNCOs in gathering social and psychological datato support patient evaluation. Under the super-vision of the m ental health officer and NCOs, theyprovide initial screening of patients su ffering 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 to

assist an NCO brigade CSC coordinator or mentalhealth oficer.

Serving as squad leaderfor up to 12 jun ior enlisted grad e 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 th e divisionsupport, area (DSA).

In add ition to the above du ties, they operate andmaintain assigned vehicles.

2-3. Area Supp ort Medical Battalion M en-tal Health Section

The mental h ealth section is the m edical elementwith primar y respon sibility for assisting un its inthe corps support area in controlling combat stress.Combat stress is controlled through vigorous pre-vention, consultation, and restoration p rogram s.These program s are designed to m aximize theRTD ra te of BF soldiers by identifying com batstress reactions and p roviding rest/ restorationwithin or near their unit areas. Under the direc-tion of the ASMB psychiatrist, the mental healthsection provid es mental health/ CSC servicesthroughout the ASMBs AO. The mental health

section collocates with the headquarters and sup-port company (HSC) clearing station and deploysmental health/ CSC personnel w ithin 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 p sychological aspect of surety pr ograms.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. Other

responsibilities for the mental health section staffinclude

Providing command consultationand making recommendations for reducingstressors.

Evaluating NP, BF, and miscondu ctstress behavior cases.

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

Providing select ive shor t-termrestoration for HOLD category BF cases.

Coordinating support activities withmed ical compan y, CSC elements, when attachedor in su pp ort of the ASMB.

a. Mental Health Support. The ASMBS3 and the m ental health section mon itor 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 m ajor items ofequipment assigned, see Appendix A. The consoli-da tion of assigned m ental 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 sup ervise the behav-ioral science NCOs an d sp ecialists.

Provide staff input to su pp ortedcommands.

Provide clinical evaluation an dsup ervision of treatment for all NP an d p roblem-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 wh ere required th rough-out the AO.

(1) Psychiatrist. The psychiatrist(MAJ, MC, AOC 60W00) is the section leader.The psychiatrist is also a wor king ph ysician wh oapp lies the knowledg e and p rinciples of psychia-try and med icine in the treatment of all patients.He examines, diagnoses, and treats, or recom-mend s 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.

Provid ing 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-du ct stress behavior cases.

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

Provid ing consu lt at ionand 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 u nits within th eASMBs AO. The social work officer assists inthe d evelopment, m anagement, and supervisionof the battalions men tal health (com bat men tal

fitness) program for the AO. His responsibilitiesare to app ly the knowledge and principles of socialwork to

Evaluate th e social rela-ted ness of BF and m iscond uct stress behaviorsoldiers in th eir units and families.

Identify and resolve orga-nizational and social environmental factors wh ichinterfere with combat read iness.

Ensure support for

soldiers and their families from Arm y and civiliancommunity support agencies.

Apprise unit leaders, pri-mary care physicians, and other clinical person-nel of ava ilable social service resour ces.

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Provide consultation toun it comm and ers and to m ental health sectionpersonnel regarding problem cases.

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

Coordinate and ensure thereturn of BF and N P soldiers to du ty and theirreintegration into their original or new un its.

(3) Senior behavioral science non-commissioned officer. The senior behavioralscience N CO (E-7, MO S 91G40) is the sectionsergeant for the battalion mental health section.This senior N CO assists the m ental health officersin accomplishing their duties. He provides assist-ance with man agement of both the technical andtactical operations of the section and sup ervisessubordinate mem bers. His specific duties include-

Keeping the ASMB psy-chiatrist and mental h ealth officers informed.

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

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

Coordinating additionalmental health sup port for the battalions AO asdirected w ith the medical brigade/ group.

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

(4)Behavioral science noncommis-sioned officers. There are four beh avioral scienceNC Os assigned to the section (one E-6, MOS91G30, and th ree E-5, MOS 91 G20). The E-6 is

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the assistant section sergeant an d aids th e sectionsergeant with the accomplishment of his duties.Behavioral science NCOs collect and record social

and psychological data an d counsel personnelwith personal, behavioral, or psychological prob-lems. All these NCOs assist with the man age-men t of the m ental health section. These NCOsmay be deployed with area support medical com-pan ies (ASMCs) as CSC coordinators to prov idemental health/ CSC supp ort. They assist theASMCs with matters pertaining to mental health/CSC. As required , the CSC coordinators p artici-pate in staff planning to represent and coordinatemental health/ CSC activities throughou t theASMCs AO. They are especially concerned withassisting and training

Small unit leaders.

Unit ministry teams.

Battalion medical platoons.

Patient-holding squad andtreatment squ ad p ersonnel of the ASMC.

They provide training and adv ice 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 andsupp ort to the supp orted units by the mentalhealth officers of the ASMB mental healthsection. The beh aviora l science NCOs collect andrecord social and psychological data an d coun selpersonnel with personal, behavioral, or psycho-logical problem s. Their general d uties include-

Assisting in a wide rangeof psychological and social services.

Compiling caseload data.

Providingsoldiers experiencing emotionallems.

counseling toor social pr ob-


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Referring soldiers tospecific men tal hea lth officers, physicians, oragencies when indicated.

Assisting with group de-briefings, coun seling an d th erap y sessions, andleading group discussions.

Providing individual caseconsultation to comm and ers, NCOs, chap lains,battalion surgeons, and ph ysician assistantswithin the supported brigade.

Collecting informationfrom units regarding un it cohesion and moralewhich include

Obtaining data ondisciplinary actions.

Collecting informa-tion with questionnaires.

Conducting struc-tured interviews.

Collecting informat ion onind ividu al BF soldier cases pertaining to

Prior effectiveness ofthe soldier.

Precipitating factorscausing BF.

Potential for RTD

When the supported units are tactically deployed,the beha vioral science NCOs u se 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 comm and ers, they keep abreast of the

tactical situation an d plan and project require-men ts for CSC sup port w hen u nits are pulledback for rest and recup eration.

(5) Behavioral science specialist.There are th ree beha vioral science specialists(E-4 an d E-3, MOS 91 G1O). These sp ecialistsassist 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 du ties, they op erate and m aintainassigned vehicles. Under the supervision of a

men tal health officer or an N CO, their sp ecificduties include

Providing supportive coun-seling for patients experiencing emotional orsocial p roblems.

Assisting in the evalua-tion of the emotionally distu rbed or menta lly 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 m ental healthofficer.

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

2-4. Mental Health Personn el in theSeparate Brigades

In the separate brigades, both light and heavy,mental health personnel are assigned to themed ical company, separate brigade. In the lightseparate brigad e, one behavioral science NCOis assigned to the m edical comp any clearingsection. He functions as a brigade CSC

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e. Employment in the Theater. Them edical com pan y, CSC operates in the corpsarea and deploys its assets forward, as required,in support of operations for supported divi-sions and separate brigades. In th e corps area,it provides CSC sup port on an area basis andcondu cts CSC consultation, restoration, and re-conditioning program s. The medical company,CSC norm ally operates from th e med ical brigadeor group headquarters. The medical company,

CSC m ay be attached to ASMBs, combat su p-port hosp itals (CSH s), or other corps m edicalun its. The task-organized CSC elemen t is alsodeployed into the supported division areas,as required, to augm ent the m edical detach-men t, CSC and organic division m ental healthsection/ CSC personn el. The m edical compan y,CSC provides advice and assistance to itshigher headquarters on combat stress and N Pissues.

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2-6. Headquarters Section

The headquarters section provides command andcontrol (C2) and un it-level ad ministrative andmaintenance support to its subordinate sectionswh en they are collocated with the comp any. Theheadquarters section may also provide assistanceto detached elements by ma king site visits if theelements are within a feasible distance for groundtransportation. The medical comp any, CSC ele-ments normally deploy with limited maintenanceand are without ad ministrative sup port. Whenthese CSC elements deploy, they are dependent

on 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.

Comman ders driver/ behavior-

Prescribed load list (PLL)

Armorer.

Motor sergeant.

Light-wheeled vehicle mechanic

Power generation equipmentrepairman.

Cook (three).

Personnel from the headquarters section aredep loyed with team s or task-organized CSC ele-ments as required.

a. Company Commander. The medicalcompany, CSC commander (Lieutenant Colonel[LTC], MC, AO C 60W00) plans, d irects, andsup ervises the operations of the compan y. The

comman der is also responsible for the training,discipline, billeting, and security of the company.He provides daily reports to his higher head -qu arters as established by the tactical stand ingoperating p rocedu res (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 p atients. He exercises clinical super-vision over all treatment pr ovided by the CSCsections and d etachments. He performs p hysicaland men tal status evaluations in emergen cy orcomm and evaluation situations; this includesdiagnosing, p rescribing initial treatmen t, anddetermining disposition. The commander inter-faces with higher and supp orted headqu artersand with supported CSC medical detachments,ASMB mental health sections, and division men-tal health sections. He keeps informed on CSCoperations through d aily reports and by frequentvisits to task-organized CSC elements deployedfrom his comp any.

b. Chaplain. The chaplain ( CPT,

Chaplain [CH], AOC 56AOO) provides religious/ethical education and perspective to the dispersedsections for the p revention and treatment of BFand miscondu ct stress behaviors. He interfacesCSC activities with unit ministry teams inma neu ver un its, hospital chap lains, and w ithstaff chaplains at each headquarters level. The


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chaplain usually accompanies the medical com-pan y, CSC comm and er when he visits supp ortedunits and task-organized CSC elements deployedin sup port of those units. The chap lain ha s achaplains kit to conduct services but is without achaplains assistant. The chaplains primary roleis to aid CSC personnel in p reventive stress con-trol and in working with BF casualties and mis-conduct stress behaviors. In ad dition to h is 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 th e compan y com-man der on all matters p ertaining to the tacticalemployment of comp any assets. He is responsiblefor overseeing operations and administrative,supply, and maintenance activities within thecompany. His resp onsibiliti

United States Army Fm 8-51-30 January 1998

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