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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 MedicalDepartment�s (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).

FM 8-51

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 Department’s (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 one’s 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 commander’s 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 body’s processes for dealingwith uncertain changes and danger. Eliminationof stress is both impossible and undesirable inthe Army’s 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 soldier’s 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 anindividual’s 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 of“physical” 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 than“routine” 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 stressbehaviors—those 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 unit’s

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

The above positive combat stress behaviorscombine to form unit cohesion—the 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 soldier’s 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 nation’s 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 unit’s 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 with“war 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 General’s 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 as“war 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 their“kitchen trains” (where recovering soldiers weremonitored by the battalion surgeon). There were“exhaustion 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 thedivision’s “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 exhaustion”was 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 thesoldier’s 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 unit’s 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 division’smental 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, physician’s 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 division’s 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 division’s 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 patient’smental 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 ASMB’s AO. The mental healthsection collocates with the headquarters and sup-port company (HSC) clearing station and deploysmental health/CSC personnel within the ASMB’sAO (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 theASMB’s AO. The social work officer assists inthe development, management, and supervisionof the battalion’s 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 battalion’s AO.

Coordinating additionalmental health support for the battalion’s 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 patient’s 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 NCO’s 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.

Commander’s 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 achaplain’s kit to conduct services but is without achaplain’s assistant. The chaplain’s 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 divisions’tactical 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. Commander’s Driver/BehavioralScience Noncommissioned Officer. The com-mander’s 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, operations, history, maintenance,modifications and calibration. He is responsiblefor requesting, receiving, recording, and storingparts and tools. In addition, he issues such partsto motor vehicle and power generation repairpersonnel as required. He is also responsiblefor—

i.

Providing input for the mate-riel readiness report.

Assisting in the scheduling ofmaintenance and repair services.

Issuing tools to motor vehicleand power generation repair personnel, as re-quired.

j. Armorer. The supply specialist/armorer (E4, MOS 92Y1O) maintains the weaponsstorage area, issues and receives munitions, andperforms small arms unit maintenance. He

assists with general supply activities and operatesthe vehicle assigned to the supply element.

k. Motor Sergeant. The motor sergeant,a senior vehicle mechanic (E-6, MOS 63 B30),supervises and performs maintenance on unitvehicles. He advises, trains, and supervises othermaintenance personnel assigned to the company.His responsibilities also include—

Preparing daily work sheetsand charts.

Supervising scheduled mainte-nance and repair services.

Implementing the Army OilAnalysis Program.

Recommending maintenanceprocedures.

Supervising and performingvehicle recovery operations.

Ensuring that company equip-ment meets calibration times and services.

l. Light-Wheeled Vehicle Mechanic.There are two light-wheeled vehicle mechanics(one E-5, MOS 63B20 and one E-3, MOS 63BIO)who perform organizational maintenance andwork under the supervision of the motor sergeant.They perform organizational preventive main-tenance and repairs on gasoline and diesel-fueled,light-wheeled vehicles. Light-wheeled vehiclesinclude prime movers designated as 5 tons or lessand their trailers and associated items. Duties ofthe light-wheeled vehicle mechanics include—

light-wheel

ment probl

Diagnosing malfunctions ofed vehicles and associated items.

Troubleshooting engine/equip-ems using technical manuals (TMs).

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test yand diagnostic measurement equipment(TMDE), and other equipment as required.

Applying applicable safety pre-cautions.

Performing scheduled mainte-nance and repairs on vehicles and equipmentassisted by the vehicle operator.

Maintaining and accounting fortools and equipment issued to him.

Deploying with companyelement (task-organized CSC element) to providemaintenance for company or attached vehicles.When deployed, they work with the maintenancesection/element of the unit to which the task-organized CSC element is attached.

m. Power Generation Equipment Re-pairman. The power generation equipment re-pairman (E4, MOS 52D1O) performs unit main-tenance functions. The major functions and tasksof the repairman include—

Applying applicable safety pre-cautions.

Inspecting equipment, deter-mining category of maintenance and extent ofrepairs, and recording results.

Classifying unserviceable com-ponents and assemblages as required.

Performing preventive main-tenance checks and services (PMCS) on shopequipment.

Maintaining and accounting fortools issued.

Training unit personnel on howto properly operate and perform user mainte-nance on assigned generators.

n. Cooks. Three cooks (two E4 and oneE3, MOS 94B10) provide food service (tray-packheating) for the company when it is assembled.More often, they are deployed with a task-organized CSC element and further attached forwork with the food service section of the sup-ported medical unit. They also train CSC per-sonnel on food tasks which may be used as a partof their CSC restoration or reconditioning pro-gram. They serve as work group leaders for BFcasualties performing food service tasks as partof the BF casualty’s treatment.

2-7. Preventive Section

This section has 6 psychiatrists, 6 social workofficers, and 12 behavioral science specialistsassigned to the section. This section can divideinto six 4-person combat stress preventive teams.Elements of the section may also be task-organized with elements of the restoration sectionto form task-organized CSC elements for deploy-ment to conduct CSC operations. The companycommander will appoint the combat stress pre-ventive team or task-organized CSC elementleaders, considering rank, professional qualifica-tions, and especially experience. The preventivesection’s responsibilities include—

Providing preventive consulta-tion.

Assisting units with RESTcategory BF cases and RTD of recovered BFcasualties.

Providing NP triage and stabi-lization as required.

Supervising restoration of cat-egory HOLD BF casualties by medical personnel.

Providing medical, psychiatric,and social work expertise to restoration and re-conditioning programs.

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Deploying combat stress pre-ventive teams to reinforce CSC elements opera-ting in the divisions and corps areas.

Providing reconstitution men-tal health support to physically and mentallyexhausted units.

a. Psychiatrist. The six psychiatrists(MAJ [three], CPT [three], MC, AOC 60W00)assigned to this section examine patients andprovide consultation. They make neuropsycho-logical and medical diagnosis and prescribe andprovide treatment. They also direct dispositionof patients. The senior psychiatrist performs theduties of section leader and directs the activitiesof the section when the section is assembled.Psychiatrists assigned to this section may bedeployed in support of CSC operations with thesection, or as members of either a combat stresspreventive team or a task-organized CSC ele-ments. When deployed as a member of a combatstress preventive team or a task-organized CSCelement, the psychiatrist’s duties include—

Establishing and providingCSC support.

Providing staff consultation tosupported units as required. This includesnuclear surety, security clearances, and alcoholand drug abuse preventive program.

Being responsible for thediagnosis, treatment, rehabilitation, and disposi-tion of NP and problematic BF cases.

Participating in the diagnosisand treatment of the wounded, ill, and injured,especially of those who can RTD quickly.

Consulting and providingtraining to unit leaders and medical personnelregarding identification and management of NPdisorders, BF, and misconduct stress behaviors.

Providing therapy or referralfor soldiers with NP disorders.

Providing supervision and train-ing of assigned and attached mental healthpersonnel.

Conducting and supervising unitsurvey interviews and critical event debriefings.

b. Social Work Officer. Six social workofficers (MAJ [two], CPT [four], MS, AOC 73A67)are assigned to this section. They provide pro-active consultation, give individual and groupcounseling, supervise restoration/reconditioning,and coordinate RTD of recovered cases. They alsoprovide staff advice and coordinate Army andcivilian social services support. These social workofficers may be divided among several task-organized CSC elements or be utilized as a memb-er of a combat stress preventive team. Whendeployed as a member of a combat stress preven-tive team or task-organized CSC element, thesocial work officer’s duties include—

Evaluating psychosocial (unitand family) functioning of soldiers with BF andmisconduct stress behavior.

Coordinating and ensuring thereturn of recovered BF and NP soldiers to dutyand their reintegration into their original or newunit.

Identifying and resolving or-ganizational and social environmental factorswhich interfere with combat readiness.

Coordinating support for sol-diers and their families through Army and civil-ian community support agencies, when possible.

Apprising unit leaders, pri-mary care physicians, and others health careproviders of available social service resources.

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Providing consultation to sup-ported unit commanders and to other mentalhealth/CSC personnel regarding problem cases.

Counseling and providingtherapy or referral for soldiers with psychologicalproblems.

Conducting and supervisingunit survey interviews and critical event de-briefings.

Preventive Section Sergeant. Thesenior behavioral science NCO (E-7, MOS 91G40)is the preventive section sergeant. This seniorNCO provides management assistance to themental health officers for both the technical andtactical operations of the section. He supervisessubordinate members. His specific dutiesinclude—

c.

Keeping the section leaderinformed.

Monitoring, facilitating, andsupervising the training activities of the section.

Monitoring and coordinatingsituation reports from deployed task-organizedCSC elements or combat stress preventive teams.

Conducting classes on selectedmental health topics for senior NCOs of supportedunits.

Conducting and supervisingunit survey interviews and critical event de-briefings.

d. Behavioral Science Noncommiss-ioned Officer. There are five behavioral scienceNCOs (two E-6, MOS 91G30 and three E-5, MOS91G20). The two NCOs (E-6) act as assistantsection sergeant and assist the section sergeantwith his duties. The NCOs collect and recordsocial and psychological data and counsel

personnel with personal, behavioral, or psycho-logical problems. They assist with the manage-ment of the preventive section. The NCOs alsodeploy as NCOICs of combat stress preventiveteams, or as members of task-organized CSCelements. Their general duties include—

Assisting in a wide range ofpsychological and social services.

Compiling caseload data andreferring patients to specific mental healthofficers and physicians in supporting MTFs.

Providing counseling to sol-diers experiencing emotional or social problems.

Assisting with group counsel-ing and debriefing sessions and leading groupdiscussions.

Collecting data in unit surveyinterviews pertaining to unit cohesion, morale,and individual mental readiness for combat.

Assisting in critical event de-briefings.

e. Behavioral Science Specialist.There are six behavioral science specialists (threeE-4 and three E-3, MOS 91G20) assigned to thesection. These specialists assist the mental healthofficer and NCOs in gathering social and psycho-logical data to support patient evaluations. Underthe supervision of the mental health officer andNCOs, they provide initial screening of patientssuffering emotional or social problems. In addi-tion to their duties, they operate and maintainassigned vehicles. Under the supervision of themental health officer, their specific dutiesinclude—

Serving as team leaders andproviding supportive counseling to BF casualtiesand misconduct stress behaviors cases experienc-ing emotional or social problems.

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Assisting in the evaluation ofBF casualties and misconduct stress behaviors.

Assessing the mental status ofBF casualties and misconduct stress behaviors(level of functioning capacity) and their need forprofessional services.

Collecting data in unit surveyinterviews.

Assisting inbriefings.

critical event de-

2-8. Restoration Section

The restoration section consists of 4 psychiatricnurses, 4 clinical psychologists, 4 occupationaltherapy (OT) officers and 4 patient administrationspecialists. It also has 1 senior psychiatric ward-master, 7 psychiatric specialists, 8 OT specialists,and 12 behavioral science specialists. This sectioncan divide into four combat stress restorationteams. Elements of this section are usually task-organized with elements of the preventive sectionto form task-organized CSC elements whichoperate restoration or reconditioning centers. Atthese centers, they provide NP triage, diagnosis,stabilization, treatment, and disposition. Sectionpersonnel, as members of task-organized CSCelements or combat stress restoration teams, alsodeploy routinely to provide preventive consulta-tion and reconstitution support to units in thecorps area. They reinforce and may reconstitutemedical detachment, CSC teams in the divisionsupport areas.

NOTE

The priority role for all CSC personnelis the prevention of BF and otherstress-related casualties. This is astrue for the restoration section as it isfor the preventive section.

The section leader position may be held by any ofthe officers assigned to the section. The companycommander will appoint the section leader basedon rank, professional qualifications, andespecially experience. This same rationale is usedin selecting leaders for the task-organized CSCelements and combat stress restoration teams.

a. Occupational Therapy Officer. FourOT officers (MAJ [two], CPT [two], Army MedicalSpecialist Corps [SP], AOC 65A00) are assignedto the section. They serve as environmentalmanagers using daily living task, physical recon-ditioning, work, and other activities to counteractcombat stress reactions. Preventive treatmentprograms include individual work assignments,organized group work projects, common soldiertask review, stress management education,recreation, and physical reconditioning. Theirresponsibilities include—

Providing command consulta-tion to leaders regarding work schedules andrestorative off-duty activity programs.

Performing functional occupa-tional evaluations of BF casualties.

Performing neuromuscularevaluations, especially upper extremities andhands.

Assigning BF casualties tophysical reconditioning and work groups.

Overseeing physical recondi-tioning and work programs for BF casualties.

Selecting appropriate activitiesbased on a BF casualty’s assessment.

Evaluating functional work ca-pacity.

Modifying reconditioning pro-grams as required.

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Maintaining records of therapy/treatment.

Reporting status of BF casual-ties to psychiatrists and staff members on a dailybasis, or in accordance with the TSOPs.

Conducting unit survey inter-views and critical event debriefings. c .

b. Psychiatric/Mental Health Nurse.The section consist of four psychiatric/mentalhealth nurses (MAJ [two], CPT [two], Army NurseCorps [AN], AOC 66C00). The two majors posi-tions should be filled by clinical nurse specialists(AOC 66C7T). The psychiatric nurses providespecialized care, as required, for all BF, miscon-duct stress behaviors and NP casualties, espe-cially those with severe behavioral disturbancesand/or concurrent physical illness or injury. Theyadminister medications according to thepsychiatrist/physician’s orders. The clinical nursespecialist (AOC 66 C7T), when properly trained,prescribes medications under the supervision ofa psychiatrist/physician. In coordination with thepsychiatrist, clinical psychologist, occupationaltherapist, and other section members, the psy-chiatric nurses responsibilities include—

Conducting individual andgroup therapy and stress control educationsessions.

Providing preventive and com-mand consultation, especially to medical units.

Assisting with the developmentof the RTD plan for each case.

Ensuring the BF casualty’stherapeutic program, as outlined in the RTD plan,is followed.

Monitoring the BF casualty’sstatus and record pertinent case data.

Conducting nursing reports inaccordance with TSOPs to update sectionmembers.

Conducting and supervisingunit survey interviews and critical eventdebriefings.

Clinical Psychologist. There arefour clinical psychologists (MAJ [one], CPT[three], MS, AOC 73B67) assigned to the section.Their duties include—

Providing diagnostic expertisefor triage.

Conducting psychological andneuropsychological testing.

Providing behavioral treatmentand counseling.

Conducting and supervisingsurveys of unit cohesion, morale, and individualmental readiness for combat.

Providing command consulta-tion.

Supervising subordinate per-sonnel.

Conducting and supervisingcritical event debriefings.

d. Senior Behavioral Science Noncom-missioned Officer. The senior behavioral scienceNCO (E-7, MOS 91G40) assists the section leaderand the clinical psychologist with the accomplish-ment of their duties. He provides assistance tothe mental health officers with their adminis-trative and clinical duties. He supervises thebehavioral science specialists working with theclinical element of the section. He assists withthe management and operations of the clinical

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element of the section. He provides assistancewith the management of operations (technical andtactical ) of the section. His specific duties in-clude—

Keeping the section leaderinformed.

Monitoring, facilitating, andsupervising the training activities of subordinatesin the clinical element.

Monitoring and coordinatingsituation reports from deployed task-organizedCSC elements or combat stress preventive teams.

Conducting classes on selectedmental health topics for senior NCOs of supportedunits.

Conducting and supervisingunit survey interviews and critical event de-briefings.

Senior Psychiatric Wardmaster.The psychiatric wardmaster (E7, MOS 91F40)assists the section leader with administrative andclinical duties and supervises the restoration orreconditioning center operations. He providesdirect supervision for the seven psychiatric spe-cialists (MOS91F) and three patient administra-tion specialists (MOS71G) (ward clerks). If therestoration and reconditioning centers’ operationsare centrally located, he assists with the overallmanagement of their operations. If the sectiondivides into two or more task-organized CSCelements, he manages the restoration and recon-ditioning center that is most likely to have thegreatest need. His responsibilities includeassisting with planning and executing the estab-lishment, disestablishment, movement, andoperations of the restoration and reconditioningcenters. He is responsible for assisting the psy-chiatric nurses with BF casualty care activities.He also assists the section leader with the

management and operations (technical and tacti-cal) of the section, His specific duties include—

Keeping the section leader in-formed.

Monitoring, facilitating, andsupervising the training activities of assignedpersonnel.

Monitoring and coordinatingsituation reports from deployed restoration andreconditioning centers, either with task-organizedCSC elements or combat stress preventive teams.

f. Psychiatric Noncommissioned Offi-cer. Two psychiatric NCOs (E-6, MOS 91F30,and E-5, MOS 91F20) are assigned to the section.They manage and provide supervision for the BFcasualty’s care. They deploy with either combatstress restoration teams or task-organized CSCelements. They function as BF casualty caremanagers for the restoration and reconditioningcenters. They assist the psychiatric nurse(s)with— e.

Planning and executing theestablishment, disestablishment, and movementof the restoration or reconditioning center.

Conducting restoration and re-conditioning center operations.

Providing guidance and train-ing to subordinate psychiatric specialists andother BF casualty care providers.

Administering medications.

As squad leaders, they provide direct supervisionfor BF casualties and monitor their progress.They also assist with unit survey interviews andcritical event debriefings.

Psychiatric Specialist. Five psychi-atric specialists (three E-4 and two E-3, MOS

g.

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91F20) provide BF casualty care and intervention,as required. These specialists deploy with eitherthe combat stress restoration teams or task-organized CSC elements. Their duties include—

Following the RTD plans forcases placed under their supervision.

Coordinating with the psychi-atric nurse and other staff members on questionspertaining to the

BF casualties (astheir progress.

RTD plan.

Providing direct supervision forsquad leaders) and monitoring

Recording and reporting to thepsychiatric nurses and other mental health staffmembers on the status and any other pertinentobservation of cases assigned to them.

Assisting with unit survey in-terviews and critical event debriefings.

Operating and maintainingassigned vehicles.

h. Behavioral Science Noncommiss-ioned Officer. Five behavioral science NCO (twoE-6, MOS 91G30, and three E-5, MOS 91G20)are assigned to the section. Their responsibilitiesinclude—

Collecting and recording socialand psychological data.

Counseling soldiers with per-sonal, behavioral, or psychological problems.

Assisting with the manage-ment of the section.

Deploying as members of com-bat stress preventive team or task-organized CSCelements.

Their general duties include—

Assisting in a wide range ofpsychological and social services.

Assisting with initial screeningand assessment of new cases.

Compiling caseload data andreferring BF casualties to specific mental healthofficers and psychiatrists.

Providing counseling to BF ca-sualties experiencing emotional or social prob-lems.

Assisting the psychologist withadministration of psychological testing.

Assisting with group counsel-ing and therapy sessions and leading group dis-cussions.

Assisting with unit survey in-terviews and critical event debriefings.

i. Behavioral Science Specialist. Sixbehavioral science specialists (three E-4 and threeE-3, MOS 91G20) are assigned to the section.Their duties are consistent with those previouslyidentified above (2-7e ).

j. Occupational Therapy Noncommis-sioned Officer. Three OT NCOs (one E-6, MOS91L30, and two E-5, MOS 91L20) are assigned tothe section. They assist the occupational thera-pists with—

Evaluating functional capacityand supervising physical reconditioning pro-grams.

workunits

Coordinating and setting upprograms with supported and supportingand overseeing work programs.

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Supervising and ensuring ap-propriate training for subordinate OT specialistsand other mental health personnel.

Providing BF casualty statusupdates to the occupational therapists and otherstaff members as required.

Providing direct supervision ofBF casualties and squad leaders.

Assisting with unit survey in-terview and critical event debriefings.

The OT NCOs deploy with either combat stressrestoration teams or task-organized CSC elements.

k. Occupational Therapy Specialist. FiveOT specialists (two E-4 and three E-3, MOS91L20)work under the supervision of the occupationaltherapists and OT NCOs. Their duties include—

Assisting the occupationaltherapists with evaluating functional capacity.

m .Assisting with the supervision

of work programs.

Assisting with the identifica-tion of useful work projects.

Assisting with organizing ac-tivities which facilitate the recovery of the BFcasualties.

Serving as team leader for upto 12 BF casualties.

Assisting with unit surveyinterviews and critical event debriefings.

These OT specialists deploy with combat stressrestoration teams or task-organized CSC elements.

1. Patient Administration Noncom-missioned Officer. The patient administrationNCO(E-5,MOS 71G) is responsible for managing

patient statistics of all BF casualties seen by thecompany element. He is normally located withthe company headquarters but makes visits totask-organized CSC elements as required to ensurecompany elements are complying with patientadministrative requirements. He is responsiblefor forwarding the Medical Summary Report (RCSMed-302 [R3]) in accordance with AR 40-400, andensures that all BF casualty accountability andstatus reports are forwarded as directed by higherheadquarters. He initiates the field medical card(FMC) (DD Form 1380) on all BF casualties seenfor consultation and medical treatment and thoseplaced in the center for restoration or recondition-ing programs. He ensures that all restorationand reconditioning centers maintain the DailyDisposition Log. He supervises subordinate pa-tient administrative specialists. He coordinatestransportation and evacuation, as required, forBF casualties sent rearward for additional resto-ration or reconditioning and for recovered BFcasualties returning to their units.

Patient Administration Specialists.The patient administration specialists (two E-4and one E-3, MOS71G20) participate in the in-processing of BF casualties into restoration andreconditioning centers. They are responsible forinitiating reports and forms identified in thepreceding paragraph. They maintain the DailyDisposition Log. When deployed with a combatstress restoration team or task-organized CSCelements, they work with the patient admin-istration section of the medical unit to which thetask-organized CSC element or combat stressrestoration team is attached. Through the patientadministration section of the unit they areattached to, they coordinate BF casualty evac-uation and transportation requirements. Theymaintain assigned vehicles and operate companyradios. They coordinate the disposition of BFcasualties through supporting unit communica-tions assets. Patient administration specialistsdeploy with combat stress restoration teams ortask-organized CSC elements.

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Section III. COMBAT STRESS CONTROL DETACHMENT

2-9. Medical Detachment, Combat StressControl (TOE 08-567LA00)

The medical detachment, CSC (Figure 2-4) is a23-person unit composed of a headquarters, acombat stress preventive section, and combatstress restoration teams. The modular CSC teamsfound in the medical detachment, CSC are similarto those found in the CSC medical company. Themedical detachment, CSC provides CSC planning,consultation, training, and staff advice to C2headquarters and the units to which they areassigned regarding—

sors affecting theCombat and noncombat stres-troops.

Mental readiness.

Morale and cohesion.

Potential for BF casualties.

The detachment provides NP triage, basic stabili-zation, and restoration for BF casualties. Undersome circumstances, it may provide recondition-ing for NP and alcohol and drug abuse patients.This unit is dependent on support from appro-priate elements of the corps to include—

Religious.

Finance.

Legal.

Personnel and administrative.

Food service.

Supply and field services.

Local security support.

Unit maintenance services.

The detachment is dependent on units to whichattached for support to include—

Medical administration.

Logistical, including health ser-vices logistics.

Medical regulating of patients.

Battle fatigue casualtyuation.

Coordination for RTD ofered BF soldiers.

Personnel resources to

evac-

recov-

guardenemy prisoner of war (EPW) patients providedby the echelon commander.

Food service.

Supply and field services.

Local security support.

Unit maintenance services.

a. Mission. The medical detachment,CSC provides comprehensive CSC support to adivision, or to two or three separate brigades orregiments. As the tactical situation permits, thisdetachment can provide all six of the CSC func-tions identified, but reconditioning is unlikelywhen it is deployed forward of the corps. For alisting of major items of equipment assigned, seeAppendix A.

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b. Assignment. The medical detach-ment, CSC is normally assigned to a corps medicalbrigade with further attachment to a medicalgroup, medical company, CSC, ASMB, or to aDISCOM of a supported division.

2-10. Detachment Headquarters

The detachment headquarters provides C2 for thedetachment. The headquarters section is re-sponsible for planning, coordinating, and imple-menting CSC support for supported units. Theheadquarters has two personnel assigned: thedetachment commander and the detachmentNCOIC. The detachment commander also servesas a treating physician with the preventive sec-tion. The detachment NCOIC (a senior behav-ioral science NCO) also serves as the restorationteam sergeant. Detachment officers and NCOsfrom the preventive team and the restorationteam may be assigned additional duties whichenhance the overall effectiveness of the head-quarters section.may include—

Additional duty

Maintenance.

Training.

responsibilities

Security, plans, and operations.

Nuclear, biological, and chemi-cal defense officer/NCO.

supply.

These duties may be rotated to achieve maximumcross-training.

a. Detachment Commander. The de-tachment commander, a psychiatrist (MAJ, MC,AOC 60W00), performs normal C2 and supervi-sory functions as well as serving as a treatingphysician in one of the combat stress preventive

teams. He coordinates with the command sur-geon and mental health sections regarding careand disposition of patients. He exercises clinicalsupervision over treatment in all the CSC teams.He provides NP expertise to supported unit head-quarters. In conjunction with supported unitheadquarters and MTFs, the detachment com-mander plans CSC support for the unit’s opera-tions. He deploys the detachment’s teams sepa-rately, or task organizes personnel across teamsas needed to form task-organized CSC elements.He appoints team leaders based on best quali-fications by experience as well as by AOCs.

b. Detachment Noncommissioned Offi-cer In Charge. The detachment NCOIC (E-7,MOS 91G) assists the detachment commander inthe accomplishment of his duties. He performsadministrative duties; he receives and consoli-dates reports from deployed detachment elementsand forwards them to higher headquarters. Thedetachment NCOIC coordinates support for thedetachment and for detachment elements deploy-ed to supported units. He represents the com-mander at staff meetings and on-site visits to theCSC teams when the commander is occupied withclinical duties. When the detachment is dividedinto combat stress preventive and combat stressrestoration teams or task-organized CSCelements, the NCOIC normally locates with thecombat stress restoration team. The combatstress restoration team is usually the largest andrear-most of the medical detachment, CSCelements. It is usually located closest to thesupported unit headquarters and coordinatingstaff (DMOC and MSB headquarters).

2-11. Preventive Section

This section has three psychiatrists, three socialwork officers, and six behavioral science special-ists assigned to the section. This section candivide into three 4-person combat stress preven-tive teams. Combat stress control preventive

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team leaders are selected by the detachmentcommander based on experience as well as ongrade and specialty. Elements of the section mayalso be task-organized with elements of the resto-ration team to form task-organized CSC elementsfor special CSC operations. The preventive sec-tion’s responsibilities include—

Providing preventive consulta-tion support to leaders, chaplains, and medicalpersonnel located in and around the brigade sup-port area.

Assisting nonmedical unitswith REST category BF casualties and the RTDof recovered BF soldiers.

Providing NP triage and stabi-lization.

Supervising restoration ofHOLD category BF casualties by medical per-sonnel and providing restoration for selectedcases.

c.

Providing medical, psychiatric,and social work expertise to restoration programsstaffed by medical detachment, CSC restorationteam.

Deploying to units to providereconstitution support.

a. Psychiatrist. The three psychiatrists(MAJ [also the detachment commander], CPT[two], MC, AOC 60W00) are assigned to thissection. The senior psychiatrist/detachmentcommander directs the activities of the section.Psychiatrists assigned to this section are usuallydeployed in support of CSC operations as mem-bers of a combat stress preventive team, but mayremain with the combat stress restoration teamunder some circumstances. These psychiatristswill usually associate closely with the supportedFSMC’s area support treatment team. They

coordinate CSC operations, as required, and per-form those duties previously identified aboveparagraph 2-7 a).

b. Social Work Officer. Three socialwork officers (MAJ [one], CPT [two], MS, AOC73A67) are assigned to this section. These socialwork officers usually deploy as members of thecombat stress preventive teams, but could remainwith the combat stress restoration team based onmission requirements. As a member of a combatstress preventive team or other CSC element,in addition to those duties identified above(paragraph 2-7 b), the social work officer’s dutiesinclude—

Evaluating soldiers with BFand misconduct stress behavior.

Supervising subordinate per-sonnel.

Preventive Section Sergeant. Thesenior behavioral science NCO (E-6, MOS 91G30)is the preventive section sergeant. His duties arethe same as those previously identified above(paragraph 2-7 c).

d. Behavioral Science Noncommis -sioned Officer. There are two behavioral scienceNCOs (E-5, MOS 91 G20). These two NCOs actas assistant section sergeant and assist the sec-tion sergeant with his duties. Their duties areconsistent with those identified above (paragraph2-7 d). They deploy as NCOICs of teams and maybe assigned as the team leader for up to 14 BFcasualties in a restoration center.

e. Behavioral Science Specialist.There are three behavioral science specialists (twoE-4 and one E-3, MOS 91G20) assigned to thesection. These specialists perform those dutiespreviously identified above (paragraph 2-7 e). Inaddition to their duties, they operate andmaintain assigned vehicles.

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2-12. Restoration Team

The restoration team provides staff and equip-ment for operating a restoration or (rarely) re-conditioning center. The center provides NPtriage, stabilization, treatment, and disposition.The team, or its members, deploy as necessary toprovide consultation and reconstitution supportto units. The combat stress restoration teamleader’s AOC is immaterial; any of the officersassigned to the section may be appointed as theteam leader by the unit commander. The com-mander will base his selection on experience aswell as specialty and grade.

c .

a. Occupational Therapy Officer. TheOT officer (CPT, SP, AOC 65AOO) performs thoseduties previously identified above (paragraph2-8 a).

b. Psychiatric/Mental Health Nurse.The psychiatric/mental health nurse (MAJ, AN,AOC 66COO) provides specialized nursing careand management of BF casualties. This positionshould be filled by clinical nurse specialist (AOC66C7T). The duties of the psychiatric/mentalhealth nurse are consistent with those previouslyidentified above (paragraph 2-8 b).

c. Clinical Psychologist. The clinicalpsychologist (CPT, MS, AOC 731367) assigned tothe section performs those duties previouslyidentified above (paragraph 2-8 c).

d. Senior Behavioral ScienceNoncommissioned Offiicer. The senior behavioralscience NCO (E-7, MOS 91G40) is also thedetachment NCOIC. He assists the combat stressrestoration team leader with the accomplishmentof his duties. He provides assistance with themanagement of technical and tactical operationsof the team. His specific duties include—

g.

Keeping the team leaderinformed.

Monitoring, facilitating, andsupervising the training activities ofsubordinates.

Monitoring and coordinatingsituation reports from deployed combat stresspreventive teams.

Conducting classes on selectedmental health topics for senior NCOs of supportedunits.

Psychiatric Noncommissioned Offi-cer. The psychiatric NCO (E-5, MOS 91F20)manages and provides supervision for BF casualtycare. He deploys with the combat stress restora-tion team to supervise and function as the BFcasualty care manager for the restoration center.He assists with establishment, disestablishment,and movement of the team. The psychiatric NCOalso assists with conducting restoration and re-conditioning center operations. His duties areconsistent with those identified above {paragraph2-8 f). As a squad leader, he may provide directsupervision for up to 12 BF casualties. He maybe deployed temporarily to reinforce a combatstress preventive team.

f Psychiatric Specialist. The psychia-tric specialist (E-4, MOS 91F20) provides BFcasualty care and intervention, as required. Hisduties are consistent with those identified above(paragraph 2-8 g). This specialist may be tempo-rarily deployed to reinforce a combat stresspreventive team. In addition to his duties, heoperates and maintains the assigned vehicle.

Behavioral Science Noncommiss-ioned Officer. The behavioral science NCO (E-5,MOS 91G20) assists the clinical psychologist. Hisduties are consistent with those identified above(paragraph 2-7 d). He assists with the manage-ment of the combat stress restoration team. ThisNCO may be assigned temporarily to reinforce/augment a combat stress preventive team.

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h. Behavioral Science Specialist. Thebehavioral science specialist (E-4, MOS 91G20)assists the mental health officer in gatheringsocial and psychological data to support BF cas-ualty evaluations. His duties are consistent withthose identified above (2-7 e). In addition to hisduties, he operates and maintains the assignedvehicle. He may be deployed to reinforce/augmenta combat stress preventive team.

Occupational Therapy Noncommiss-ioned officer. The OT NCO (E-5, MOS 91L20)assists the occupational therapist. His duties areconsistent with those identified above (paragraph2-8 j). He also functions as team leader for up to12 BF casualties in restoration.

i.

j. Occupational Therapy Specialist.The OT specialist (E-4, MOS91L20) works under

the supervision of the occupational therapist andOT NCO. His duties are consistent with thoseidentified above (paragraph 2-8 k).

k. Patient Administration Specialist.The patient administration specialist (E-4, MOS71G20) is responsible for initiating the reportsand forms identified in paragraph 2-8 m above.He maintains the Daily Disposition Log. Heinterfaces with the supporting MTF’s patientadministration section on arrival and dispositionof HOLD category BF casualties. He coordinatesevacuation and transportation requirements, asrequired. He maintains assigned vehicle andoperates the detachment radio. He coordinatesthe disposition of BF casualties through the sup-porting unit’s radio communications net.

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«FOR INFORMATION ON MENTAL HEALTH AND COMBAT STRESS CONTROL ELEMENTSREORGANIZED UNDER THE MRI, SEE APPENDIX E.

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 the divisions, thecorps, and the COMMZ. In the divisions, they areassigned to the medical company of the main supportbattalion (MSB). In the corps and COMMZ, they areassigned to the ASMB headquarters. In separatebrigades, they are assigned to the medical company.

2-2. Division Mental Health Section

The division mental health section is assigned to themain support medical company (MSMC), which is adivision support command (DISCOM) asset (see FMs8-10-1, 8-10-3, and 63-21).

NOTE

The responsibilities of the division mentalhealth section extend to all divisionelements and require a mental health/CSCpresence at the combat maneuver brigades.

The division mental health section is the medicalelement in the division with primary responsibility forassisting the command in controlling combat stress.Combat stress is controlled through sound leadership,assisted by CSC training, consultation, and restorationprograms conducted by this section. The divisionmental health section enhances unit effectiveness andminimizes losses due to BF, misconduct stressbehaviors, and NP disorders. Under the direction ofthe division psychiatrist, the division mental health

section provides mental health/CSC services through-out the division. This section, acting for the divisionsurgeon, has staff responsibility for establishing policyand guidance for the prevention, diagnosis, treatment,and management of NP, BF, and misconduct stressbehavior cases within the division area of operations(AO). It has technical responsibility for the psycho-logical aspect of surety programs. The staff of thissection provides training to unit leaders and their staffs,chaplains, medical personnel, and troops. Theymonitor morale, cohesion, and mental fitness ofsupported units. Other responsibilities for the divisionmental health section staff include�

Monitoring indicators of dysfunctionalstress in units.

Evaluating NP, BF, and misconductstress behavior cases.

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

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

Coordinating support activities ofattached corps-level CSC elements.

The division mental health section normallycollocates with the MSMC clearing station. For alisting of major equipment assigned, see Appendix A.The staffing of the division mental health section allowsfor this section to be split into teams which deployforward to provide CSC support, as required, to

�

�

�

�

�

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C 1, FM 8-51

Maintain communications andunity of efforts when division mental health sectionpersonnel are dispersed to the brigades.

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

DIVISION MENTAL HEALTH SECTION STAFF

PsychiatristClinical PsychologistSocial Work OfficerSenior Behavioral Science NCO (NCOIC, E-7)Behavioral Science NCO (E-6)Behavioral Science Sergeant (E-5) (two)Behavioral Science Specialist (three)

Figure 2-1. Division mental health section staff.

(1) Psychiatrist. The division psy-chiatrist (Major [MAJ], Medical Corps [MC], area ofconcentration [AOC] 60W00) is the officer in chargeof the division mental health section. The psychiatristis also a working physician who applies the knowledgeand principles of psychiatry and medicine in thetreatment of all patients. He examines, diagnoses, andtreats, or recommends courses of treatment forpersonnel suffering from emotional or mental illness,situational maladjustment, BF (combat stressreactions), and misconduct stress behaviors. Hisspecific functions include�

Directing the division�smental health (combat mental fitness) program.

Being a staff consultant forthe division surgeon on matters having psychiatricaspects, which include�

Personnel reliabilityprogram.

Security clearances.

brigades in the division. Normally, each brigade issupported by a brigade CSC team. This team consistsof a mental health officer who is designated the brigademental health officer and a behavioral science NCOthat is designated the brigade CSC coordinator. If nomental health officer is available, the senior behavioralscience noncommissioned officer in charge (NCOIC)substitutes as the brigade CSC team leader. Thedivision psychiatrist oversees all brigade CSC teamsand provides consultation as necessary.

a. Mental Health/Combat Stress ControlSupport. The division psychiatrist provides input tothe division surgeon on CSC-related matters. Heworks with the division medical operations center(DMOC) to monitor and prioritize mental healthsupport missions in accordance with the division combathealth support (CHS) operation plans (OPLANs) oroperation orders (OPORDs). Coordination for mentalhealth personnel augmentation is accomplished throughthe MSB Operations and Training Officer (US Army)(S3) and the DMOC.

b. Division Mental Health Section Staff.The division mental health section is staffed as shownin Figure 2-1. The consolidation of assigned mentalhealth officers and behavioral science specialists in onedivision mental health section provides unity of CSCsupport for all division prevention, training, andtreatment responsibilities of the section. It providesmulti-disciplinary mental health professional expertiseto�

Supervise and train the behavioralscience NCOs and specialists.

Provide staff input to the com-mands within the division AO.

Assure clinical evaluation andsupervision of treatment for all NP and problematicBF cases before they leave the division.

�

�

�

�

�

�

�

�

�

FM 8-51

CHAPTER 3

COMBAT STRESS CONTROL OPERATIONSIN THE COMBAT ZONE

Section I. DIVISION MENTAL HEALTH/COMBATSTRESS CONTROL OPERATIONS

3-1. Division Mental Health Section De-ployment

If the division deploys tactically, the divisionmental health section deploys the brigade CSCteams by echelon with the brigade FSMCs. Ateam consists of one mental health officer plus anNCO. When the division is assembled in anassembly area or garrison, the mental healthofficers may consolidate at the MSMC. Thedivision psychiatrist deploys with the MSMC orearlier as needed. The division psychiatristcovers the MSMC in the DSA and uses it as abase of operations. Those division mental healthsection assets that were not deployed with theFSMCs will establish the division mental healthsection near the area support squad treatmentelement (division clearing station). As stated inChapter 2, the division mental health sectionroutinely details one behavioral science NCO toeach of the brigades; these NCOs perform thefunctions of brigade CSC coordinator. The mentalhealth officers from the division mental healthsection are designated as the brigade mentalhealth officers. They join the brigade CSCcoordinators to form the brigade CSC teams whenthe brigades deploy away from the MSMC. Otherdivision mental health section personnel aredeployed to the supported BSAs to augment/reinforce the brigade CSC teams as required. Thedivision psychiatrist actively supports the brigadeCSC teams in their unit-based preventive mentalhealth and training programs and will also deployto brigade level to provide assistance, or makeconsultation site visits to the FSMCs. Duringtactical operations, the division psychiatristprovides a 24-hour NP triage capability at theMSMC. He trains and supervises MSMC treat-ment platoon personnel in all areas pertaining to

NP and CSC to include handling and treatmentof NP patient and combat stress-relatedcasualties. The psychiatrist also initiates thecoordination for corps CSC augmentation asrequired.

3-2. Division Combat Stress Control Es-timate and Plan

a. Mental Health/Combat Stress Con-trol Estimates. The division psychiatrist, assistedby the division mental health section staff,prepares mental health/CSC estimates as directedor required for CHS operations. Mental health/CSC estimates are developed in accordance withFM 8-55, FM 8-42 and division CHS TSOPs (seeAppendix B). Mental health/CSC estimates aresubmitted via technical medical channels to theDMOC which collects them for the divisionsurgeon. Estimates are provided via commandchannel (if formal tasking) through the MSMCand MSB headquarters to the DMOC whichcollects them for the division surgeon. Thedivision psychiatrist may coordinate directly withthe division surgeon or DMOC to obtain division/DISCOM staff input. These estimates are usedby the division surgeon and DMOC to developthe division CHS OPLANs/OPORDs. The mentalhealth/CSC estimate may include—

Mental health status of thedivision.

Current status of morale andunit cohesion in division units.

Status of mental health/CSCpersonnel/elements.

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FM 8-51

Battle fatigue casualty esti-mates.

Fatigue, sleep loss.

Percent of casualties; intensityof combat.

Home-front stressors (naturaldisaster, unpopular support of the conflict,terrorist attacks in or around home base).

Restoration requirements.

Corps CSC support require-ments.

The mental health/CSC estimate should includeany assumptions required as a basis for initiating,planning, or preparing the estimates. Any mentalhealth/CSC deficiencies are identified, usingthose tactical courses of action listed in thecommander’s estimate. The advantages anddisadvantages of each tactical course of actionunder consideration from the mental health/CSCstandpoint are provided. In addition, the estimateprovides methods of overcoming deficiencies ormodifications required in each course of action.

b. Mental Health/Combat Stress Con-trol Plan. The division psychiatrist, assisted bythe division mental health section staff, developsthe mental health/CSC input for the division CHSOPLAN/OPORD in accordance with FMs 8-55and 8-42. This input is based on the mentalhealth/CSC estimate and feedback from thecommander, MSB support operations section,DMOC, and division surgeon. The divisionpsychiatrist and mental health officers mustensure that all mental health/CSC requirementsfor the division are included in their input for thedivision OPLAN/OPORD. The mental health/CSC subparagraph in the CHS annex of thedivision OPLAN/OPORD should include—

Providing divisionwide mentalhealth/CSC coverage.

Ensuring policies and proce-dures for the prevention, acquisition, restoration,and treatment for BF, misconduct stress behav-ior, and NP disorders are clearly defined anddisseminated.

Providing consultation ser-vices.

Establishing restoration areasas required at division MTFs.

Coordinating requirements formental health/CSC augmentation.

Providing reconstitution sup-port.

Coordinating for corps-levelmental health/CSC support.

Establishing procedures for thetimely and accurate reporting of BF, misconductstress behavior, and NP disorders seen by divisionmental health section elements/personnel.

The division psychiatrist, assisted by the mentalhealth staff, is responsible for supervising andcoordinating the implementation of the divisionmental health/CSC support operations. Imple-menting the mental health/CSC support inaccordance with CHS annex of the divisionOPLAN/OPORD should include—

Ensuring that DSA and BSAconsultation duties are delineated.

permittedwith theelements.

Coordinating as required andby the MSMC and MSB commanderDMOC and supporting corps CSC

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Coordinating the establish-ment of restoration and reconditioning centerswith supporting corps-level CSC elements.

Establishing procedures forunits to request mental health/CSC support.

Deploying and reinforcing bri-gade CSC teams and other division mental healthsection personnel, as required, to support CSCrequirements.

Ensuring transportation of BFcasualties in nonambulance vehicles (such ascargo trucks returning empty after deliveringtheir loads) is coordinated by the DMOC in ac-cordance with the TSOP.

3-3. Division Mental Health Section Em-ployment

The employment concept for mental healthsupport in the division is dependent on theeffectiveness of the division combat, mental fitnessprogram. It is also dependent on the assignmentand proper distribution of division mental healthpersonnel. It is essential that medical com-manders promote training which include fieldexperience and cross-training of critical non-medical skills. For division mental healthpersonnel to fill their roles in combat, they mustbe thoroughly familiar with the units theysupport. They must also be known and trustedby the leaders and personnel of the supportedunits.

a. Division Mental Health/CombatStress Control Support. The MSMC commanderprioritizes division mental health section missionsbased on input from the division psychiatrist andon the provisions of the division CHS plan. Thedivision mental health section coordinatesthrough the MSMC commander, MSB supportoperation, and the DMOC when requesting

mental health/CSC augmentation. Request forcorps-level mental health/CSC support isnormally coordinated by the DMOC with thesupporting medical brigade or group. The deploy-ment of the medical detachment, CSC is discussedin Section III of this chapter. It must be recog-nized that corps CSC assets can be diverted toother areas of the corps by the medical brigade ormedical group even during heavy combat. Themedical detachment, CSC may be deployed forpeacetime contingency operations. The medicaldetachment, CSC support is likely to beintermittent and selective in OOTW (conflicts).The division mental health section plans must beprepared to provide CSC coverage withoutaugmentation.

b. Brigade Mental Health/ CombatStress Control Support.

(1) A behavioral science NCO isroutinely detailed to each FSMC to assist thebrigade with CSC. This NCO performs duties asthe mental health liaison NCO and brigade CSCcoordinator. He works for the brigade surgeonunder the general supervision of a division mentalhealth section officer. Specifically, one mentalhealth officer from the division mental healthsection is designated as the brigade mental healthofficer. The brigade CSC coordinator routinelycirculates throughout the brigade to train andadvise brigade andinclude—

supporting personnel to

Medical personnel.

Chaplains.

Combat lifesavers.

Unit leaders.

Soldiers (unit members).

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FM 8-51

The brigade CSC coordinator establishes andconducts unit preventive mental health andtraining programs for the supported brigade andattached units operating with the brigade.

(2) When a brigade is deployedforward, the brigade mental health officer (witha division mental health section vehicle) and(optionally) a behavioral science specialist willalso deploy to the BSA. The brigade mentalhealth officer and the brigade CSC coordinatortogether form the brigade CSC team. The brigadeCSC team visits supported units regularly withinthe BSA and goes forward for consultation to thesupported maneuver battalions, as transportationand other missions permit. The brigade mentalhealth officer advises the FSMC on mental health/CSC issues and provides technical supervision fortreatment of NP or BF casualties. He providesdirect supervision for other division mental healthsection personnel deployed to the BSA. Thebrigade mental health officer ensures adequateprofessional standards for all counseling by CSCcoordinators and for command consultation ac-tivities.

(3) Severe BF or NP cases whichcannot be managed at the FSMCs clearingstations are evaluated by the brigade CSC team.These cases may be sent to the MSMC forevaluation by the division psychiatrist or hisrepresentative. No NP or BF casualty is evacu-ated from the division without being evaluatedby the division psychiatrist or his representative.

(4) The division psychiatrist mayalso deploy to units throughout the division inresponse to requests for consultation. The divi-sion psychiatrist regularly visits the brigade CSCteams in the BSA and reinforces them at timesof special need. He identifies problems in unitsand provides or coordinates consultation follow-ing critical events such as a fatal accident, rearbattle incident with loss of life, or other cata-

strophic events. The psychiatrist and mentalhealth officers provide CSC prevention training,consultation, critical event debriefing, andrestoration support when indicated.

(5) The brigade CSC teams deploywith the supported brigade CSS elements to theirBSAs. The brigade CSC teams maintain knowl-edge of the tactical situation, normally throughthe brigade surgeons. They assist the brigadesurgeons with planning and projecting require-ments for stress casualty prevention and recon-stitution support. It is important that the brigadeCSC teams keep the brigade surgeons andsupported commanders updated on CSC issues.The brigade CSC teams also have a responsibilityto keep the division psychiatrist informed inaccordance with the TSOP. The brigade CSCteams request reinforcement from the divisionmental health section, as required, especiallywhen there is an increase in the stress casualtyand NP caseloads that are beyond their capabilityto handle. When reinforced, the brigade CSCteam orients and updates the mental health/CSCaugmenting personnel on CSC issues and require-ments. The brigade CSC teams use the clearingstations of the FSMCs as the centers of theiroperations but must not be confined to thatlocation. The priorities of functions for brigadeCSC teams in support of the brigades are—

(a) Deploying forward to am-bulance exchange points (AXPs) and combattrains to provide preventive support and imme-diate stress control intervention when possible.

(b) Triaging BF casualties,misconduct stress behaviors, and NP disordersprior to their evacuation, and advising theattending physician to

of BF RESTfield trains.

(c)category

prevent overevacuation.

Facilitating the treatmentcases in their battalions’

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FM 8-51

(d) Advising FSMC healthcare providers on treatment requirements for BFcasualties.

(e) Coordinating the RTDprocess for recovered BF casualties.

(f) Facilitating postcombatstress debriefings at small units.

(6) The employment. of the medicaldetachment, CSC provides for a CSC preventiveteam to augment the brigade CSC team at theFSMC in each BSA. The CSC preventive teamhas a psychiatrist, social work officer, and twobehavioral science specialists. This team has a5/4-ton vehicle for transportation. This corps CSCpreventive team could be diverted elsewhere. Thebrigade CSC team and brigade must be preparedto function without them. The mission of theCSC preventive team is discussed in Section IIIof this chapter.

Unit-Level Mental HealthlCombatStress Control Support. Unit-level mental health/CSCsupport is provided by the brigade CSC teamand the division psychiatrist, as required. Thebrigade CSC team officer and the NCO (or thebrigade CSC coordinator alone) conduct site visitsto all the units in the BSA on a frequent basis.The brigade CSC team ideally has preestablishedpoints of contact (officers and NCOs) in each unit.Site visits by the brigade CSC team to supportedunits are performed for several reasons whichinvolve both the units and the brigade CSC team.The primary reasons for these frequent site visitsinclude—

c .

Establishing trust and confi-dence between the brigade CSC team and unitpersonnel.

Establishing familiarity withthe unit’s operations, mission, and tasks and

being able to converse with unit personnel andunderstand about what they do.

Monitoring units for morale,unit cohesion, and indicators of excessive stress/stressors.

Advising unit commanders,leaders, and personnel on stress management andcoping techniques.

Identifying, providing, or coor-dinating training on mental health/CSC subjectareas.

Providing preventive consul-tation.

Providing feedback to thebrigade surgeon and division psychiatrist on themental health status of supported units.

Monitoring the progress ofREST and DUTY category BF soldiers that arerecovering in their units.

(1) When a division mental healthsection’s vehicle is in the BSA, the brigade CSCteam uses this vehicle to visit supported units. Ifa designated vehicle from the division mentalhealth section is not available (as when thebrigade CSC coordinator is working without thebrigade mental health officer being present), it isnecessary to find alternative means of getting tothe supported units. The transportation needsare dependent on the size of the BSA and theamount of traffic movement between units. Insome situations when there are short distancesbetween units, it may be feasible for the brigadeCSC team to walk to the supported units locatedin the BSA or to coordinate rides with unit vehi-cles. The unit ministry teams (chaplains) can beespecially helpful because of the common featuresof CSC and the chaplains’ ministry and CSCsupport.

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(2) The brigade CSC team mustkeep the FSMC informed of their whereabouts.This is done by reporting to the FSMC (using thevisited unit’s radio or land lines) immediatelyupon arriving and again just before departing,specifying the next destination. The brigade CSCteam provides updates on the CSC situation atthe unit just visited by using short brevity-codedmessages. This constant contact with the FSMCpermits the redirecting of the brigade CSC teamto areas of special need.

(3) When combat is imminent orongoing, the brigade CSC team may deployforward to the AXPs to provide rapid evaluationand CSC intervention. The brigade mental healthofficer and brigade CSC coordinator may be atdifferent locations. In some situations, one orboth may go forward to a battalion aid station(BAS) located in the combat trains area.

(4) During lulls before or aftercombat actions, the brigade CSC coordinator maygo forward to unit combat trains and BASS forpreventive consultation. They meet with a unitin reserve that has experienced intensive combator other problems. The brigade CSC team mayuse the division mental health section vehicle,ride in ambulances, or travel with the logisticpackage convoy or reconstitution teams goingforward. The brigade CSC team updates andassists any mental health/CSC personnel sent tothe brigade for reinforcing/augmentation support.

d. Clinical Duties of the Brigade Com-bat Stress Control Team in the Brigade SupportArea. The brigade CSC team provides assistanceto unit-level medical officers and physician assis-tants, as required, to ensure correct dispositionfor BF, misconduct stress behavior, and NP cases.At the BSA, the brigade CSC team assists inpatient triage and in the evaluation of problematicBF and NP cases. The brigade CSC team assiststhe attending physician and patient-holdingwardrnaster in providing general guidance and

3-6

training for patient-holding squad personnel.The CSC team’s guidance and training willinclude the emotional and behavioral aspects ofpatient care for the minimally sick and woundedas well as for BF and NP cases. Following thetreatment protocol established by the divisionpsychiatrist, and in accordance with the mentalhealth/CSC plan, the brigade CSC team makesrecommendations on the triage, management,and treatment of combat stress-related cases.Triaging of BF cases into the appropriate cate-gories is essential for effective management andtreatment. Management and treatment of thefollowing triage categories are examples of howthe brigade CSC team can manage combat stress-related casualties in the BSA. Additional infor-mation on combat NP triage, restoration, andconsultation is provided in subsequent chapters.The BF casualty may be triaged and placed inone of the following categories:

DUTY

REST

HOLD

REFER

(1) Mild BF cases who reach thebrigade MTF will be triaged as DUTY category.Some of these cases will require a brief time torecuperate (less than an hour to no more than 6hours). This short period for recovery mayinclude—

dier.

Food and nourishment.

Fluid to drink.

A quiet place

Reassurance

to nap.

to the sol-

FM 8-51

The opportunity for talk-ing about his experiences.

The DUTY category cases are sent back to theirunits with recommendations for full duty. If thesoldier’s unit is known to be in reserve statuswhere everyone is resting and recovering, a lowerlevel of combat functioning could still qualify asDUTY BF. However, if a soldier is classified asDUTY, he must be capable of caring for himselfand responding appropriately to his duties if theunit comes under attack.

(2) REST category cases from ma-neuver units may require being away from far-forward areas for a few days. Normally, thesecases are sent for 1 to 2 days of duty in thesoldiers’ own battalion HSC or battery. Alter-natively, these soldiers may be held in BSA unitsunder the control of the FSMC or brigadeAdjutant (US Army) (S1) for 1 or 2 days. In bothsituations coordination is required, and thesoldier must be accounted for until he returns tohis own unit. REST category cases placed in unitsare monitored by the brigade CSC team. Thebrigade CSC team monitors these cases either bydirect interview or by talking with the soldier’ssupervisors. The brigade CSC team listens to thesoldier’s story and gives perspective-reorientingcounseling when indicated. REST cases arereturned to the FSMC and placed in the HOLDcategory if symptoms persist and they fail toimprove. These cases will be provided restorationtreatment and additional evaluation at the FSMC.These cases are accounted for until they RTD withtheir own units.

(3) HOLD category BF cases arethose who require medical observation andassistance. If feasible, these cases are providedrestoration treatment at the FSMCs for 1 day (orup to 3 days if RTD is expected). When thesecases are held in the FSMC’s patient-holdingarea, it should be emphasized to them that BFsoldiers are not patients, just tired soldiers. The

feasibility of holding BF casualty cases at theFSMC depends on the tactical situation, patientwork load, and the soldiers’ symptoms. Res-toration treatment for HOLD category casesplaced in the patient-holding area of the FSMCincludes—

Reassuringnormal and temporary.

Providing aextreme danger or stress.

that BF is

respite from

Ensuring dehydration.

Providing replenishment(food and hygiene).

Providing the opportunityfor rest (sleep).

Recounting (verbally re-constructing) the recent stressful events andregaining perspective.

Restoring confidencethrough activities which maintain the individual’sidentity as a soldier.

(4) REFER category are BF andNP cases which cannot be safely held or treatedat the FSMC. These cases may be triaged intothe REFER category at the initial evaluation orthey may be cases that have not responded toinitial restoration treatment at the FSMC. Thesecases are evaluated at the FSMCs by the divisionpsychiatrist or mental health officers if they arein the forward areas, or they are sent to DSAclearing station for evaluation and disposition bydivision mental health section or the designatedalternates. The preferred method of evacuatingthese cases is by nonmedical vehicle, but groundambulances are used, as necessary. Physicalrestraints and/or medication are used duringtransportation only if necessary for safety.

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NOTE

A few BF or NP symptoms could alsobe caused by life- or limb-threateningmedical/surgical conditions. These ca-sualties may be evacuated directly to acorps-level hospital as determined bythe attending physician.

Wounded casualties with concurrent BF or NPsymptoms, who are either combative or violent,are placed in patient restraints as determined bythe attending physician. If these types of patientsare evacuated by air ambulance, physicalrestraints are required. The preferred method oftransporting an unwounded BF casualty is by anonmedical vehicle. The use of a nonmedicalvehicle would help prevent the BF casualty fromthinking that his condition is anything other thanjust being a very tired soldier. On the other hand,by placing the BF casualty in an ambulance whichis clearly marked with the symbol of the redcrosses, the BF casualty is under a protectedstatus according to the rules established by theGeneva Conventions. The decision that confrontsthe health care provider is which of two methodsis more beneficial for the overall safety andrecovery of the BF casualty.

e. Mental Health/Combat Stress Con-trol Support in the Division Support Area. Thedivision mental health section personnel locatenear and work with the DSA clearing station toensure mental health/CSC coverage to supportthe DSA is available. They evaluate BF, mis-conduct stress behavior, and NP cases referredfrom throughout the division AO. The initialtriage of cases from the DSA is the same asperformed in the BSAs. The division mentalhealth section staff in the DSA spends substantialtime with evaluating the REFER category BFcasualty sent from the forward areas of thedivision. Any of the REFER cases with goodpotential for RTD within 72 hours are held for

treatment and placed in the MSMC patient-holding section. The total period of time forholding BF casualties in the division is 72 hours.If the BF casualty is held in the BSA for 24 hours,he can be held in the DSA only for an additional48 hours. These cases are provided restorationtreatment at the MSMC for up to 3 days. Thefeasibility of holding BF casualty cases at theMSMC depends on the tactical situation, patientwork load, and the soldiers’ symptoms. Res-toration treatment for HOLD category casesplaced in the patient-holding section of the MSMCis the same as identified for the FSMCS. Thenumber of days (within the 72-hour time frame)of restoration that the MSMC can provide couldbe shortened or lengthened, depending on thetactical situation, available resources, and theactual or projected caseloads.

(1) The division psychiatrist, as-sisted by the clinical psychologist and social workofficer (if they are not deployed to the BSAS),exercises technical supervision for the man-agement of BF soldiers and NP patients placed inthe patient-holding section. If possible, thesecases are housed away from the ill, injured, orwounded patients.

(2) The division psychiatrist maydesignate a behavioral science specialist to assistthe patient-holding squad with treatment of BFcasualties. This treatment consists of replen-ishing sleep, hydration, nutrition, hygiene, andgeneral health and restoring confidence throughgroup activities, appropriate military workdetails, and individual counseling, as needed.These activities include those patients withminor wounds, injuries, and illnesses who do notneed continual bed rest and who may have BFsymptoms.

(3) The division psychiatrist fol-lows the soldiers' progress, reevaluates, and givesindividual attention, as needed. Medication isprescribed sparingly and only when needed to

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temporarily support sleep or manage disruptivesymptoms. Those cases who (on initial evaluationor after a period of observation) have a poorprognosis for RTD, or whose behavior is toodisruptive or dangerous to manage in the holdingfacility, are evacuated to the supporting corps-level hospital. Such patients must be suitablyrestrained and medicated for transport. Theevacuation priority for these NP patients isroutine.

(4) Those cases who (on initialevaluation or after observation) require longerthan the holding policy at the division-level MTFallows but who have reasonable prognosis forRTD within the corps evacuation policy aretransferred to a corps-level restoration andreconditioning facility. Corps restoration andreconditioning facilities are staffed and operatedby the medical company, CSC.

(5) Soldiers sent directly from adivision MTF to a restoration and reconditioningcenter will ideally be transported in trucks, notambulances. Prior coordination with the divisionAssistant Chief of Staff (Personnel) (Gl) and corpsAdjutant General (AG) personnel replacementsystem may facilitate the returning of recoveredBF casualties to their original units.

(6) For all recovered BF soldiersreturned to duty from the DSA, the divisionmental health section coordinates with thedivision G1 and with the soldier’s unit. Thecoordination is made directly or through the CSCcoordinator in the DSA or brigade CSC team inthe BSAS, the chaplains’ ministry, or otherchannels. This is to ensure successful rein-tegration of these soldiers back into their units.

f. Division Support Area CombatStress Control Coordinator. The CSC coordinatorin the DSA performs functions similar to those ofthe brigade CSC coordinators for units located inthe division rear but on a less independent scale.

He works under the direct supervision of thedivision psychiatrist or the division mental healthsection NCOIC. The CSC coordinator’s activitiescan be closely supervised and reinforced by thedivision psychiatrist; this position requires lessexperience and independence than the brigadeCSC coordinators. This is a suitable preparatorytraining assignment for less senior behavioralscience specialists before they become brigadeCSC coordinators. However, the special problemsof BF in CS and CSS units in the rear area makethe DSA CSC coordinator’s role no less importantto the success of the division. It is essential toassign an individual with whom the units canidentify and develop trust.

(1) During lulls in tactical activi-ties, the DSA CSC coordinator conducts classeson mental fitness; provides consultation for unitleaders; provides crisis intervention counselingfor soldiers; and gives counseling and referral fortroubled soldiers.

(2) During tactical operations, theDSA CSC coordinator keeps current on thelocation and status of CS/CSS units, continues toprovide consultation to these units, and coor-dinates the resting of DUTY and REST BFsoldiers in or near their units.

3-4. Reinforcement of Brigade CombatStress Control Team Using DivisionMental Health Section Assets Only

a. Consultation Visits. Frequent visitsto the BSAs and their brigade CSC teams shouldbe scheduled on a routine basis by the divisionpsychiatrist. These consultation visits maylast hours or even 1 to 2 days. The divisionpsychiatrist, in coordination with the MSMCcommander, the DMOC, and the division surgeon,should consider enhancing support in the forwardareas—

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(1) When increased numbers ofcases are being evaluated and followed at anFSMC such that the brigade CSC team cannotprovide continuous coverage and still performtheir consultation mission.

(2) If a member of the brigade CSCteam becomes a casualty.

(3) When (in a static tactical situ-ation) there are more cases who can be held fortreatment at a particular BSA clearing stationthan its holding squad staff can manage.

(4) When conditions do not permitREFER cases to be evacuated to the DSA forevaluation.

(5) When there is a mass casualtysituation and additional BF and NP diagnosticexpertise is needed to triage those patients whorequire immediate evacuation and those who canbe treated locally for quick RTD.

(6) When a battalion- or company-sized unit stands down (pulled back) for rest andrecuperation or for regeneration. When thereconstitution process requires regeneration ofheavily attrited units, mental health/CSCpersonnel should deploy along with other CSScontact teams to assist surviving members,assuring that all members get good quality restand physical recuperation. During the “after-action debriefing,” mental health/CSC personnelassist surviving members to review their recentcombat experiences and restore a positive copingperspective to the group. Mental health/CSCpersonnel also assist with integrating survivorsand replacements into cohesive teams (seeChapter 5).

b. Options for Reinforcing the BrigadeMental Health/Combat Stress Control Support.The division psychiatrist may use the following

options to reinforce the brigade CSC teams in theforward areas with division mental health sectionassets:

(1) Send one behavioral sciencespecialist to reinforce a brigade CSC team at theFSMC holding facility.

(2) Place two brigade CSC teamstemporarily in support of a brigade that has largenumbers of BF casualties.

(3) Deploy himself forward tosupervise and assist the brigade CSC team untilthe situation or crisis has been resolved.

3-5. Corps-Level Mental Healtl/CombatStress Control Support Reinforce-ment

The division psychiatrist should consider re-questing additional corps-level mental health/CSC augmentation when—

Caseload and/or geographical dis-persion prevents the division mental healthsection from providing divisionwide consultationservices.

Combat stress-related casualties arebeyond the treatment capabilities of divisionmental health section and whatever corps CSCassets that are attached.

A battalion or brigade is withdrawnfrom a forward area back into the DSA for restand reconstitution.

Enemy forces have used NBC weap-ons.

Other high stress factors (such asheavy losses as a result of prolonged and intensebattles) are present.

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The division psychiatrist may request, through from the corps will be provided by the medi-the MSMC commander, the MSB support cal detachment, CSC or by elements from theoperations section, and the DMOC, reinforc- medical company, CSC. Both the medicaling CSC support from corps. The DMOC company, CSC and medical detachment, CSCcoordinates corps CSC support with the medical operations are discussed in Sections III and IV ofbrigade or group. Mental health/CSC support this chapter.

Section II. AREA SUPPORT MEDICAL BATTALION MENTALHEALTH/COMBAT STRESS CONTROL SUPPORT OPERATIONS

3-6. Mental Health Section Employment

a. Area Support Medical BattalionMental Health Support. The ASMB mentalhealth section deploys with the HSC of the ASMB.When the ASMB deploys tactically, the mentalhealth section collocates with the battalionheadquarters but disperses its personnel andresources to support the ASMB’s entire AO. TheASMB commander prioritizes the area mentalhealth support mission based on input from theASMB psychiatrist and battalion medicaloperations center in accordance with medicalbrigade/group and ASMB CHS plans. BattalionCP personnel coordinate with the ASMBpsychiatrist and the ASMCs for the deploymentof the mental health section’s assets to supporttheir AO. Each ASMC is normally allocated oneNCO CSC coordinator. The battalion CP, inconsultation with the ASMB psychiatrist, shouldconsider enhancing mental health/CSC resourceswithin an ASMC’s AO when—

Stress-related casualties arebeyond the treatment capabilities of an ASMCand its CSC coordinator.

A battalion- or company-sizedunit is withdrawn from a forward area back intothe ASMC AO for rest and regeneration.

Enemy forces have used NBCweapons.

to include—

ters to a unit.

Other high stress factors occur,

Major accidents or disas-

Heavy losses as a resultof rear battles.

Friendly fire incidents.

Heavy casualties or suf-fering among noncombatants.

The ASMB psychiatrist may use four options toreinforce mental health support within thesupported AO:

(1) Send one junior behavioralscience specialist to the patient-holding sectionof the ASMC to reinforce the CSC coordinatorpreviously deployed from the mental healthsection.

(2) Send the social work officer orthe ASMB psychiatrist to the ASMC. This allowsthe CSC coordinator to relocate to other areas, asnecessary. This officer can go unaccompanied toother locations within the supported AO. TheCSC coordinator coordinates the requirementsfor such actions with the ASMC headquarterselement.

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(3) Use one mental health officerand one behavioral science specialist for a mobileteam. They are provided a vehicle for movementto each location. The mobile team has theflexibility to move and provide CSC support atsuccessive locations.

(4) Augment the mental healthsection with a CSC team from the supporting CSCcompany or detachment. Augmentation of men-tal health personnel should be considered (orplanned) for all scenarios in which increasesin BF and NP casualties are anticipated. Themental health section coordinates through theASMB commander and battalion CP when re-questing additional mental health/CSC support.The ASMB CP (medical operations center)forwards requests for mental health/CSC aug-mentation through the medical brigade/group tothe CSC company. In the COMMZ, the requestis sent to the medical brigade.

b. Area Mental Health/Combat StressControl Support Operations. Upon deploymentof the ASMB to its AO, area mental health sup-port operations begin. The psychiatrist and oneor two junior behavioral science specialistsroutinely locate at and work with the HSCclearing station. The social work officer andNCOIC (senior behavioral science specialist) mayalso locate with the HSC clearing station or withthe battalion headquarters.

(1) The social work officer andNCOIC as directed by the battalion psychiatristcoordinate mental health section activities withthe battalion CP. Coordination includes activitiessuch as traveling to ASMCs and supported unitsand obtaining status updates of ASMCs andsupported units. The social work officer andNCOIC actively support the CSC coordinators intheir unit-based preventive mental health andtraining programs. They provide technicalsupervision and quality assurance over all the

CSC coordinators’ counseling and commandconsultation activities.

(2) One behavioral science NCOfrom the mental health section is allocated to eachASMC where he routinely serves as the mentalhealth section’s CSC coordinator for the supportedAO. The CSC coordinator provides behavioralscience advice to the ASMC commanders andtreatment teams in assessment and triage. Hetrains the patient-holding squad personnel inmanagement of stress casualties who must beheld for restoration and treatment. The CSCcoordinator also trains patient-holding squadpersonnel in stress intervention techniques forother DNBI patients. He visits units throughoutthe AO to routinely support recovery of DUTYand REST category BF soldiers. In addition tothe above, the CSC coordinator will—

Assist with the reinte-gration of recovered BF casualties into theiroriginal or new units.

Provide command consul-tation.

Conduct training forleaders in stress control principles and tech-niques.

Facilitate after-action de-briefings.

Conduct critical incidentstress debriefings, as necessary.

(3) To foster a good working re-lationship with supported units, the CSCcoordinator (and all mental health personnel )should deploy to observe the unit at work or intactical training exercises. The mental health/CSC mission objective is to become familiar witheach of the different types of units and includesthe—

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Unit’s mission.

Equipment.

Vocabulary (words andoperational or technical terms which are com-monly used in the unit).

Working conditions.

Typical stressors.

This knowledge is essential to gain the trust andconfidence of the unit’s leaders and troops. It isnecessary information for evaluating soldiers andtheir mental fitness to perform duties.

3-7. Disposition of Battle Fatigue andNeuropsychiatric Cases from theArea Support Medical Battalion

The ASMCs refer BF and NP cases who cannotbe managed at the ASMC clearing stations to thepsychiatrist at the HSC clearing station as soonas tactical conditions permit.

a. Preferred Method of Transport forBattle Fatigue and Neuropsychiatric Cases. Thepreferred method of transport for those BF andNP cases that are manageable without the use of

medication or restraints is by a nonambulanceground vehicle. If physical restraints and/ormedications are required during evacuation, thepreferred method of transport is by groundambulance. An air ambulance should be usedonly if no other means of transportation isavailable. Physical restraints are used onlyduring transport and medications are given onlyif needed for reasons of safety.

b. Time and Distances Factors. Whentime and distance factors preclude the evacuationof BF and NP cases to the HSC, these cases maybe evacuated to the nearest CSH, field hospital(FH), or general hospital (GH) for evaluation andtreatment by that hospital’s NP service. (Thesecases are not evacuated to a mobile army surgicalhospital [MASH].) Consultation with the ASMBpsychiatrist via telephone or radio is appropriateprior to evacuation. Direct evacuation from theASMC clearing stations is accomplished withoutconsultation when the BF or NP patient also hasa life- or limb-threatening medical or surgicalcondition, or a life-threatening NP condition (forexample, a suicide attempt) which cannot bestabilized at the ASMC clearing station. Thisdecision is made by the attending physician, butideally, the CSC coordinator should be advised.Cases with true NP disorders, or who do notrespond to brief restoration treatment, are evacu-ated to supporting corps hospital or to the medicalcompany, CSC.

Section III. SUPPORT OPERATIONS CONDUCTED BY THEDETACHMENT, COMBAT STRESS CONTROL

MEDICAL

3-8. Medical Detachment, Combat Stress other medical C2 headquarters and may beControl Employment further attached to supported medical companies

or medical company, CSC. Its employment ina. Medical Detachment, Combat Stress the theater depends on the intensity of the

Control Support Operations. The CSC medical conflict. The medical detachment, CSC isdetachment is assigned to a medical group or employed in all intensities of conflicts whenever

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a division or two separate brigades/regiments aredeployed.

b. Support for Division Combat Opera-tions During War. The medical detachment, CSCmay be attached to the CSC medical company forC2. The detachment receives administrative andmaintenance support from the CSC companyheadquarters. The detachment’s teams are rein-forced or provided personnel replacements byCSC teams or task-organized CSC elements fromthe company when necessary. A CSC detachment.which supports a division is usually attached tothe supported division’s MSMC of the MSB. It isunder the operational control of the MSB andMSMC but works under the technical supervisionof the division psychiatrist and division surgeon.Long-term relationships of CSC detachments withspecific divisions are standard. However, as acorps asset, the detachment (or its modularteams) may be cross-attached to support otherunits or missions as work load requires. Itdepends on the unit(s) to which it is attached foradministrative and logistics support.

(1) Upon the initial attachment ofthe detachment, its three 4-person CSC pre-ventive teams are usually further attached. OneCSC preventive team is attached to each FSMCwell before combat is imminent. This permitsthem to link up with and augment the brigade’sCSC team and the FSMC. Each CSC preventiveteam provides another mental health officer anda psychiatrist (with a behavioral science specialistand vehicle) to increase triage, stabilization, andrestoration capability at the FSMC. The CSCpreventive team performs the following:

Conducts regular visits tothe BSA to provide consultation throughout theFSB while the CSC restoration team is furtherforward.

Operates further forwardduring ongoing combat by cross-exchangingpersonnel with the brigade CSC team.

Deploys to provide recon-stitution support to units undergoing hasty ordeliberate reorganization.

In some operations, however, some or all of theCSC preventive team personnel may remain backat the supporting corps-level medical company orbe concentrated at another brigade or recon-stitution site with a heavier work load.

(a) While the brigade is onthe move, BF soldiers who cannot return imme-diately to their forward units may be rested andtransported by their own unit’s field trains. Theyeat, drink, restore hygiene, catch up on sleep,talk, and perform useful duties while regainingfull effectiveness on the move. The readiness ofunits to keep such cases will depend on theirknowing that trusted CSC personnel are presentas backup. The BF cases who require medicalobservation for only a few hours are transportedwith the CSC preventive teams and the FSMC.

(b) Any stress casualties whorequire more extensive restoration must betransported to the rear echelon of the medicaldetachment, CSC at the MSMC. Transportationin backhaul supply trucks is preferred to groundor air ambulances for most BF casualties. If thedistances involved require the use of supplyhelicopters or air ambulances, the CSC personnelmust assure that the BF casualties do not overflythe next echelon and are not evacuated furtherto the rear than necessary.

(2) The medical detachment, CSC’s11-person CSC restoration team (including theNCOIC of the headquarters section) remainswith the division mental health section at theMSMC in the DSA. The detachment has tentsand equipment to operate a restoration centerand provides expertise in clinical psychology,psychiatric nursing, and OT. The center providesintensive restoration treatment for RTD within 3days. The CSC restoration team provides triageand stabilization at the MSMC and consultation

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to nearby division units. The CSC restorationteam staff may go forward by truck or airambulance to temporarily reinforce or recon-stitute a CSC preventive team at the brigade, orto escort BF casualties in truck backhaul to therestoration center. The CSC restoration teampersonnel give reconstitution support to attritedunits, especially when the units return to theDSA. The C3C restoration team supplements thedivision psychiatrist, brigade CSC teams, CSCpreventive teams, and chaplains and leaders inafter-action debriefings. They help integrate therecovered soldiers and new replacements into theunits during reorganization activities.

(3) The medical detachment, CSCand its elements are dependent on the units towhich they are attached for food, water, fuel,maintenance, and administrative support.

(4) When the DSA is tactically toounstable to allow restoration, the CSC restorationteam and perhaps the CSC preventive sectionmay locate further to the rear. They may locatewith an ASMB or a corps hospital which is closeenough for them to continue their support to thedivision.

(5) When all three CSC preventiveteams are forward at the brigades, the detach-ment commander/psychiatrist is forward with oneof the CSC preventive teams. This is usuallyacceptable, as the detachment is attached(operational control [OPCON]) to the MSMCunder the supervision of the division psy-chiatrist. Under some situations, the detachmentcommander may elect to remain with the CSCpreventive team. He may leave his CSC pre-ventive team with only one social work officerand two behavioral science specialists if work loadat the BSA is light. In other situations, he mayelect to send the clinical psychologist from theCSC restoration team to take his place. Thedetachment NCOIC and the officers of the CSCrestoration team keep the commander informedand represent him as needed. If the division has

only two maneuver brigades, the CSC preventiveteam which includes the detachment commandernormally remains with the division mental healthsection and CSC restoration team in the DSA.

c. Support to Separate Brigades orArmored Cavalry Regiments During War. A sepa-rate brigade or ACR in a mid- to high-intensityconflict is dependent on division or corps CSCassets for support.

(1) A medical detachment, CSCwhich supports two or three separate brigades orregiments is normally attached to the medicalgroup or the medical company, CSC which sup-ports the AO.

(2) If two brigades or ACRs aresupported, two of the detachment CSC preventiveteams are deployed forward and attached to theFSMCs of the two supported brigades or ACRs.The detachment commander’s team locates whereit can best provide backup support to the forwardelements and coordinates administrative andlogistical support. The CSC preventive teamswith each separate brigade operate as describedabove for divisional brigades, except they arereinforcing a brigade CSC team which has only abehavioral science NCO in charge. The ACRshave no CSC team to reinforce. The CSC pre-ventive team, therefore, needs to be much moreactive in making contact and establishing trustand cohesion with the following elements andpersonnel:

Medical company person-nel.

Battalion or squadronmedical platoons.

Brigade or regiment chap-lain and unit ministry teams.

Unit commander andleaders at all levels.

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It is especially important that this process beginsas far in advance of the onset of combat operationsas possible, preferably before deployment.

(3) If a third separate brigade issupported, the detachment commander’s CSCpreventive team deploys to it.

(4) The CSC restoration teameither locates with the detachment commanderand provides restoration treatment at thatlocation or augments a corps-level MTF wherecases from the supported brigades can best betreated. It integrates its restoration and recon-ditioning programs with those of the othersupporting CSC units.

d. Combat Stress Control Detachmentin Operations Other Than War. In a prolongedconflict involving a contingency corps with one ormore divisions and/or several separate brigadesand regiments, only CSC medical detachments(no CSC medical company) maybe mobilized. Forcontingency operations of short duration, task-organized CSC elements from the CSC medicaldetachments could be deployed.

(1) The CSC preventive teamssupporting the brigades may operate out of acentral base of operations. The teams go forwardto the BSAS (base camps or fire bases) whencoordinated by the division mental health section.Such visits would be in response to—

quirements.

a unit.

stress behaviors.

theater.

3-16

Anticipated battle.

Post-action debriefing re-

Alcohol/drug problems in

Incidents of misconduct

Unit rotation in or out of

(2) Several CSC restoration andCSC preventive teams from two or more CSCmedical detachments may be consolidated underthe command of the senior medical detachment,CSC commander to staff a central reconditioningprogram for the corps. This may also functionas an alcohol/drug detoxification rehabilitationprogram. The CSC center will also provideconsultation and treatment support to militarypolice (MP) confinement facilities where mis-conduct stress behaviors may have led toincarceration (see Appendix C).

(3) In OOTW, if the force deployedis smaller than a division, a medical detachment,CSC would not be required to provide CSCsupport. In such cases, either the medical com-pany, CSC or the medical detachment, CSC maybe tasked with providing either a CSC team ora task-organized CSC element. The CSC teamor the task-organized CSC element is attached tothe supporting medical headquarters or to anMTF and conducts its mobile consultationmission.

3-9. Medical Detachment, Combat StressControl Interface and CoordinationRequirements

The medical detachment, CSC must interfacewith its higher medical headquarters element andwith the unit to which they will be attached. Thehigher headquarters may be the medical brigade,medical group, medical company, CSC or anASMB. The medical brigade or medical groupwhich controls a CSC company will normallyutilize that CSC company to monitor the CSCdetachment. The CSC company makes recom-mendations regarding the employment andsupport of any medical detachment, CSC as-signed to their AO. This includes CSC medicaldetachments that have been attached to thesupported divisions. The medical company, CSC,in turn, will task its task-organized sections tosupport specific CSC medical detachments. When

FM 8-51

required, the task-organized CSC elements mayreinforce or provide replacement personnel forthose CSC medical detachments. Maximal com-munications are encouraged between the CSCmedical detachments and the task-organized CSCelements directly through technical channels.The mental health staff sections of the medicalbrigade and medical group ensure that CSCmedical companies are updated. They providethe medical company, CSC headquarters and therelevant task-organized CSC elements withinformation copies of all status reports receivedfrom the CSC medical detachments in their AO.For detailed information pertaining to medicalcompany, CSC headquarters and task-organizedCSC elements, see Section IV. Normally, thedetachment is attached for OPCON to an MSMCof the MSB in the divisions. If it is supporting inthe corps area, then it could be attached to amedical company, CSC, an ASMB, or directly tothe medical group. Interface and coordinationare essential if CSC support requirements are tobe accomplished.

a. Interface Between the Detachmentand Its Higher Headquarters. The medicaldetachment, CSC interfaces with its higherheadquarters pertaining to its assigned mission.It provides estimates and has input to theOPLANs. The detachment receives its OPORDsfrom the higher headquarters. Interface betweenthe detachment and the staff of its higherheadquarters will focus on providing CSC whichincludes preventive activities and consultationsupport. Interface between the detachment andhigher headquarters staff elements will includethe following subject areas:

Combat stress control opera-tions.

Assignment or attachment ofthe medical detachment, CSC elements.

Daily personnel and equipmentstatus reports.

status and supply requirements.

Casualty Feeder Reports.

Statistical summaries per-taining to work load, including consultation andtriage activities, restoration or reconditioningcenter censuses, and special reconstitution sup-port activities.

Operation plans.

Operation orders.

Personnel replacement for thedetachment.

Medical intelligence informa-tion.

Mental health/CSC consulta-tion taskings and results.

Class VIII (medical supply)

request.

tion operations.

Maintenance requirements and

Replacement and reconstitu-

Civil-military operations.

Host-nation support.

Communications (signal opera-tion instructions [S0I], access to message centersand nets, and transmission of CSC messagesthrough medical and other channels).

Mass casualty plan.

Road movement clearances.

Tactical updates.

Contingency operations.

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Return-to-duty and nonreturn-to-duty procedures.

Medical evacuation procedures(air and ground ambulances).

Changes in locations of sup-ported unit.

b. Interface and Coordination with theUnit That Has Operational Control of the MedicalDetachment. Combat Stress Control. The head-quarters of the unit with OPCON is responsiblefor providing the administrative and logisticalsupport requirements of the detachment. Theserequirements are normally identified in theattachment order. If not identified in theattachment order, they must be coordinatedby the detachment’s higher headquarters priorto deployment. The CSC detachment mustcoordinate daily with the headquarters staff andsection leaders (if required) of the unit to whichthey are attached. The staff shares informationwith the detachment commander or his repre-sentative. Daily updates pertaining to the threat,tactical situation, patient/BF casualty status, andchanges in CHS requirements are provided to thedetachment. Coordination activities and subjectarea information exchange should include—

Command and control proce-dures.

ventive teams.

ments.

replacement.

antes.

countability.

Status of FSMCs and CSC pre-

Communications (SOI).

Operational support require-

Civil-military operations.

Restoration operations.

Reinforcement and personnel

Maintenance.

Personnel replacement.

Road movement and clear-

Casualty reporting and ac-

Patient-holding procedures.

Nuclear, biological, and chemi-cal defensive operations.

Section IV. SUPPORT OPERATIONS CONDUCTED BY THE MEDICALCOMPANY, COMBAT STRESS CONTROL

3-10. Medical Company, Combat Stress war, one medical company, CSC may supportControl Employment from two to five divisions depending on the level

of operations. The company is reinforced bya. Medical Company, Combat Stress attachment of a variable number of CSC medical

Control Support Operations. The medical com- detachments. Normally, one CSC detachment ispany, CSC is assigned to a MEDCOM, medical allocated per division and one per two or threebrigade, or medical group. The medical company, separate brigades or regiments in the corps. TheCSC is employed for a war when estimates medical detachment, CSC is discussed earlier inindicate large numbers of BF casualties. During Section III.

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b. Methods of Operations for the Medi-cal Company, Combat Stress Control. Methodsof operations for the medical company, CSC aredependent on the CSC support requirements andthe tactical situation. The CSC medical companycommander can deploy modular CSC preventiveand CSC restoration teams from the company’spreventive and restoration sections. He also hasthe option to combine elements from both sectionsto form task-organized CSC elements, dependingon CSC requirements. The personnel in the pre-ventive and restoration sections do not have to betask-organized in rigid compliance with the mod-ular CSC preventive and CSC restoration teambuilding blocks. For example, one task-organizedCSC element may be given most of the psychiatricnursing assets, while another may receive moreof the OT resources. This decision would be basedon the shifting requirements set by the recon-ditioning or restoration caseloads at differentplaces and other priority missions. The intent isto give the commander flexibility to accomplishhis changing mission requirements for CSC.

(1) Task-organized CSC elementemployment. The task-organized CSC elementsare employed to provide CSC support in theirarea of responsibility. They must coordinatewith the supporting ASMB and hospital NPresources within their AO. The task-organizedCSC element leader is responsible for allocatingthe CSC resources which the medical company,CSC commander has given his element. He mustmeet the changing requirements for—

Preventive consultationand CSC education in the corps (supporting theASMB) (see Chapter 4).

Reconstitution support (amajor, but intermittent priority mission taskedby the higher headquarters) (see Chapter 5).

Neuropsychiatric triage(shared with the ASMB and hospital NPconsultation services) (see Chapter 6).

Stabilization under emer-gency situations; normally, this is the mission ofthe hospital NP ward/service (see Chapter 7).

Restoration (in areaswhere the task-organized CSC element is closerto the soldier’s units than an ASMC, or by sendinga team to reinforce an ASMC) (see Chapter 8).

Reconditioning (theunique mission of the CSC company’s task-organized CSC elements in corps and in mostscenarios, but of lower priority than the missionslisted above) (see Chapter 9).

Temporary support (send-ing CSC teams to reinforce the medical detach-ment, CSC which are operating forward in thedivision and brigade areas, or when reconstitutionsupport and restoration work loads require).

Reinforcement of themedical detachment, CSC, division mental healthsection, or ASMB mental health section, ifnecessary or providing replacement personnel.

(2) Restoration and especially re-conditioning are provided for BF soldiers andselected NP and alcohol/drug misuse cases fromthe supported division and corps units. The task-organized CSC elements attach to or collocatewith medical units as near to the supported unitsas is tactically feasible. In the initial intensivephase of conflict, CSC teams may be dispersedto reinforce the CSC medical detachments inthe divisions. They may be attached to an ASMCor a CSH where they can readily support thedivisions and heavily committed corps units. Inthis phase, reconditioning treatment in the corpsarea will rarely continue beyond 3 days, inaddition to the initial 3 days of restoration. Asthe conflict stabilizes and the requirement forrestoration decreases, reconditioning extends toseven days. If feasible, and with approval of thecorps commander, it is extended to 14 days. The

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task-organized CSC element’s combat fitness andreconditioning center is usually attached (notOPCON) to a CSH.

(3) A task-organized CSC elementfrom the medical company, CSC usually deploysin the corps area behind each supported divi-sion. The task-organized CSC element behindeach division has two or three CSC preventiveteams and one to three CSC restoration teams,depending on support requirements. Each task-organized CSC element may be reinforced byone or two support personnel (cook, mechanic)detailed from the medical company, CSC head-

quarters. Each task-organized CSC elementsends modular teams forward to reinforce themedical detachment, CSC in the supported divi-sion, as needed. Table 3-1 shows the ways thatteams could be distributed as task-organized CSCelements to support two to five divisions.

(4) When not task-organized witha CSC preventive team, the CSC restorationteams normally collocate with a CSH or with theHSC of an ASMB. Both the CSH and head-quarters and support company of the ASMBprovide a psychiatrist. This is of lesser impor-tance if the psychiatric nurse of the CSC

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FM 8-51

restoration team is a clinical nurse specialist or ifthe psychologist is especially trained to prescribemedications. A CSC restoration team may bedeployed forward without a CSC preventive teamto support a heavily committed division or anASMC in the corps.

c. Reconditioning Centers. The medi-cal company, CSC will use task-organized CSCelements to staff separate, small reconditioning

centers behind each division. However, undersome circumstances, the medical company, CSCmay consolidate teams to establish a large recon-ditioning center which supports two or threedivisions. Reconditioning facilities normally lo-cate near a CSH. Figure 3-1 illustrates the task-organized CSC elements of the CSC medicalcompany operating a reconditioning center neara CSH. For definitive information on recondi-tioning center operations, see Chapter 9.

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FM 8-51

3-11. Medical Company, Combat StressControl Coordination and InterfaceRequirements

The medical company, CSC coordinates with itshigher medical headquarters element and withthe units to which the company’s CSC elementswill be attached. The higher headquarters maybe the medical brigade or medical group.Interface and coordination are essential forproviding and ensuring CSC support require-ments to prevent or limit the effects of combatstress and the number of BF casualties areaccomplished.

a. Coordination and Interface betweenthe Medical Company and Its Higher Head-quarters. The medical company, CSC coordinateswith its higher headquarters pertaining to itsassigned mission. The mental health staff sectionof the medical brigade and medical group arepoints of contact for this coordination. It providesestimates and has input to the OPLANs. Thecompany receives its OPORDs from the higherheadquarters. Interface between the companyand the staff of its higher headquarters will focuson providing CSC, which includes preventiveactivities and operating restoration and recon-ditioning centers for the support divisions. Thisinterface between the company and higherheadquarters staff elements will include thefollowing subject areas:

Combat stress control opera-tions.

Assignment or attachment ofthe CSC preventive teams, CSC restorationteams, or task-organized CSC elements from thecompany.

Daily personnel and equipmentstatus reports.

Class VIII status and resupplyrequirements.

3-22

Casualty feeder reports.

Work load summaries includ-ing consultation and triage activities, restorationor reconditioning center censuses, and specialreconstitution support activities.

detachment.

tion.

ter(s).

tion.

requests.

tion operations.

Operation

Personnel

plans and orders

replacement for the

Medical intelligence informa-

Status of restoration center(s).

Status of reconditioning cen-

Mental health/CSC consulta-

Maintenance requirements and

Replacement and reconstitu-

Civil-military operations.

Host-nation support.

Communications (S01, accessto message center and nets, and transmission ofCSC messages throughnels).

Mass

Road

medical and other chan-

casualty plan.

movement clearances.

Tactical updates.

Contingency operations.

FM 8-51

Return-to-duty and nonreturn-to-duty procedures.

Medical evacuation procedures(air and ground ambulances).

Locations of supported units orchanges in their location.

b. Interface and Coordination with theUnit that has Operational Control of the MedicalCompany, Combat Stress Control Teams or Task-Organized Combat Stress Control Elements. Theheadquarters of the unit with OPCON is re-sponsible for providing the administrative andlogistical support requirements of the company’steams or task-organized CSC elements. Theserequirements are normally identified in theattachment order. If not identified in the at-tachment order, they must be coordinated by themedical company, CSC headquarters prior to thedeployment of its elements. Deployed teams ortask-organized CSC elements from the medicalcompany, CSC coordinate daily with the head-quarters staff and section leaders (if required)of the unit to which they are attached. Thatheadquarters transmits the CSC element’smessages and reports to the receiving medicalheadquarters via medical C2 channels. The team/task-organized CSC elements’ leader sharesinformation with team members and updates themedical company, CSC commander as required.The medical company, CSC elements are provideddaily updates from the headquarters element ofthe unit to whom attached. These daily updatesmay include information pertaining to:

Threat situation.

Tactical situation.

Patient/BF casualty status.

Changes in CHS requirements.

Coordination activities and exchange of subjectarea information should include—

dures.

ventive teams.

ments.

tion.

tions.

antes.

countability.

Command and control proce-

Status of F’SMCs and CSC pre-

Communications.

Operational support require-

Civil-military operations.

Restoration operations.

Reinforcement and reconstitu-

Reconditioning

Maintenance.

center

Personnel replacement.

Road movement and

opera-

clear-

Casualty reporting and ac-

Patient-holding procedures.

Nuclear,cal defensive operations.

Hospitalsition procedures.

biological, and chemi-

admission and dispo-

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CHAPTER 4

COMBAT STRESS CONTROL CONSULTATION

4-1. Priorities and General Principles

a. Primary Emphasis of Combat StressControl. The primary emphasis of CSC is on theenhancement of positive, mission-oriented motiv-ation and the prevention of stress-relatedcasualties. Combat stress control personnel pro-vide consultation and training (either formal orinformal) on many topics including—

Enhancement of unit cohesion,leadership, and readiness.

Risk factors (stressors).

Recognition signs of stresssymptoms and behaviors.

Leaders’ actions to controlstressors and stress.

Individual stress managementtechniques and skills.

b. Combat Stress Prevention. Combatstress prevention programs reduce the incidenceof new combat stress-related casualties. Theseprograms promote the early recovery and RTD ofstress casualties. They reduce the cases whichcould otherwise overload the CHS system. Over-all, combat stress prevention programs are signi-ficant combat multipliers which enhance theArmy’s fighting strength and its ability to performits mission while significantly reducing thenumber of casualties.

NOTE

Overall, consultation has the highestpriority among the CSC functions.

If consultation is deferred due to tactical or othercritical situations, consultation services should be

reinstated at the earliest possible time. If notquickly reinstated, other functions could soon beoverwhelmed by the casualty caseload.

(1) Army operations during war.During war, the primary efforts are toward theprevention of and successful RTD of BF casual-ties. Historically, BF casualties have representedfrom one-sixth to one-third of all battle casualtiesin high-intensity wars. Failure to reduce/preventBF casualties or RTD a large numbers of thesecases could affect the outcome of key battles. Thefast pace of the high-technology battle requiresthat CSC preventive consultation be ongoingbefore the fighting starts.

(2) Operations other than war. Inconflict and peacetime contingency operations,CSC consultation activities are more focusedtoward prevention of misconduct stress behaviorsand on maintaining unit cohesion, morale, andesprit de corps than on preventing BF casualties.This is done because BF casualties are rarely seenin OOTW, but the reported incidence of mis-conduct stress behaviors are relatively frequent.The enemy in 00TW may deliberately use stressto try to provoke our soldiers to commit misc-onduct. Misconduct, especially commission ofatrocities, not only endangers mission accom-plishment but can severely damage US or alliednational interests.

(3) All intensities of conflict. Psy-chologically, traumatic and catastrophic eventsoccur in war and OOTW. Combat stress controlpersonnel must be prepared to provide CSC inter-vention. Combat stress control preventive pro-grams and CSC intervention for catastrophicevents will assist in protecting soldiers fromPTSDs.

c. Modes of Combat Stress ControlConsultation. Combat stress control consultationis defined as providing expert advice, education,

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FM 8-51

training, and planning assistance. The objectivesof consultation are the improvement of psycho-logical readiness and the prevention and treat-ment of BF, misconduct stress behaviors, PTSDS,and all stress-related problems. This consultationsupport is provided to commanders, leaders, andthe staff and medical personnel of supportedunits. Consultation on all topics related to theprevention, treatment, and RTD (or otherdisposition) of BF casualties, misconduct stressbehaviors, PTSDS, and NP disorders is provided.

(1) Combat stress control person-nel are the primary resource for advice and train-ing on ways to control stressors and stress. Sup-porting CSC personnel interface with—

Unit commanders.

Staff elements.

Leaders.

Chaplains (very impor-tant contact).

Medical personnel (otherthan mental health/CSC personnel).

Other personnel.

Leaders at all levels must be made aware thatCSC measures can reduce BF casualties to fewerthan one per ten WIA and can expedite the earlyreturn of BF casualties to full duty (see FM 22-51). These measures also help in reducing pro-blem behaviors and incidents which detract fromthe overall readiness of a unit. Some of thesedetractors include—

Substance abuse.

Suicides.

Home front problems.

Misconduct.

Other stress disorders.

(2) Consultation may be providedin response to a specific request or be initiated bymental health personnel. Methods for providingconsultation and training include—

One-on-one.

Small discussion group.

Large groups.

Consultation is an ongoing process which is per-formed in both peacetime and wartime. It isconducted before, during, and after combat.

(3) Consultation is best initiatedthrough face-to-face contact, preferably at thesupported unit’s location. Telephone and radiomay be used to set up further sessions or toprovide follow-up consultation. Audio tapes and/videotapes may also be used if the unit or meetingsite has the equipment to play them, Follow-upconsultations also works best when the face-to-face contact method is used.

(4) Successful consultation is de-pendent on trust and the familiarity establishedbetween the consultant and the soldier(s) withwhom he is working. Especially in a hierarchical,high-stress, time-pressured setting like the Army,the consultant must possess a credible militarybearing. He should have a thorough knowledgeof the military (the units, missions, vocabulary,acronyms, and skills involved). He must be realis-tic and self-confident about the accomplishmentof his work. In some instances, sufficient rankmay also be necessary. These visible militaryfeatures are often more important in establishingcredibility than are academic or clinical creden-tials. In a peacetime environment, academic andclinical credentials are important for long-termcredibility.

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FM 8-51

(5) Therefore, when possible, theconsultant should establish contact and rapportwith the personnel of supported units long beforeaction becomes imminent. In general, the longerthe relationship is established prior to the onsetof tactical operations, the greater the effectivenessof the consultation.

d. Consultants. All mental health/CSCprofessional disciplines and enlisted MOSS mayserve as consultants in mental health/CSC areas.

(1) There are five disciplines in themental health/CSC area and each one has specificsubject areas. These disciplines include—

Psychiatry.

Psychiatric nursing.

and especially the NCOs must have sufficientrank and experience to establish face-to-facevalidity as advisors and counselors to line officersand senior NCOs. Similarly, each mental healthdiscipline (psychiatry, clinical psychology, socialwork, psychiatric nursing, and OT) has areas ofunique professional expertise. A multidisci-plinary approach is required which providesmutual access to each discipline at key levels inthe CSC unit organization. There must also besharing of information within the CSC units toincrease the areas of shared expertise.

(3) Other personnel will be in-volved in recognition and control of stress as aresult of their position or duty assignments.Consultation and training to develop them intoeffective CSC consultants is a high priority formental health/CSC personnel. These personnelwill include—

Clinical psychology.Unit leaders.

Social work.

Occupational therapy.

Consultants will naturally rely and focus on theirspecific specialty. Each of the disciplines shouldalso be able to provide routine consultation for allbasic topics. Therefore, it is essential that in-formation be shared ongoing among the fivemental health disciplines and between officersand their enlisted assistants. This mutual under-standing also expedites the appropriate referralto the relevant specialist, as required.

(2) Experience shows that the CSCconsultation mission (and to a lesser extent, thetreatment mission) is functionally divided intoprofessional mental health-credentialed officerresponsibilities and experienced mental healthNCO responsibilities. Since each has a uniquerole, neither officer nor NCO can do the other’sbusiness with full effectiveness. The solution isto form cohesive officer/NCO teams. The officer

Chaplains and chaplains’assistants.

Other physicians andphysician assistants.

Combat medics.

Other supporting medicalpersonnel.

NOTE

The role of a good consultant is to trainothers to use his knowledge rather thanto guard his information as a tradesecret.

e. Audience for Consultation. Thetarget audiences for consultation vary, depending

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on location and mission. Consultation and train-ing activities should be identified, prioritized, andscheduled to achieve maximum participation fromall supported units. Depending on the units inthe area of support, broad types or categories ofpersonnel are considered for consultation activi-ties. These personnel may include—

The command or unit surgeonand his staff.

Staff chaplain and unit minis-try team.

The senior commander and thesenior NCO (of the unit or the command ser-geants major of the corps, division, brigade, and/or battalion).

Staff officers and NCOs, includ-ing adjutant and personnel (S1/G1), intelligence( S2/G2 ), operations (S3/G3), logistics (S4/G4), civilaffairs (G5), DMOCS, and the judge advocategeneral (JAG).

Company-grade leaders, espe-cially company commanders, executive officers,first sergeants, platoon leaders, and platoon ser-geants.

Assembled troops of combat,CS, and CSS units.

Medical personnel includingphysicians, physician assistants, dentists, nurses,practical nurses, medical specialists and NCOs,and the nursing services of CZ and COMMZhospitals.

Some of these medical personnel may be recentadditions to their units who are likely to be fromthe Professional Filler System (PROFIS) or Indi-vidual Ready Reserve. Such individuals mayhave special need for quick education in CSCprinciples.

NOTE

A critical issue is to ensure that medicalpersonnel do not overdiagnose stresscasualties.

Stress cases should not be diagnosed as NP orphysical disability cases. Stress cases should notbe prematurely evacuated out of the theater with-out adequate trial of the CSC restoration andreconditioning program.

4-2. Consultant Activities During Pre-deployment and During Buildup andWaiting Phases in the Theater ofOperations

a. Knowledge of the Supported Units.The mental health/CSC personnel should trainin the field with the units they will support duringcombat. They must become knowledgeable ofthese units and familiar with their personnel.Through contact with supported units and in-volvement in training activities, mental health/CSC personnel gain the trust and confidence ofthose personnel. The trust, confidence, and famil-iarity of unit personnel will significantly enhancemental healthlCSC personnel’s ability to performtheir mission. All available time during pre-deployment and build up in the TO should beutilized to gain familiarity with any new units.Mental health/CSC personnel must also make aneffort to maintain relationships already estab-lished through training. Some of the informationprovided below pertains to establishing relation-ships with the new unit and may apply to main-taining relationships.

(1) Present a briefing on the men-tal health/CSC mission and its relevance at com-mander calls, officer/NCO professional develop-ment sessions, and as part of the combatorientation of new replacement units arriving inthe TO.

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FM 8-51

(2) Arrange to visit unit leadersand work areas. Choose times when they canexplain and demonstrate their mission. Partici-pate as an observer at the crew and team level inmaneuver or live fire training exercises. Empha-size that the purpose of the visit involves themental health/CSC mission to support themduring combat. Explain to them that the mentalhealth/CSC mission requires that mental health/CSC personnel be knowledgeable of what theydo; that the mental health/CSC personnel needto be aware of stressful conditions associated withtheir mission.

(3) Attend ceremonies of supportedunits and participate in their unit activities suchas physical training.

(4) Provide briefings, classes, in-formation papers, and more importantly practicalexercises in topics which are relevant to the mis-sion scenario. Topics should include—

Combat stress/BF recog-nition and management (appropriate for thebranch, rank, and duties of the audience).

Techniques for buildingunit cohesion.

Performing stress man-agement and relaxation techniques.

Maintaining performancein continuous and sustained operations.

Ensuring psychologicalpreparation for NBC defense.

Preventing BF and mis-conduct stress behaviors by defending against thestresses of terrorism, guerrilla operations andrestrictive rules of engagement.

Treating EPWs accordingto the provisions of the Geneva Conventions.

Orienting soldiers to thecustoms, traditions, religion, and other socio-economic values of the civilian population.

Recognizing the over-stressed soldier.

Recognizing signs of sub-stance abuse and preventing, treating, and re-habilitating abusers.

Improving leadershipskills for interviewing, counseling, and assistingproblem soldiers.

Developing leadershipskills to conduct after-action debriefings (rou-tinely and for serious accidents, or combat situa-tions).

Conducting grief manage-ment (the chaplain should be included).

Improving time manage-ment, organizational skills, and leisure time skills.

Controlling family issues,including how to access supporting agencies suchas—

Red Cross.

Army CommunityService.

Army EmergencyRelief.

Exceptional FamilyMember Program.

Family AdvocacyProgram.

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FM 8-51

Medical care and theCivilian Health and Medical Programs of theUniformed Services and Delta Dental Plan.

Preparing families fordeployment of the service member’s unit.

NOTE

Time invested in consultation is neverwasted. New knowledge, insight, andpoints of contact are always worthgaining. Just ask questions and listen.

b. Conduct Unit Survey and FocusInterviews. Interview 8 to 12 soldiers as a groupand ask a series of general or structured ques-tions. Survey interviews use open-ended ques-tions and seek answers to a wide range of issues.Focus interviews use more direct questions toanswer a specific issue; for example, the adequacyof the unit’s sleep plan. In both types of inter-views, the responses are recorded and trends areidentified. These interviews can be done in thefield as battlefield interviews and can be used todebrief and to gather data, Collected data is thenused as a basis to train or provide consultation.

c. Administer Survey Instruments(Questionnaires). Survey questionnaires are nor-mally used in conjunction with briefings, focusedinterviews, classes, or field exercises. They areused to assess unit cohesion, confidence, readi-ness for combat, and familiarity with stress con-trol, or to identify areas which need further train-ing or command attention. Surveys may also beconducted to answer specific command questionsabout unit morale and readiness. Survey resultsand recommendations are provided to unit leaders.

(1) Such surveys work best whenthey are endorsed (and perhaps mandated) byhigher command, but are advertised and imple-mented as an aid to the junior leaders, not a pass-fail test.

(2) Results should be shared withthe junior leaders first and should be worded inpositive terms: “Here is what looks good, here iswhat needs more work, and here are some ideas(not orders) for how to do it.”

(3) The questionnaire should beadministered in a way that guarantees anonymityto the responders: It is best to administer it all atone time and to have it handed out and collectedby the mental health/CSC surveyors, not the unitleaders.

(4) Questionnaires need to be brief,simple, unambiguous, and easily hand- ormachine-scored to provide quick feedback. Stand-ardized, well-documented survey instruments arebest. Sharpened pencils and firm writing surfacesmust be supplied. Shelter from adverse weather(or water-resistant questionnaire sheets) may benecessary when surveys are conducted in thefield.

NOTE

Survey instruments which are cur-rently being used include Departmentof the Army Pamphlet (DA PAM) 600-69. Currently under development andtesting by Walter Reed Army Instituteof Research is another survey titled“Psychological Readiness for CombatSurvey” (see Appendix B).

d. Monitor Stress Risk Factors(Stressors) and Indicators of Stress in Units.Information about stressors and stress in a unitmay be obtained by coordinating with varioussources. These sources of information include—

Sl/G1, S2/G2, S3/G3 staffs,commanders, command sergeants major and firstsergeants,

Military police blotter reports.

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Unit surgeons.

Preventive medicine (PVNTMED)reports and personnel.

Chaplains.

Judge advocate general.

NOTE

Information obtained from the abovesources involves the statistical implica-tions without violation of AR 340-21,The Army Privacy Act Program.

Stress on the home front may be monitored bythe unit’s rear detachment, keeping in touch withthe post’s Deputy for Personnel and CivilianAffairs (DPCA) and various medical departmentactivity (MEDDAC) mental health and patientcare services.

(1) Monitor known stressors suchas—

Number of days/months

Substandard living condi-tions.

Social isolation from sur-roundings due to distance, climate, foreignculture, and hostile locals.

Inspector general (IG) orvery important person visitor.

Insufficient facilities orfunds for mission training or morale/welfare/recreation support.

Commission of terrorismor atrocities by the enemy.

Likelihood of temptationsfor substance abuse.

Recent losses and/or newreplacements in the unit.

Change in leadership.

(2) Monitor indices of excessivestress in units. Mental health/CSC personnelmonitor known warning signs of excessive stressto identify units which need special consultation.Some of these warning signs are—

in a unit.

(AWOL) rates.

plaints.

transfers.

tion and driving while

(sexual misbehavior).

self-inflicted wounds.

completions.

Many disciplinary actions

High absent without leave

Inspector

Increased

Alcohol orintoxicated

general com-

requests for

drug intoxica-charges.

High sick call rates.

Preventable diseases

Fights, minor injuries, and

Suicide gestures/attempts/

Homicide threats, at-tempts, and completions.

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(3) Monitor home front (rear de-tachment) indices of excessive stress, such as—

Spouse and child abuse.

Bad checks.

High numbers of separa-tions and divorces.

Significant numbers ofcouples in counseling.

Family members caughtshoplifting or an involvement in other crimes ormisdemeanors.

Financial problems.

e. Conduct Transition (Change of Com-mand) Workshops. Mental health/CSC personnelconduct transition (change of command) work-shops for supported units. These workshops arenormally requested by the incoming commander.The primary purpose of these workshops is to—

Facilitate staff discussion ofwhat the staff sees as the unit’s (and staffs)strong points and the areas needing more work.

Provide the new commanderthe opportunity to discuss his leadership style andhis expectations and set priorities for the staff.

f. Conduct Personal Reliability Screen-ing. Personal reliability screening is required byAR 40-501, or it may be command directed.

g. Supporting and Assisting Alcoholand Drug Prevention and Control Programs. Inthe TO, there are no formal alcohol or drug sup-port groups. Therefore, mental health/CSC per-sonnel promote the establishment of ad hocalcoholic support groups or other support groups.They evaluate cases of alcohol/drug abuse and

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recommend rehabilitation, medical treatment, oradministrative disposition.

4-3. Combat Stress Control ConsultantActivities for Staff and OperationalPlanning

a. Planning. It is important that CSCpersonnel be involved in the overall planningprocess. Combat stress control personnel provideadvice and assistance to commanders and staffon CSC issues. These issues may include—

Providing measures formonitoring and controlling stressors.

Providing stress casualtyestimates.

Providing CSC input forreconstitution support.

tive operations.

ward to provide

Conducting CSC preven-

Deploying CSC assets for-immediate restoration support.

Establishing proceduresfor CSC reconditioning, including resource andcoordination requirements.

Establishing procedureswith supporting battalion S1s for transporting BFcasualties who are able to RTD to their units.

Providing input on usingmental health/CSC asset for supporting host-nation or humanitarian civil assistance operations.

(1) Combat stress control per-sonnel provide the command surgeon input forinclusion in the CHS estimate and plan. Combatstress control personnel are included early in the

FM 8-51

mission planning process to ensure adequate CSCresources are included in the CHS plan.

(2) To enhance the performance ofCSC personnel in the decision-making and plan-ning process, they should be provided realistictraining. This training can include participationin activities such as field training and CPexercises. Additionally, mental health/CSC per-sonnel must be given the opportunity to learn,practice, and perfect their skills for providing unitconsultation and the other five functional missionareas associated with CSC and mental health.This is accomplished through their participationin various training exercises.

b. Combat Stress Control S.taff Plan-ning in Combat. The CSC consultant must assurethat staff planners keep in mind that CSC mustbe proactive and rapidly reactive.

(1) Proactive measures. Proactivemeasures include the pre-positioning of CSC per-sonnel to the maximum extent possible to supportthose units that are most likely to experiencecombat actions. This will change from day today. In order to anticipate and prioritize, theplanner should also evaluate the likelihood thatthe combat action will involve the special riskfactors for BF casualties and misconduct stressbehaviors (see Appendix B). Pre-positioning mayinclude—

Deploying organic CSCpersonnel far forward to areas of need.

Sending CSC personnel toan AXP behind the battalion entering combat.

Sending CSC personnel toa BAS in the combat trains,

Sending additional organicCSC personnel to the BSA with the supportingFSMC.

Attaching corp-level CSCteams base on casualty estimates to thesupporting medical company in the BSA, DSA, orcorps area.

Providing warning ordersto backup CSC teams in the division rear or corpsarea.

The warning orders alert CSC teams to prepareto deploy forward or to detach personnel to rein-force the teams already forward. This forewarn-ing is especially important if the backup teamsneed to reduce their ongoing treatment caseload.

(2) Rapid reaction. For rapid reac-tion, CSC personnel and teams require staffactions to identify where they need to move oncethe actions have started. The staff must alsocoordinate this move. Certain events should berecognized and reacted to when they occur. Theseevents include—

Having high numbers ofWIAs and stress casualties at a location whichwas not anticipated or covered by CSC resources.

Receiving reports that aunit has experienced an especially traumatic inci-dent (such as casualties from friendly fire).

It would be helpful for CSC personnel to partici-pate in the unit’s after-action debriefing (see sub-sequent paragraphs and after-action debriefingin Chapter 5). Definitive information on CHSplanning is found in Appendix B and in FMs 8-10, 8-10-5, 8-42, and 8-55.

4-4. Consultation During Mobilizationand Deployment

a. Planning and Consultation Activi-ties. During mobilization, contingency plans arereviewed and updated, as required, Combat stress

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control elements provide any revised informationto the command surgeon for inclusion in CHSestimates and plan. In addition to mobilizingtheir own assets, CSC elements will initiate con-sultant functions immediately. All command andstaff briefings should have a CSC representativepresent to ensure CSC personnel are aware ofdeveloping situations. Supported units are in-formed as necessary on changes/updates to theCSC operating procedures.

b. Coordination with Supported Units.All supported units are contacted by CSC person-nel to confirm preestablished points of contact(POCs) or to identify new POCs. Coordinationvisits to newly supported units must be brief toensure they do not hamper the unit’s mobilizationprocess. Only essential information pertainingto CSC consultation and support should be dis-cussed. Liaison consultants can also gain valu-able information and insight about the unit bylistening and observing without being in the way.

c. Home Station Support. During mo-bilization, the disruption of the family, finances,and other personal matters can adversely affectthe morale of the deploying soldier. It is impor-tant, therefore, to facilitate the transition fromhome station to the deployment area. Combatstress control personnel should—

Remind commanders and lead-ers of the importance of these issues.

Work toward greater partici-pation of family members in established familysupport groups.

Assist with the activation offamily support groups and coordinate home sta-tion command support when possible.

Ensure commanders providethe locations of established family assistance cen-ters to family members.

4-5. Consultation Support During Combat

a. Establishment. The CSC consultant(or team or unit) needs a secure base camp fromwhich to operate. Small consultation teams maybe able to integrate themselves into the quartersof the supporting unit. Large CSC teams willprovide their own shelter. Combat stress controlteams are usually either assigned or attached tomedical units for support.

(1) Depending on the echelon, thesupporting medical unit may be an FSMC (in theBSA), an MSMC (in the DSA), or an ASMC(operating within a base cluster in the corps andCOMMZ). Combat stress control teams or unitsmay also collocate with a CSH, FH, GH, or amedical headquarters unit (ASMB, medicalgroup, medical brigade, MEDCOM). Combatstress control personnel with primary consulta-tion missions are organic to the above hospitaland medical headquarters. In other cases, theCSC personnel are attached to the medical unitfor support, either as individuals or as teamscomposed of 1 to 15 or more personnel.

(2) Attachment of CSC elementsmust be coordinated with the supporting medicalunit by the headquarters issuing the attachmentorder. Coordination must include provision forquarters, food, and fuel. After attachment, thecommand surgeon will brief the CSC element onthe threat, SOI procedures, and other pertinentinformation as required by the situation.

b. Continuation of Consultation andTraining Activities. During combat, consultationand training activities are continued. These ac-tivities may be curtailed or suspended as a resultof the tactical situation but are continued as soonas the situation permits. The consultant coordi-nates with the command surgeon on CSC infor-mation to be presented to the commander. Ifpossible, the CSC personnel accompany the com-mand surgeon when this information is briefed.

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It is important that senior commanders and staffare briefed on the CSC operation. When thesenior leadership understands the importance ofCSC consultation and prevention programs,maximum participation within the command isachievable.

(1) Movement outside of secureareas such as BSAs, DSAs, or base clusters willbe restricted. Any movement outside of secureareas involves increased risk and requires priorcoordination. The increased threat brought onby combat requires that all CSC personnel beproficient in performing their common soldierskills. Any CSC support mission requiring g-roundmovement outside the secure area must be coor-dinated and approved. This coordination is accom-plished with either the tactical operations center(TOC) or base cluster operations center. In mostcases, preferred movement outside a secure areais done by convoy and has MP or other securityelements. Some main supply routes (MSRs) maybe considered secure during daylight hours afterthey have been cleared by security forces. Inother situations, CSC personnel may follow re-turning ground ambulances to their destination.In all cases, CSC personnel must have approvalprior to departing any secure area.

(2) Priority for CSC consultationduring combat focuses on those areas with great-est, immediate potential to conserve fightingstrength. These areas include—

Implementing the CSCsupport plan.

Assisting units with rest-ing of DUTY and REST category BF cases in theirunits when possible.

Advising and assistingwith medical triage to prevent unnecessaryevacuation of BF cases.

Facilitating RTD and rein-tegration of recovered cases into units by coor-dinating with patient administration, the S1/Gl,and directly with soldiers’ unit leaders, chaplains,and medics,

c. Staff Planning. Staff planning isconducted in coordination with the unit surgeons(medical company commander). As new opera-tions or changes in the tactical situation evolve,estimates and plans must be reviewed and up-dated as required.

d. Periodic Visits to Supported Units.The CSC consultant conducts periodic visits tosupported units. These visits should occur on apredictable, recurring basis. The objective issimply to maintain contact and find out what isreally happening. Once the pattern is estab-lished, field phones or radio contact can fill thegaps when visits are impractical.

(1) It is essential that the consult-ant (or consultant officer/NCO team) establish acommunications network so that he can be con-tacted quickly anywhere in the course of makingrounds. If the consultant does not have a radio,it is important that he keep the supporting medi-cal unit headquarters informed of his location andschedule. This is accomplished by passing amessage through the supporting unit head-quarters. The consultant uses brevity codemessages (in accordance with TSOPs) which canbe transmitted quickly by host-unit signal per-sonnel. If the schedule changes, he informs thesupporting medical unit of the change.

(2) Visiting supported units in theimmediate vicinity (within the BSA, DSA, or basecluster) is accomplished on a daily basis whenREST BF cases are being held in their unit areasfor light duty or rest. In most instances, the unitsvisited will be headquarters and headquarterscompanies (HHCs) or CSS units. It is requiredthat CSC personnel know the location of all BFcases and monitor their status on a daily basis.

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(3) Each consultant when visitinga unit first makes contact with the previouslyidentified POCs. If the consultant team includesan officer and an NCO, they naturally divide thepeople to be talked with according to officer/NCOstatus and rank. The consultant speaks with thejunior leaders who have BF casualties in theirsections. If advice or assistance is needed, thisfacilitates the identification of problem areas. Hespeaks with the BF casualties as necessary tomonitor their progress. These “work-ups” arebrief and factual, with only sufficient items re-corded in the consultants notebook to remind theCSC provider of important details. These consul-tation cases are “carded for record only” on DDForm 1380. (For additional use of DD Form 1380,refer to AR 40-66 and FMs 8-10-6 and 8-230. )

e.

(4) The consultant advises unitleaders on the care and handling of BF casualties.Potential subject areas will include how to—

Talk with soldiers experi-encing BF.

Provide reassurance.

Ensure rest/sleep require-ments are met.

Provide adequate nour-ishment and fluid replenishment.

Practice personal hygiene.

area. The consultant should advise unit medicalpersonnel or the commander to send any BFcasualties judged to be at risk of serious medical/emotional illness to the supporting MTF for NPevaluation. At the supporting MTF, the BFcasualty receives further NP triage, stabilization,restoration, or evacuation.

Initial Evaluation at a MedicalTreatment Facility. At the MTF, REST, HOLD,or REFER BF cases are evaluated by generalmedical personnel (for example, at the clearingstation). This evaluation may include advice andan interview by the CSC consultant, whenpresent. If the CSC person is a psychiatrist, hemay elect to perform the examination and triageof the BF casualty.

(1) Battle fatigue cases that re-quire medical observation and treatment are man-aged as discussed in Chapters 8 and Chapter 9.

(2) Battle fatigue cases judged ableto RTD to their unit areas include those soldiers—

Treated and returned toduty immediately (category DUTY).

Placed on limited or lightduty for 1 to 3 days of rest under the control ofthe soldier’s own battalion HHC or the brigadeS1 (category REST).

Given light duties.

Conduct work activities.NOTE

Provide recreation (if pos-sible).

Initiate after-action de-briefings.

(5) When BF casualties appearunmanageable, they are not held in their unit

Maneuver units positioned in forwardareas only have those personnel whoare fit for full duty. Limited or lightduty is nonexistent in these units. IfBF cases are sent directly to these units,they must be able to perform full dutiesfor their own and the unit’s safety.

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If limited or light duty cases (REST category) aremembers of maneuver units operating in forwardareas, alternative units are used. Alternativeunits may include the battalion’s HHC which ispositioned with the field trains. Under somecircumstances, CSS units (such as a headquartersand headquarters detachment [HHD], mainte-nance, or supply company of the FSB) may beused temporarily for REST BF casualties. Alter-native units out of the BF casualty’s organiza-tional structure are not usually preferred, as theindividual soldier does not have any social,emotional, or administrative ties with the unit.

(3) Transportation of BF cases re-turning to their units from the supporting medicalcompany may require coordination. The patientadministration specialist of the medical companymay be required to contact the brigade S1 of thesoldier’s unit and request the unit provide trans-portation. In other instances, transportation forthe BF cases back to their unit may be coord-inated through the support operations section,movement control officer, or the TOC. Thesesections can identify any vehicles going to thesoldier’s unit area. The use of ambulances ormedical vehicles (such as the CSC vehicle) totransport soldiers back to their unit is not per-mitted under the Geneva Conventions (seeAppendix D). The transporting of soldiers to theirunit area could cause a loss of protected statusfor those medical personnel involved. For addi-tional information pertaining to the Geneva Con-ventions, see Appendix D.

g.

f . Monitoring the Progress of RESTBattle Fatigue Cases. As previously discussedthe progress of soldiers returned to or held intheir unit for rest or light duty is monitored bythe CSC consultant.

(1) When those soldiers being heldin temporary units for quarters, rest, or light dutyare ready to return to the original duty unit, the

headquarters element of the temporary unitcoordinates for transportation. Logistical vehiclessupporting forward areas are the most likelymeans for returning soldiers to their units.

(2) Combat stress control person-nel may be required to enter forward areas toprovide special reintegrating instructions for aBF casualty that is returning to duty. Commonly,a brief note or oral instructions provided to thesoldier or the unit leader are the methods used toget instructions to unit commanders and firstsergeants. Special instructions may also be sentforward via the chaplain/unit ministry team orambulance drivers relaying instruction to theBAS. These instructions will assist medics andunit leaders on how to maximize successful rein-tegration of the recovered soldier.

. Reevaluation of REST BattleFatigue Cases Who Do Not Improve. Soldiers whofail to improve sufficiently to return to theiroriginal duties and unit in several days must bereevaluated. During this evaluation, the CSCconsultant attempts to rule out malingering,situations with too much “secondary gain, ” orother physical and mental disorders (see the com-bat NP triage functions, Chapter 6).

(1) Advising the supervisors to in-crease positive expectation, reduce the comfort ofthe facility (the secondary gain), and/or havingthe first sergeant or other members of the unitvisit the soldier may be sufficient to achieve fullRTD.

(2) A few cases may be recom-mended for reassignment to CSS jobs in the samebattalion. However, this must be kept to a mini-mum so as not to undermine positive expectationof full recovery and lead to resentment or imita-tion by other soldiers. If job reclassification andreassignment is judged necessary, it will usuallybe to another unit.

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(3) Cases of REST BF who fail torespond after 1 to 3 days of rest are reevaluated.Based on the reevaluation, these BF cases areeither held for restoration treatment at the sup-porting MTF or evacuated one echelon for moreintensive restoration or reconditioning treatment(see Chapters 8 and 9).

h. Debriefings. Combat stress controlconsultation following potentially traumaticevents involves three types of debriefings. Thethree types of debriefings are—

After-action debriefings.

Large group debriefings.

Critical event debriefings.

(1) After-action debriefings shouldbe conducted by all leaders of small units after alloperations. After-action debriefings are especiallyimportant after a difficult action. The leader(s)extend the lessons learned orientation of thestandard after-action review (AAR) to includesharing and recognizing the feelings, emotions,and thoughts of team members. (See Chapter 5for after-action debriefings.)

(2) Large group debriefing may bean expedient method when small group debrief-ings are impractical. Alternatively, the large groupdebriefing may be the culmination of the after-action debriefing or critical event debriefing ofthe component squads, platoons, or small groups.The leader may be either the unit’s leader or afacilitator from outside the unit. Since everyonecannot be encouraged to take an active part, theleader encourages representatives of the for-malor informal subgroups to review their subgroup’sactions and experiences. Expressions of feelingsare again encouraged, respected, and validated.Individuals who were not specifically asked tospeak are encourage to speak up if they feel thereis more that needs to be said. Information by the

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leader about the normal stress process and reac-tions may have to take the place of the sharing ofpersonal experiences.

(3) Critical event debriefings arereserved for exceptionally traumatic events. Theyare lead by trained critical event debriefers,usually in teams of two to four persons. Theteams are led by CSC personnel but may includetrained chaplains, medical personnel, and lineofficers and NCOs. The participants in the criticalevent debriefing may be members of the sameunit; they may include strangers thrown togetherby chance by a highly traumatic event (forexample, members of a unit responsible for a“friendly fire” incident).

(4) After-action, large group, andcritical event debriefings share common featuresbut differ from each others in significant ways.Each type of debriefings is preferred for a particu-lar situation, but a combination of these debrief-ings may be used for some situations. The CSCconsultant should be prepared to—

Teach other personnelhow to lead or facilitate the above debriefings.

Facilitate each type.

Lead or conduct each type.

Know when each is appro-priate.

Combat stress control debriefings are describedin Chapter 5.

4-6. Consultation to Medical TreatmentFacilities

a. Providing Consultation to MedicalTreatment Facilities. Consultation for hospitaland Echelon II MTF staffs is provided by organic.

FM 8-51

attached, or collocated CSC units or elements.Hospital neuropsychiatry staffs provideconsultation primarily to hospital staffs but alsoadvise MTFs and nonmedical units operatingwithin their area of support. Consultationassistance may include—

Evaluating newly arrived casesto rule out BF or NP disorders or triaging forpossible admission or retention and disposition.

Evaluating cases already onthe wards or in a holding section with medical/surgical diagnoses that include BF or NPdisorders.

Providing consultation andtraining for medical staff on combat stressprevention and methods of controlling stressors.

NOTE

Stress reaction in medical personnel isoften denied or overlooked. Thus, theconsultant’s efforts may have to beactive during consultation to medicalpersonnel.

b. Evaluating and Triaging New Pa-tients. The majority of these patients will be seenin triage or the emergency medical treatmentarea of a hospital or medical company. Whenproviding CSC training to personnel working inthese areas, the consultant should—

(1) Emphasize the importance ofgiving immediate reassurance to the unwoundedBF (stress) cases and moving them away immedi-ately from the surgical holding or emergencymedical treatment areas.

(2) Emphasize that even thosecases who cannot be returned to their units

quickly and must be held temporarily “for rest”are not being “admitted” or ‘hospitalized,” ( theirmedical records may show that they technicallyare admissions).

(3) Coordinate and organize a non-patient area for placement of these cases. Lifesupport and administrative support is providedby the MTF. Nonmedical personnel may be usedto staff this area and provide supervision for casesin a nonpatient status. The selected area shouldbe quiet and away from high traffic areas. Arelatively quiet area will afford these cases theopportunity to rest and sleep. Personnel that areproviding supervision for these cases should bebriefed on handling and caring for these soldiers.It is important that these soldiers be providedthe opportunity to talk about what has happenedto them. It is also important that these soldiersbe given useful light duties which reaffirm theirnonpatient status.

(4) Monitor the progress of allcases and determine their disposition in accord-ance with corps and theater evacuation policies.These cases are either returned to their unit aftersufficient time of rest ( 1 to 3 days) as DUTY orREST BF casualties, or they are transferred toan MTF established for restoration or recondi-tioning of BF casualties.

c. Consultation fbr Medical and Surgi-cal Patients with Neuropsychiatric Conditions.Neuropsychiatric personnel may be requested toevaluate medical and surgical patients who arebeing held at MTFs. These medical and surgicalpatients when suffering NP disorders can bedivided roughly into five overlapping groups.

(1) Organic mental disorderswhich may include conditions such as—

Disruptive confusion.

Disorientation.

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Hallucinations and agita-tion after high fever, or metabolic disruption ofbrain functions.

Amnesia and poor im-pulse control following head injury.

The consultant recommends psychiatric treatmentmodalities (for example, drugs and restraints) andnursing measures which are compatible with theunderlying diagnosis and treatment.

(2) Major psychiatric illness coin-cidental to a medical or surgical condition, orperhaps responsible for it, as in serious suicideattempts. The consultant recommends NP treat-ment which is compatible with the illness orinjury and the treatments prescribed for it.

(3) Patients with ongoing or poten-tial psychiatric reactions to their injuries or thecircumstances of the trauma. Many soldiers expe-rience initial relief and even euphoria on beingwounded. They may feel a sense of relief becausethey are honorably out of action and in the careof the medics. They may sense this feeling ofeuphoria as a result of receiving morphine. Onlylater may the implications of a life of physicaldisability begin to depress them. Some of thesepatients may be willing and even desperate totell the story of what happened. Other patientsmay exhibit signs of depression, hostility, agita-tion, or other behaviors as a reaction to theirsituation and injuries. Potential psychiatric reac-tions may occur in any patient, but soldiers withsome types of wounds and injuries are consideredto be at special risk. These wounds or injuriesinclude—

Genital wounds.

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Major amputations.

Serious disfigurement.

Blindness.

Any condition that causesparalysis,

Empathic management by all health care provid-ers is critical and can greatly facilitate rehabilita-tion and minimize PTSDs. This is important evenif the patient appears to be unconscious.

(4) Patients with wounds that re-quire hospitalization but will be returned to dutywithin the theater. Some of these patients haveresidual BF and reactions to the circumstances oftrauma. A few of these patients experience antici-patory BF at the prospect of returning to combat.These patients should be placed in a minimal carearea as soon as their condition permits and beprovided treatment which is similar to that pro-vided to BF cases.

(5) Soldiers reacting to home frontproblems unrelated to their combat duties orinjuries. The consultant helps identify problems,provides guidance as appropriate, and mobilizessocial service support agencies, if applicable.

d. Providing Combat Stress ControlConsultation to Medical Personnel. Medical per-sonnel are not immune to the increased stressassociated with supporting combat operations. Itis important that medical personnel are not over-looked and that CSC consultation support beprovided to all MTFs, medical units, and medicalelements in the theater.

(1) Neuropsychiatric and CSC con-sultation personnel advise the chain of commandand supervisors about general measures to bufferthe intense stressors associated with providingcombat medical care. These stressors mayinclude—

Providing round-the-clockemergency care for severely injured patients.

Facing the moral dilemmaof placing patients in the surgical triage

FM 8-51

“Expectant” category (these patients receive onlysupportive care as time permits).

Facing the moral dilemmaof saving the grossly, lamentably disabled whenthere is not a mass casualty situation and they donot have to be placed in the surgical “Expectant”category. This is even more difficult if the patientis asking to be euthanatized.

Facing the moral dilemmaof placing patients in the surgical “minimal” orRTD category. Those soldiers are expected toreturn to the horrors and dangers of combat; mostmedical personnel are not subjected to similarrisk.

Treating and providingcare for wounded soldiers who are related orsomeone whom they know.

Maintaining appropriateinterpersonal relationships when everyone isunder extreme stress.

Knowing how to unwindduring lulls in the action without slipping intomisconduct stress behaviors.

Dealing with the boredomwhen patient activities come to a halt for longperiods of time.

(2) Combat stress control consult-ants’ recommendations for resolving or reducingthose stressors identified above include—

Establishing a sleep planand shift schedules.

Developing time-manage-ment skills.

Building team and unitcohesion.

Providing leisure time andrecreational activities, if possible.

Training on how to con-duct routine and special after action debriefingsor rap sessions (and to use shift changes construc-tively for these purposes).

(3) Remember, it is not only directpatient care givers who undergo extreme stress.Do not forget food service, laboratory, main-tenance, and administration personnel. Mortuaryaffairs personnel also require special support andconsideration.

(4) The NP/CSC consultants workclosely with MTFs’ and commands’ chaplains onthese issues that create stress in health careproviders and other medical personnel. Thechaplains also deserve help in dealing with theirown emotional responses. The CSC consultantsthemselves are not immune to stress and mustrely on each other and the chaplains to share thestrain. A plan for care of CSC personnel shouldbe in place. The plan should provide for assess-ment of the emotional well-being of the CSCconsultant. Use a rotating roster to assure thatthe mental health professionals are aware of thestatus of other team members.

(5) The consultant provides one-on-one or small group therapy when appropriate.

4-7. Consultation During Demobilizationand Homecoming

At the conclusion of the conflict, as militaryactivities phase down or as units or individualsrotate home, CSC personnel advise command onstress issues.

a. Scheduling Considerations. Theconsultant strongly recommends that some freetime be scheduled for all soldiers who are

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deploying home. During this time, these soldiersare provided the opportunity to talk about theirexperiences with their comrades or with otherswho experienced similar stressors.

(1) These times when soldiers dis-cuss experiences should be initiated days beforedeparture by air. If sea transport is used, thiscould be accomplished during travel.

Keep this time as free aspossible from mission duties.

Keep teams, squads, andplatoons together.

(2) Keep unit personnel togetherfor several days after reaching the home station.

Do not immediately grantblock leaves to the unit.

Maintain a half-day, light-duty schedule.

Grant soldiers liberal com-mander’s time, as needed, to resolve personalproblems.

(3) Appropriate memorial ceremo-nies and celebrations are recommended, both inthe TO before departure and at the home station.These events recognize and provide comfort tothose who have suffered. Such rituals give asense of closure. These events should—

Encourage grass rootsparticipation rather than being dictated fromabove.

Use or adapt traditionalceremonies.

b. Postcombat Debriefing. Combatstress control personnel will participate in formal

debriefings for leaders of small units, chaplains,and others, or for ad hoc collections of individualswith similar combat experiences. The CSC con-sultant may conduct or participate in such de-briefings for units or individuals at special risk,such as former prisoners of war (POW) or victimsof friendly fire. The debriefings for units orindividuals begin while they are still in the TO, iffeasible, and may continue soon after return toCONUS.

(1) The debriefings focus on thecommon experiences of war. These events mayinclude—

Traumatic experiences(death of buddies).

Morally conflicting issues(death of noncombatants).

Frustrations (rules ofengagement, errors of leadership, and perceivedfailures of support).

A feeling of loss at thebreaking of the bonds formed with the combatunit.

Delay in the rebondingwith home and family.

(2) The soldiers are forewarned ofthe normal, common symptoms which combatveterans experience on return to a peacetimeenvironment. Normal, common symptoms mayinclude—

Bad dreams.

Alerting reactions tostimuli or situations similar to those of combat.

A sense of being differentand alienated from others who have not beenthrough combat (including spouse and family).

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This can lead to social withdrawal and perhaps asense of letdown and boredom.

c. Reunion Briefings. Combat stresscontrol personnel, chaplains, and others givegroup briefings to all soldiers and units. Thebriefers forewarn of the common strains thatoften develop in relationships between spousesand their families during long separations.

(1) Soldiers are prepared for theways that their families, friends, and society mayhave changed since they were deployed. Specialattention may be needed to explore popular feel-ings about the war and how veterans can expectto be treated by civilians. If this is likely to benegative, ways to cope are illustrated.

(2) While troops are being de-briefed in the theater, similar debriefings shouldbe conducted with families in CONUS to preparethem for the returning soldiers.

(3) When feasible, unit families areincluded in the later home station debriefings.

d. Noncombat Debriefings. Similar de-briefing procedures are equally important follow-ing noncombat deployments such as 6-monthpeacekeeping rotations or prolonged training mis-sions. Issues discussed are different.

e. Continuing Debriefings. A continu-ing debriefing process may extend over weeks ormonths in some special cases. Follow-up de-briefings will be especially relevant when—

Reserve Component units aredemobilized after a prolonged period of activeduty.

Units are deactivated as aresult of reduction in force.

Large numbers of personnelare being considered for reduction in force. Suchmajor changes are in themselves highly stressfuland can lead to much inefficiency, distress, andlong-term problems unless the personnel are sup-ported and aided with coping skills and pro-cedures.

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CHAPTER 5

COMBAT STRESS CONTROL FOR RECONSTITUTION SUPPORT

5-1. Reconstitution Support

Reconstitution is extraordinary actions that com-manders plan and implement to restore units toa desired level of combat effectiveness commen-surate with mission requirements and availableresources. Besides normal support actions, recon-stitution may include—

Removing the unit from combat.

Assisting the unit with externalassets.

Reestablishing the chain of com-mand.

Training the unit for future opera-tions.

Reestablishing unit cohesion.

All CSC personnel should be thoroughly familiarwith FM 100-9. The following summarizes thedoctrine and elaborates on stress issues andmental health/CSC actions in support of unitreconstitution.

a. Reconstitution Process. Reconstitu-tion of units transcends normal day-to-day forcesustainment actions. It is defined as extra-ordinary actions that are planned andimplemented by commanders to restore units to adesired level of combat effectiveness commen-surate with mission requirements and availabilityof resources. Reconstitution is a total process.Its major elements are reorganization, asses-sment, and regeneration, in that order.

(1) Reorganization primarily in-volves a shifting of internal resources and isaccomplished as either immediate or deliberatereorganization.

(a) Immediate reorganizationis the quick and usually temporary restoring ofdegraded units to minimum levels of effec-tiveness. Normally, the commander implementsit in the combat position or as close to that site aspossible to meet near term needs.

(b) Deliberate reorganizationis done to restore a unit to the specified degree ofcombat effectiveness. Usually, more time andresources are available further to the rear.Procedures are similar to immediate reorgani-zation except that some personnel and weaponssystem replacement resources may be available,equipment repair is more intensive, and moreextensive cross-leveling is possible.

NOTE

When used in reorganization, cross-leveling involves the movement ofpersonnel and/or equipment betweenunits to achieve equalization. The pro-cess is accomplished while maintainingor restoring the combat effectivenessof the units involved.

(2) Assessment measures a unit’scapability to perform its mission. It occurs in twophases. The unit commander conducts the firstphase. He continually assesses his unit before,during, and after operations. If he determines itis no longer mission capable even after reorga-nization, he notifies his commander. Higherheadquarters either changes the mission of theunit to match its degraded capability or removesit from combat. External elements may also haveto assess the unit after it disengages. This is thesecond phase. These elements do a morethorough evaluation to determine regenerationneeds. They also consider the resources available.

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(3) Regeneration is required whenheavy losses of personnel and equipment leave aunit combat ineffective and unable to continueits mission. Regeneration has two variations:incremental regeneration or whole-unit re-generation (a and b, below, explain each).Regeneration involves rebuilding a unit throughlarge-scale replacement of personnel, equipment,supplies, and if required, internal reorganization;reestablishing or replacing essential C2; andconducting mission essential training for thereconstituted unit.

(a) Incremental regenerationis the massive infusion of individual personnelreplacements and single items of equipment intothe surviving unit elements.

(b) Whole-unit regenerationis the replacement of whole units, or definableSubelements such as squads, crews, and teams.

b. Authority for Reconstitution. Re-constitution decisions belong to the commander.The commander controlling assets to conduct aregeneration decides whether to use resources forthis purpose. The commander of the attrited unitdecides to reorganize when required. The unitcommander begins the reconstitution process.

c. Characteristic of Regeneration. Thedefining characteristic of regeneration, as dis-tinct from simple internal reorganization orconsolidation, is the massive infusion ofpersonnel, equipment, and assistance at thedirection of higher headquarters. The processbegins with an initial survey by a team sent bythe higher headquarters. This team determinesthe status and needs of the attrited and exhaustedunit as it moves to the regeneration site.

(l) Combat stress assessment ofunit personnel should be included in the initialevaluation. The supporting medical elementshould include CSC personnel (teams) as part oftheir initial regeneration support efforts to the

unit. Some of the key issues in estimating theCSC needs of the unit include—

Determining the percent-age and nature of casualties.

Looking at the duration ofoperations and environmental exposure.

Estimating the loss andcurrent effectiveness of leaders.

Evaluating attitudes, per-ceptions and level of confidence of unit survivors.

Evaluating the status ofnutrition and hydration.

(2) The scale of CSC involvementdepends on the size of the unit, the nature andextent of the attrition it has suffered, the locationof the reconstitution site, and the time andresources available.

(3) The S1/G1, S4/G4, and medicalstaffs also coordinate the dispatch of theregeneration task force teams. These teamsoccupy the reconstitution site before arrival ofthe exhausted unit. The reconstitution task forceguides each element of the arriving units into itsdesignated areas. The regeneration task forceprovides for the immediate needs of the survivors.This should include persona] gear, sleeping bags,and tentage to replace lost or damaged items.Assistance teams may include cooks, medicalteams, repair and maintenance teams forvehicles, and ordnance and special equipmentpersonnel. Medical teams provide sick callservices while organic medical personnel rest. Asrequired, CHS and other teams may include—

Combat stress control per-sonnel/team.

Preventive medicine team.

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Dental team.

Nuclear, biological, andchemical decontamination teams.

(2) Combat stress control recon-stitution support requirements for larger unitsthat are undergoing regeneration in the divisionrear, corps, or COMMZ will vary. Factors whichinfluence the requirements include—

Personnel service team.The size of the unit.

Combat service supportcontact teams.

Replacement personnel are sent to the re-constitution site, and when present, CSCpersonnel will assist with their assimilation intothe regenerated unit.

d. Scope of Combat Stress ControlInwolvernent in Reconstitution Support. The CSCreconstitution support mission ranges fromproviding assistance to small units close to thebattle that are undergoing reorganization toproviding assistance to large units involved inregeneration conducted far to the rear.

(1) Combat stress control recon-stitution support may not be available for smallunit-level elements such as a platoon undergoingimmediate reorganization. If CSC personnel aredeployed this far forward, the CSC reconstitutionsupport mission will merge into the consultationmission to units held in reserve. Ideally, a two orfour-person CSC team might deploy to a company-sized unit with the other maintenance andmedical teams. The CSC team assists thecommand with the deliberate reorganization ofsmall unit-level elements and facilitates after-action debriefings by and for all leaders in thecompany. The CSC team may conduct criticalevent debriefings if the unit has experienced anespecially traumatic (tragic, horrible) event. TheCSC team could also conduct critical eventdebriefing if the after-action debriefing showsother issues need to be resolved. The availabilityof the CSC team and the time to provide suchsupport will depend on mission priorities andcurrent work load.

Number of subunitswhich have suffered heavy casualties.

The extent of emotionaltrauma.

Time available.

Combat stress control personnel required tosupport regeneration is dependent on the abovefactors. A guideline is provided in Table 5-1.

e . Phases of Combat Stress ControlReconstitution Support. Reconstitution supportis divided into phases, based on the changing ofthe unit. The pattern is similar to that ofrestoration of an individual BF casualty. Therelative time and effort required for each phasevaries, depending on the recent experience ofthe unit. For example, physical/physiologicreplenishment may be extremely important insome situations and completely unnecessary inothers.

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NOTE

The following paragraphs pertain tothe phases of CSC support provided tocombat arms units which have beenengaged in heavy, continuous fighting.

5-2. Phase I: Preparation and Deploy-ment

a. Coordination. Coordination for de-ploying a CSC reconstitution support mission isaccomplished through the supporting medicalunit.

(1) The headquarters which ordersthe reconstitution effort must be aware of theimportance of CSC involvement in the task andof the availability of resources. The commandsurgeon is responsible for recommending whatCHS assets are committed for reconstitutionsupport. It is the responsibility of the CSCcommander or the psychiatrist to provideconsultation training to all command surgeons sothey are aware of the importance of includingCSC personnel in all reconstitution operations.

(2) The initial evaluation teamshould include a CSC member. Depending onthe size and location of the unit, this could be—

A brigade CSC teammember.

The division psychiatristor a mental health officer from the divisionmental health section or attached CSC elements.

A psychiatrist or a mentalhealth officer from the medical company, CSC orthe medical

social work

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detachment, CSC. -

An ASMB psychiatrist,officer, or NCO in the corps.

The medical group socialwork officer or psychologist,

The medical brigade orMEDCOM psychiatrist or social work officer.

(3) Movement orders for the eval-uation team and for the subsequent assistanceteam are generated and coordinated by the higherheadquarters (for example, the FSB, DISCOM[DMOC], or medical group headquarters). TheCSC elements move as part of a convoy with theother contact teams and CSS elements.

b. Familiarity with the Unit. Recon-stitution support works best when the attritedunit already has familiarity, trust, and confidencewith the CSC personnel (teams). Those CSCpersonnel need to be familiar with the unit, itshistory including recent experiences, equipment,mission, and key people. Ideallyj this includes atleast a few known, face-to-face POCs. If that isnot available, a positive reputation with strongendorsements from respected second partieshelps. The endorsement of the higher head-quarters is essential.

c. Unfamiliarity with the Unit. A CSCteam which deploys to a completely unfamiliarunit under these extreme stress conditions willbe at a disadvantage but can overcome it by—

Getting all the information itcan on the unit prior to arrival.

Coordinatingthe chain of command, chain ofmental health, and medicalchaplains to obtain information.

with and usingsupport, organicpersonnel and

Demonstrating competence(quickly), self-sufficiency, and helpfulness with-out appearing as if trying to step in and takeover.

FM 8-51

5-3. Phase II: Reduction of HumanPhysical/Physiologic and CognitiveStressors

a. Monitoring. The CSC team mon-itors the unit to assure that the following stepsare taken by unit leaders and the reconstitutionsupport elements. The CSC personnel ensure, asneeded, that the following aspects of recon-stitution treatment are being accomplished. Theyreport any short-falls to the reconstitution controlelement.

NOTE

The Sl/Gl and S4/G4 staff of supplyand services or quartermaster units isresponsible for providing the means forwarming or cooling, rehydrating,feeding, and sheltering. They are alsoresponsible for latrine and showerfacilities. These are not the respon-sibilities of CSC personnel or units.

(1) Treat environmental exposureimmediately by providing shelter, cooling,warming, and/or drying, as necessary.

(2) Push oral, palatable fluids im-mediately (cool or warm, depending on thetemperature) to correct probable dehydration.

(3) Provide plenty of good palat-able food, mostly carbohydrate but with someprotein, and as much as they want to eat. Thefood may be soups which simplify preparation andcombine feeding and fluid replacement. A-rationsare best. Tray-packs are acceptable but requirespecial effort. Heating tray-packs will improvetexture; providing optional condiments and spiceswill be a plus. Meals, ready-to eat (MREs) alsocan be used if efforts are made to heat them andadditional condiments are provided.

(4) Ensure leaders and troops aregiven a brief orientation on what they will bedoing and when it will happen.

(5) Provide hot showers rightaway, if feasible. If not feasible, the unit shouldbe provided time for sleep as soon as possible.

(6) Allow for sleep under the bestconditions possible for 8, 12, or 16 hours(depending on the degree of sleep debt and theamount of time available).

(a) It is best to sleep throughthe night and awaken in the morning to continuethe program, but in forward locations this maybe reversed (sleep in the day, awaken at night) tomaintain reverse cycle requirements.

(b) If possible, have otherunits provide perimeter security so that allmembers of the exhausted unit can sleep at thesame time.

(c) Unit leaders need thissleep most! The reconstitution support elementsprovide security and all necessary supportactions, while unit leaders are ordered to sleep sothey will not feel that they have to stay awake.

(d) If necessary, the CSCteam psychiatrist prescribes fast-acting medi-cations that are rapidly eliminated from the body.For example, diphenhydramine (Benadryl), orternazepam (Restoril) are given to those keypersonnel who do not relax and respond positivelyto strong suggestion or approval. Low dosediazepam (Valium) is permissible under somecircumstances but not preferred. Chlorpromazine(Thorazine) should not be used for this purpose.Before admimistering minor tranquilizers, theprescriber must ascertain if the soldier has ahistory of alcohol or drug abuse and specifically ifthe soldier is in recovery.

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b. Involvement of Combat StressControl Personnel During Physical/PhysiologicReplenishment. The importance of physical/physiologic measures should not be underesti-mated in the haste of the reconstitution efforts.Combat stress control elements through theiractions should encourage and facilitate theirspeedy delivery.

(1) Delay, loss, or nonavailabilityof equipment and materiels when and whereneeded may hamper the speedy delivery ofphysical/physiologic measures. If this happens,the CSC teams along with other medical supportand CSS teams must be prepared to step in andassist the attrited unit to improvise self-help.

(2) Combat stress control teamsfacilitate the means to boil water to heat tray-packs or MREs, to prepare hot soups, and toprovide hot water for shaving, sponge baths, orbucket showers. Personnel from the reconstitutedunit will provide most of the labor.

(3) Facilitating restorative sleepunder adverse conditions is more difficult becauseCSC units do not carry large volumes of sleepingbags, ground pads, cots, or tents. They canprovide disposable ear plugs (an effective way todampen distracting background noise) andcravats (to cover eyes against bright daylight).Disposable foil “space blankets” should be avail-able for use in cold or wet weather when bettershelter and bedding are not available.

(4) During the intensive physicalreplenishment phase, the CSC personnel willlearn as much as they can about the recent expe-riences of the involved unit and coordinate a planof action to meet the specific needs of the unitand its situation.

c. Continuing Physiologic Replenish-ment. After sleep, physiologic replenishmentcontinues.

(1) Unit personnel are awakenedfor a good, hot, high-protein breakfast (A-rationif possible; tray-pack is acceptable if well-heatedwhen served).

(2) Unit personnel work to restorehygiene (shower, shave, good latrine facilities,and clothing exchange) and take care of personalgear.

(3) Some CSC personnel assist byorganizing self-help activities involving the troopsas the unit’s leaders concentrate on the debriefingprocess. These CSC personnel continue to gatherdata by—

Observation.

Structured interviewswith individuals or small groups.

Short, easily scored ques-tionnaires.

5-4. Phase III: After-Action Debriefing

a. Small Team and Subunit After-Action Debriefing. Surviving unit leaders beginthe after-action debriefing process during lulls inthe battle or as soon as the mission or timepermits. In some instances, the after-actiondebriefings may not be accomplished until theunit reaches a reconstitution site. Standard after-action debriefings as described in FM 22-51 willbe conducted by all unit elements to obtain a clearand accurate assessment of what really happened.After-action debriefing will be conducted by theleaders of teams, crews, squads, sections, andplatoons within the company. If the originalleader was replaced, the new leader will conductthe after-action debriefing. Attached personnel,such as medics, forward observers, engineers, orartillery fire support team, are included in theunit after-action debriefings.

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b. Ascending Levels of Leader After-Action Debriefing. Once the subunit debriefingsare completed, the company commander conductshis after-action debriefing for the subordinateleaders. Subsequent debriefings are held atbattalion, brigade, and even division levels inlarge scale reconstitution efforts. The unit’sTSOPs will identify who attends the after-actiondebriefing at a particular level. For example, atthe company level, all the leaders in the companywill attend the company commander’s after-actiondebriefing. The battalion commander’s after-action debriefing will involve all company com-manders, first sergeants, key battalion staff,sergeants major and may be key NCOs within thebattalion. Regardless of what level the leaderattends, he brings his unit’s/subunit’s consensus(reconstruction) of what really happened. Also,he is prepared to brief about the emotionalreactions of his personnel to the events thatoccurred. The participating leaders share theirinformation along the succeeding time-line of thelarger operation. The senior commander, NCO,and key staff personnel contribute their input tothe reconstruction of the event. As in the AAR,the after-action debriefing identifies operationallessons learned. In addition, the after-actiondebriefing shares, acknowledges, and normalizesthe feeling raised by the event. It also enhancesvertical and horizontal bonding of personnelwhich is the essential framework of unit cohesion.The senior leaders then take the group’sconsensus (reconstruction) on to the next higherlevel of leader debriefing. The process of after-action debriefings from the bottom up has thefollowing advantages:

Each level can reconstructthe most accurate picture possible of what ac-tually happened. They build upon the alreadyclarified memories and observations of eachsubunit.

Misconceptions, misunderstand-ings, and unrealistic expectations are likely to be

clarified. The right lessons are more likely to belearned.

The junior leaders can com-municate their clearer understanding of thelarger picture back down to their subordinates.

It provides transition work-shops for new leaders if the unit has suffered aloss of key leaders and staff. If a new commanderis required, this type of workshop facilitates hisassumption of command.

c. Large Group Debriefings. At eachlevel, it may be possible for soldiers and juniorleaders to listen to the next higher level of leaderdebriefing(s). This, in effect, constitutes a largegroup briefing. Large group debriefings involvelower echelon personnel. However, large groupdebriefings can only be conducted at a relativelysafe site. There must be adequate time to conductthe debriefing. The large group debriefings arenot conducted if personnel are involved withequipment repair, reissue, and other recuperativeactivities. The large group debriefing maximizesthe sharing of common experiences and theextension of unit cohesion.

d. Attached Support Personnel (Spe-cialty Branch) Debriefings. Attached personnelwill participate in the after-action debriefingprocess with the unit to whom they are attached.They contribute their own perspectives on theevent in concert with other attached supportpersonnel. Later, if METT-T at the reconstitutionsite allows, these support personnel should bedrawn together by their parent units to debrief.The objectives of this specialty debriefings is toderive lessons learned and to express andnormalize the intense emotions involved. Unlikethe small unit or leader after-action debriefings,the specialty debriefings will usually not bereconstructing the overall event on a commontime line. Rather, they share their different

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experiences of practicing their common specialtyin different situations.

e. Facilitators in After-Action De-briefings. When a unit has suffered especiallydistressing or traumatic events, the commandershould request trained facilitators to assist withthe debriefing process. These facilitators shouldbe present with the unit through all levels of theafter-action debriefing process. The higher head-quarters of the unit that has experienced atraumatic event should request debriefingfacilitators and assure that they are available atthe scheduled time and place. Certain situationsare best handled by trained facilitators. Thesesituations may include—

Teams or units whose keyleaders were casualties or were replaced and nownew leaders are conducting the debriefing.

Serious friendly fire incidentsor other disastrous mistakes.

(1) It is essential that the facil-itators be perceived as impartial, friends ofthe units, trustworthy, and privileged to main-tain confidentiality about what is shared inthe debriefing. They must not be perceived asinvestigators or “spies” from the higherheadquarters, inspector generals, or criminalinvestigators.

(2) The facilitators should havereceived formal instruction in critical eventdebriefings. Ideally, they will have participatedin or led prior critical event debriefings.

(3) The trained facilitator can befrom the CSC or mental health team. He may bean officer or NCO of any professional or para-professional discipline. Line unit officer or NCOs(peer debriefers) who have had critical eventdebriefing training can also be effectivefacilitators.

(4) The trained facilitator assiststhe after-action debriefing process by—

Helping the debriefingleaders assure the ground rules are clearly statedand understood by all personnel.

Asking questions to get aclear picture of what actually happened—when,where, how, and to whom.

Assuring that the com-plete time line is filled in, extending from beforethe critical incidents all the way through to theaftermath.

Assuring the processstays constructive and does not turn destructive.

Ensuring the groundrules are followed, military bearing and respectmaintained, and verbal attacks or scapegoatingnot permitted.

Assisting with the valida-tion and normalization of feelings, such as fear,guilt, and grief, as they come out by providingthe broader or expert perspective.

Monitoring the partici-pants for signs of serious distress and/ordetachment or psychological withdrawal from thegroup.

Encouraging those sol-diers with signs of serious distress to workthrough the distress or withdrawal during thedebriefing.

Checking with those indi-viduals one-on-one after the debriefing.

Providing group with in-formation about what assistance is available tohelp them with working out their distress.

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Advising the unit andleadership about whether a follow-up formalcritical event debriefing would be worthwhile.

NOTE

Often, a well-facilitated, after-actiondebriefing will make a formal criticalevent debriefing unnecessary.

b. Conducting Critical Event Debriefi-ings. Information obtained by after-actiondebriefings or from the higher headquarterspertaining to the traumatic event is provided toCSC personnel. This information is used todetermine which subunits need more directinvolvement. Critical event debriefings are thenscheduled (with the approval of the leaders thatwere involved) with those units/subunits where ahighly disruptive or traumatic event occurred.Combat stress control personnel will conduct thecritical event debriefing or will advise (previouslytrained) unit chaplains and medical participantson how to conduct the critical event debriefings.

(1) The need for critical event de-briefings is indicated by—

Evident distress of manyparticipants.

A consensus of the par-ticipants at the after-action debriefing that theywant to talk more about the event.

Evident reluctance of unitmembers to talk through the event in the after-action debriefing under their own leadership.

The expressed wished fora consolidated or combined debriefing, bringingthe unit together with representatives of otherinvolved units, such as the survivors of a friendlyfire incident with the perpetrators.

NOTE

At least one trained and experiencedcritical event debriefing facilitatorshould be included in critical eventdebriefings.

(2) The techniques of a criticalevent debriefing are similar to those of after-action debriefings but are more dependent on theskills and experience of the facilitator. Thefacilitator must be able to recognize and interveneto help those in serious distress.

5-5. Phase IV. Rebuilding Unit Cohesion

a. Assisting Units to Rebuild Cohesion.Combat stress control personnel advise thecommanders and staff on planning the reas-signment of surviving unit members and theassignments of replacements. This advice isbased on the results of the leader-leveldebriefings. AG information, and any otherpertinent observation/data collected by the CSCteam. The objectives of this process are tomaximize remaining unit cohesion and promotenew bonding. Some of the techniques andprinciples that may be employed to maintainenhance unit cohesion during the redistributionand replacement process include—

Keeping a new/replacementbuddy pair, crew, or small team together andassigning all members to the same platoon orsection of the attrited unit. Depending on thespecific circumstances, new/replacement per-sonnel may not be kept together. They may bedispersed among small closely-knitted groups ofveterans.

Assigning veteran soldiers fromother attrited units or sections so that level ofexpertise is not lost. These personnel should also

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be transferred as crews or teams, or at least asbuddy pairs.

b. Small Unit Leaders and VeteransIntegrate New Replacements. Small unit leadersactively integrate all new soldiers while CSCpersonnel, unit ministry teams, or medical platoonmembers monitor and provide feedback. Newreplacements are introduced throughout the unit.Group discussions are conducted for—

Combinations of older veteransreassigned from other parts of the unit.

Newer veterans returning toduty from medical channels.

Replacements from rear areajobs in corps and COMMZ.

Replacements fresh fromCONUS.

In these group sessions, the story of the recentaction, as clarified in the after-action debriefing,are discussed. Feedback to the small unit leadersfrom, CSC personnel pertaining to the processshould include—

Identifying potential problemsand recommending solutions.

Recommending additional meet-ings with CSC personnel for further ventilation,discussion, or work group sessions.

Recommending individual orgroup training on combat stress, stress man-agement, relaxation techniques, and BF.

Recommending unit leaders,assisted by chaplains, conduct memorial servicesfor the unit’s dead.

c. AssistingBattle Fatigue. Small

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Individual Soldiers withunit leaders may identify

BF soldiers as a result of unit after-actiondebriefings. When soldiers are provided the op-portunity to talk about what has really happenedto them, they may exhibit true signs of BF. Thismay be apparent as one observes their reactions,interactions, and behaviors during the debriefingprocess. Battle fatigue cases may be identified bytheir leaders or buddies, by self-referral, or bythe CSC staff observations. When these soldiersare identified as having BF, begin treatment.without flagging them as patients.

(1) Since the unit is in a stand-down position. CSC personnel can initiatetreatment quickly. They will determine theseverity of the BF and initiate rest, light duty, orother appropriate activities.

(2) Those BF cases that tempo-rarily require continuous medical observationmay be rested and watched by the treatment team(part of the reconstitution support package) or atthe BAS after its personnel have the opportunityto rest.

(3) A few of these BF cases mayrequire evacuation, but only to the next rearwardechelon.

5-6. Phase V: Performing Final CombatStress Control Requirements forReconstitution Support

a. Phase V. Phase V begins after thenewly reconstituted unit has had additional sleep,food, and opportunities for hygiene. Unitpersonnel, during this phase, are working activelywith each other and with the reconstitutionsupport teams to prepare the unit for return tocombat.

b. Unit Cohesion. Combat stress con-trol personnel monitor the ongoing work activitiesto ensure that unit cohesion is being built and

FM 8-51

that veterans are accepting and teaching the newreplacements. Questionnaire-type surveys maybe administered to collect comprehensive data.Combat stress control personnel continue toadvise unit leaders and facilitate further groupwork sessions and transition workshops. Notethat the word is facilitate, not lead or direct.

c. Building Unit Confidence. Thesuccessful completion of military training, suchas crew drills, squad and platoon tactics, and fieldtraining exercises (FTXs), will assist in buildingunit cohesion and confidence. Depending on thelocation and time available, CSC personnel mayhelp commanders organize recreational activitiesand/or sports competitions. Sporting activities

can provide confidence-building and stress-reducing physical exercise. They are scheduledin ways which maximize the development offamiliarity and cohesive bonds within andbetween the recently reassembled unit.

d. Closing Out Reconstitution Support.It is essential that the reconstitution supportteam close out (officially end) its role with eachunit in the formal reconstitution process. Thereconstituted units are left with positiveexpectations that the unit and its individualsoldiers will be able to perform their mission anddo well on their own. Ideally, the same CSCpersonnel (team) will continue to provide CSCsupport when the unit returns to combat.

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CHAPTER 6

COMBAT NEUROPSYCHIATRIC TRIAGE

6-1. Triage

a. Definition and Comparison. CombatNP triage is the sorting of BF, NP and substanceabuse cases (including those with physical injury)based on how far forward they can be managedand treated to maximize rapid RTD. Combat NPtriage derives from the proven combat psychiatryprinciples of PIES (Proximity to the unit; Im-mediacy in initiating treatment for all cases;expressed Expectancy of providing rapid and fullrecovery; and Simplicity by using simple andshort treatment methods. )

(1) Combat NP triage is fundamen-tally different from surgical triage. Surgicaltriage divides cases into the categories of Im-mediate, Minimal, Delayed, or Expectant basedon how soon, if at all, they will go to surgery.The Immediate cases go to surgery immediatelybecause any delay is likely to result in death orpermanent disability, such as loss of a limb. Mini-mal cases do not require surgery and can RTDwith a minimal investment of time and effort. Insurgical triage, stress and psychiatric casualtieswould all be categorized as Minimal because theynever go to surgery. Delayed cases can wait forsurgery without suffering increased risk of per-manent harm. Expectant cases are not expectedto survive, given the amount or type of treatmentthat is available to give them, so they do not go tosurgery at all.

(2) With BF, however, there is asignificant increased risk of lifelong psychiatricdisability from prolonged delay of treatment, justas there is a risk of physical disability from delayof medical-surgical treatment. Most cases areexpected to recover and RTD with prompt andcorrect treatment, no matter how disabling theirsymptoms appear. For these reasons, triage offi-cers need to be taught that stress and psychiatriccasualties need to be referred for treatment assoon as possible. It should always be remembered

that a small number of NP cases may haveweapons and be so potentially dangerous thatthey deserve the highest priority for manage-ment regardless of the type of triage being con-ducted.

(3) In combat NP triage, diagnosticknowledge, experience, and sound judgment areimportant at the front end of the process and atthe most forward feasible echelon. Interviewingskills are essential if potentially critical mentalsymptoms, such as paranoid or suicidal ideationand thought disorders, are to be identified. Thosesymptoms bear directly on safe management. Insuch cases, diagnosis itself is deliberately de-ferred. The decision on where to send the case isdetermined on whether the case can be managedsafely for hours to days with simple treatment atthe forward echelon. If manageable, they remainwith the forward echelon. If they are unman-ageable, they are sent rearward only one echelonwhere the decision process is repeated.

b. Combat Neuropsychiatric TriageCategories. Combat NP triage involves the sort-ing of cases into categories based on where theycan be treated. There are four combat NP triagecategories. The four categories

DUTY cases.

REST cases.

HOLD cases.

are—

REFER cases.

(1) DUTY cases return to theiroriginal small unit, either for full duty or for lightduty with extra rest and replenishment. Thisoption depends on the small unit’s mission, re-sources, and the soldier’s symptoms. The triagermust, therefore, be familiar with the unit’s situa-tion and take that into account.

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NOTE emergency treatment of the potential emergencymust be available at this medical echelon.

Maneuver units positioned in forwardareas must have only personnel whoare fit for full duty. Limited or lightduty is nonexistent in these units. IfBF cases are sent forward to theseunits, they must be able to perform fullduties for their own safety and thesafety of the unit.

(2) REST cases are not return im-mediately to the small unit because the unit can-not provide an adequate environment for rest.REST cases need brief respite, physical replenish-ment, and less demanding duties for hours to daysat a less dangerous or better-resourced setting.These cases do not require close medical or mentalhealth observation or full-time treatment. Therespite and replenishment can be provided in anonmedical CSS element which supports theiroriginal unit. This option, too, depends on theresources and mission of the available CSS unitsas well as on the soldier’s symptoms. Someone inthe receiving unit must take responsibility for en-suring the soldier is fed, rested, performing someuseful work, and kept accounted for. There mustbe a reliable transportation link to return the sol-dier to his original unit after a day or two of rest.

(3) HOLD cases are those who dorequire close medical observation and evaluationbecause either—

Their symptoms are po-tentially too disruptive or burdensome for anyavailable CSS unit or element.

Their symptoms could becaused by a medical, surgical, or NP conditionwhich could suddenly turn worse and requireemergency treatment.

In addition, the resources to provide the necessarymedical observation and adequate stabilization or

(4) REFER cases present problemssimilar to the HOLD cases, but—

REFER cases are too dis-ruptive and burdensome for this medical echelon,given its mission and resources.

This echelon cannot pro-vide the acceptable level of diagnostic and treat-ment capability if an emergency occurs.

c. Distinguishing Categories by Signsand Symptoms. It should be obvious that thefour combat NP triage categories are not sharplydistinguishable based on the signs and symptomsof the case.

(1) The boundaries of each categoryare influenced as much or more by the changingtactical situation and the resources available asby the symptoms. The category may changeautomatically with time or as the case movesthrough the system. For example, REFER auto-matically becomes HOLD when the cases reachthe echelon which can manage and treat them.

(2) This flexibility is entirely inkeeping with the intent of the labeling system forBF soldiers. The intent is to avoid giving BFsoldiers a psychiatric label that sticks with themfor life. It is also in keeping with the highlychangeable nature of BF symptoms. Battle fa-tigue symptoms tend to become fixed when inap-propriately labeled and mistreated.

(3) Like the triage categories insurgical triage, the categories in combat NP triageare brevity codes. Each brevity codes (labels) sum-marizes in one word where the case should be man-aged and what treatment should be received inthe immediate short term given the current situa-tion. It has no other meaning and only transitoryrelevance. Figure 6-1 provides a decision tree orflow diagram for sorting in combat NP triage.

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6-2. Considerations

a. Importance of Expertise of Medicaland Mental Health Personnel. As noted above,making the diagnosis of specific psychiatric dis-orders is officially deferred when managing BF.However, the medical and mental health per-sonnel must be alert to the fact that many physi-cal or psychiatric illnesses may resemble BF, yetrequire specific and even emergency treatment.It may be a matter of life or death to correctlymake those diagnoses early. In more severe casesof BF, there is increased difficulty in recognizingsuch illnesses, and the expertise of medical per-sonnel is particularly important. Either the psy-chiatrist or the clinical psychologist should makediagnostic evaluations if the present of an NPdisorder is suspected or must be differentiallydiagnosed.

(1) Physical screening. All REFERand HOLD cases deserve an adequate review ofbody systems and a quick physical examination.The examination includes vital signs, head/eyes/ears/nose/throat. chest, abdomen, and extremi-ties with simple testing of reflexes and musclestrength. Negative or normal findings need to bedocumented on the FMC or according to AR 40-66.Any positive findings from the physical examina-tion should, of course, be evaluated further. Ifthe examiner has not checked various body sys-tems, it is not reassuring to tell a soldier that hisphysical or mental complaints are “only BF."DUTY and REST cases should also get this briefexamination when time and setting allow.

NOTE

Previous observations in FTXs suggestthat the physical examination is oftenneglected for cases who have beenlabeled stress, BF, or psychiatric. Thisundermines the credibility of the BFdiagnosis and must not be allowed.

(2) Neuropsychiatric screening.Problem cases will require examination by a phy-sician with NP training. This expertise must beavailable no further to the rear than the DSA(AR 40-216), and whenever feasible, should beavailable at the BSA.

(a) All physicians and phy-sician assistants must be able to perform anddocument neurological screening and mentalstatus examinations in order to identify problemcases.

(b) The other mental healthdisciplines must also be trained to perform a basicphysical screening examination. These personnelinclude clinical psychologists, social work officers,occupational therapists, and appropriate enlistedpersonnel.

(3) Considerations during physicalscreening. While a brief physical examination isessential, the clinician must resist the tempta-tion to order tests or procedures that do notdirectly influence case management, Do not, forexample, draw lines on the soldier’s skin to docu-ment where the changes in sensation occur. Suchlines, and medical tests in general, tend to vali-date and fix the symptoms in the mind of thepatient. Needless tests may delay RTD and pro-vide a distinct incentive to remain incapacitatedbecause of secondary gains, especially if there isa chance of evacuation to a safer, more comfort-able area.

(4) Treatment considerations (overtlyand covertly). The work-up therefore should belimited to those essential steps which ensurethe medical safety of the soldier and determinewhether he can—

Return to his unit.

Return to another unit forrest.

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Receive treatment at thismedical facility.

Be evacuated to the nextrearward echelon.

If no threat to life or permanent function isinvolved, it is often best to treat overtly for BFwhile monitoring covertly and providing generaltreatment for the other possibilities.

(5) Restoring confidence after tem-porary disability. As BF is often caused by acombination of mental, physical, and physiologicstressors, there is no need to try to force thesoldier to accept emotional rather than physicalexplanations for his inability to function well.Many soldiers find it easier to recover confidenceif they can believe that most of their problemsresulted from physical overload. The term BFdeliberately covers both sets of causes.

(6) Ruling out serious medical/surgical causes. If soldiers who are believed onlyto have BF must be evacuated to a hospital fordiagnostic tests to rule out worse possibilities,they should be told specifically that this is just aprecaution. They should be seen immediately onarrival by the hospital psychiatrist and scheduledfor the tests as soon as possible. The Principle ofImmediacy requires that expedient treatment beprovided. Such BF cases are not routine casesand should have priority just below that of sol-diers with life- and limb-threatening physicaldiagnoses. Remember, BF soldiers can sufferlifelong psychological disability as a consequenceof delay.

b. Importance of Recognizing PhysicalConditions. Paragraph 6-3 lists some of the physi-cal conditions which should be kept in mind inthe differential diagnoses of BF. Some of theseconditions may exist concurrently and be a con-tributing cause to the BF, but require specificadditional treatment.

6-3. Differential Diagnostic Problems

a. Low-Grade Environmental or Stress-Related Illnesses. Low-grade environmental orstress-related illnesses drain the soldiers’ strengthand confidence. Chronic diarrhea and slight feverfrom subclinical malaria or a virus may exhaust,demoralize, and contribute to BF among soldiers.These conditions should be treated medically,concurrently with the physical replenishment,rest, reassurance and organized activities whichrestore the soldier’s confidence. If they persist inspite of rest and symptomatic treatment, a moreaggressive workup and treatment is indicated.

b. Dehydration. Dehydration deservesspecial mention because it can be very subtle.Soldiers under battlefield or heavy workconditions become extremely dehydrated withoutfeeling thirsty. This is especially likely inmission-oriented protective posture (MOPP) and/or arctic gear. In both conditions, it is mechani-cally dificult to drink. An insufficient circulationof thick, dehydrated blood is less able to carryoxygen to the brain and muscles. This can resultin instant BF.

c. Hyperthermia. Hyperthermia (over-heating) in an otherwise healthy individual oftenfirst causes mild elation and excessive energy.This may be followed by irritability, disorienta-tion, and confusion. When core body temperaturereaches 105° to 106ºF, the soldier may becomebelligerent, combative, and have visual hallucina-tions. If brain temperature rises further, thesoldier collapses and convulses in heatstroke.These soldiers may require restraints and mustbe cooled as rapidly as possible. In hot climates,hyperthermia is expected, but it can occur inchemical protective gear (MOPP), cold weatherclothing, or during heavy physical work even intemperate and cold climates. As these examplesillustrate, hyperthermia is caused by a mismatchbetween environment, activity, clothing, andshelter.

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d. Hypothermia. Hypothermia maycause an individual to become disoriented whencore body temperature falls below 94°F. Theperson may move and speak slowly. His skinlooks and feels warm, leading him to take offclothing. He may even resemble a zombie. Hypo-thermia is as likely in cool, or even warm (night-time), wet climates as it is in extremely cold ones.It is also caused by a mismatch between environ-ment, activity, and clothing or shelter. Heat mustbe provided to the hypothermic soldier to preventdeath. If the soldier is extremely hypothermic,care must be taken to avoid cardiac arrhythmiaduring rewarming.

NOTE

A simple rule of thumb is: If the soldieris overheated, help him cool off. Ifthere is any possibility he is cold orhypothermic, warm him up. Have himdrink cool or warm liquids suitable forthe condition since he is probably dehy-drated.

e. Overuse Syndromes. Overuse ofmuscles, joints, and bones that have not beenprepared for the strain of field duties can lead topersisting stiffness, pain, swelling, and orthopedicinjuries. If severe, these injuries may requireevacuation to a hospital for evaluation by anorthopedic surgeon, an occupational therapist, ora physical therapist. Even if these injuries areavoided, the unfit person who overexerts havedays of stiffness, aching, and weakness. Duringthis time, such cases are likely to have BF iffurther demands are made on them. Physicalfitness exercises are a regular part of the treat-ment of BF. For these cases, the exercises shouldfirst be limited to warm-up and stretching-typecalisthenics.

f. Rhabdomyolysi.s. Rhabdomyolysis isone potentially dangerous complication of severe

muscle overuse (and of heatstroke or crush inju-ries) in which myoglobin from damaged musclecells injures the kidneys. This can cause acuterenal failure and death, or chronic renal insuffi-ciency. A warning sign is dark (tea-colored) urine,but without laboratory testing, this is not easilydistinguished from the concentrated urine of de-hydration. Cases with significant rhabdomyolysisshould be evacuated immediately to a hospital. Ifkidney failure develops, they should be evacuatedto CONUS.

g. Head Trauma. Concussion maystun the individual and cause amnesia, residualconfusion, and perhaps impulsive behavior. Forany case of suspected head trauma and for anycase of significant memory loss (especially for adiscrete period of time), check scalp, eyes, ears,nose, cranial nerve signs, and vital signs forevidence of head injury. Negative as well as anypositive signs are recorded. The main concernsare—

(1) Epidural hematoma (a blood clotforming between the skull and the toughmembrane that covers the brain). This is usuallydue to arterial bleeding, with onset of symptomsof increased intracranial pressure within minutesto a few hours. It can progress rapidly to comaand respiratory arrest.

(2) Subdural hematoma (a bloodclot forming between that tough membrane andthe brain itself). This is usually venous bleedingwith slower onset and progression but can lead tocoma and death.

(3) Intracranial pressure witheither epidural or subdural hematomas whichmay become life threatening. If one pupil be-comes larger than the other, there is little timeleft to evacuate the soldier to a hospital. Hyper-ventilating the soldier can buy time by decreasingblood flood to the brain and temporarily reducingintracranial pressure. An organic or attached

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surgical squad may drill burr holes to relieveintracranial pressure. When a surgical squad isnot present, these patients are evacuated to thesupporting hospital by the most expedient meansavailable.

(4) If a head injury is suspected,continue to monitor mental status and vitalsigns periodically, especially respiration eventhough physical findings are negative. Continuous

monitoring would be appropriate if there areserious concerns about the risk. In addition, thesoldier is awakened every hour to check andrecord state of consciousness according to theGlasgow Scale (Table 6-l). A11ow sufficient timeafter awakening for the soldier to recover fromthe normal sleep inertia (grogginess onawakening). This precaution will only slightlydecrease the restorative quality of the sleep whichcan be made up by letting the soldier sleep longer.

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(5) Skull x-rays are unlikely toshow evidence of intracranial hematoma in youngadults. They may confirm a fracture of the skull,but such a fracture would be highly unlikely insomeone who shows no bruises or other signs of ahard blow to the head. If there is significantevidence of a severe blow, with or without skullfracture, patients are evacuated to a hospital withneurosurgical capabilities.

NOTE

A problem with evacuation to a corpshospital is that soldiers are counted asa loss to their units. The personnelreplacement system counts soldiers asa loss to their units as soon as theycross the division/corps boundary.

The system does not provide for returning soldiersto their old division, let alone their own platoon,unless such a return is individually coordinatedaccording to the TSOP. If returned to combat ina strange unit, recovered BF or concussion cases,like all other soldiers, will for a time be at highrisk for BF or injury. After intracranial hemor-rhage has been ruled out at the hospital, trans-ferring the soldier briefly to the CSC recondi-tioning center (see Chapter 9) may facilitate moreselective RTD.

h. Spinal Cord Trauma. Pressure,bruising, and hematomas of the spinal cord, aswell as severing of the spinal cord, can causespinal shock, with loss of sensory and/or motorfunctions below the level of the injury in theaffected dermatome and muscle group patterns.The loss of function may be bilateral, unilateral,or partial. These cases could be confused withparalysis or sensory-loss forms of BF. Furthermanipulation of a fractured spine can worsen ormake permanent the spinal cord damage. In-formation from the history of onset, a cautious

physical and neurologic examination, or completerelief of symptoms following hypnosis or strongpositive suggestions could demonstrate convinc-ingly that this is only BF. It is best to be cautiousand keep the spine immobile during care andtransportation. Send the soldier to where ade-quate X rays can be done while still expressingoptimism that this may be only temporary BF orspinal bruising.

i. Postconcussion. Postconcussion syn-dromes may persist weeks to months beyond theperiod of acute concussion. Postconcussion syn-dromes may include perceptual or cognitive im-pairment, poor impulse control, and difficulty inplanning ahead. These are often accompanied bycranial nerve deficits or soft neurological signs.If severe and documented by examination or neuro-psychological testing, this could weigh againstrapid RTD. It may necessitate recommendingreclassification and retraining to another duty.

NOTE

Like a concussion case, it is importantto return cases who prove to have onlyBF to their original units if recovery atthe CSC reconditioning center is rapid.

j. Abdominal Trauma. Rupturedspleen or other intraperitoneal bleeding maycause shock. The soldier may arrive in a fetalposition and be unresponsive but with reflex“guarding” due to peritonitis. A case such as thiswas misdiagnosed as “catatonia” and sent to anIsraeli mental health team in Lebanon as one ofover twenty stress cases in a true mass casualtysituation. The team checked the vital signs andcorrectly returned the soldier for emergencysurgery.

k. Air Emboli and Focal Brain Isch-emia. High blast overpressures from an incoming

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high explosive ordnance can produce air emboli(bubbles in the blood) and focal brain ischemia(small areas in the brain which cannot get oxygenbecause the blood flow has been interrupted).Nuclear explosions can do this, as can high explo-sives when shock waves are magnified by reflec-tion within bunkers, buildings, and trenches. Afew cases die within seconds, perhaps with noother sign of injury, although ruptured eardrums,general trauma, and evidence of pulmonarydamage should be detectable. More cases maysurvive but have stroke symptoms which couldrun the full range from loss of muscle strengthand/or loss of sensation in parts of the body (hemi-paresis, hemianesthesia) to mild or major speechdisturbances, depending on the size, number, andlocation of bubbles that are lodged in the body.

(1) Some air emboli may leaveareas of permanent brain cell destruction and dis-ability. Other smaller ones may allow consider-able or complete recovery of functions in minutesto weeks. This occurs if collateral circulationkeeps the cells alive until the bubbles resorb or ifneighboring areas of the brain relearn the func-tion. However, even in those who have full andrapid recovery of brain functions, the symptomsmay persist as the pure loss-of-functions type ofBF. This would be because the soldier’s extremeanxiety and internal conflict have been uncon-sciously relieved by his honorable status as apatient.

(2) Specific treatment, if air emboliare suspected from the history of onset and physi-cal findings, is to assure the best feasible oxygen-ation of the brain.

l. Laser Eye Injury. Today’s laserrange finders/target designators cause smallburns on the retina if they shine directly into theeye, even at great distances and especially ifviewed through optics. The fact that lasers travelsilently at the speed of light along a line of sightadds new urgency to the saying, "If you can be

seen, you can be hit.” However, the second partof the saying, “If you can be hit, you can be killed,”is not so true. The flashes of light the personsees may even warn him to take action to evadethe missile or bullet that may follow. However,after laser eye injury has happened to severalleaders or gunners in a unit or as rumors of itspread, other soldiers who must view the enemymay find their own vision failing for purely psy-chological reasons. Vision is one of mankind’sprimary means of relating to the world; it is usedby those who have it in performing most tasks.Vision is also the medium for many pleasures.Fear of major degradation of visual acuity andespecially total blindness is, therefore, an un-usually strong fear. In the imagination of somesoldiers, especially those whose careers, activities,and self-image depend on vision, blindness mayrank high as a crippling wound which makes aperson helpless and an object of pity.

(1) If the laser beam causes a smallretinal blood vessel to bleed inside the eyeball,the person will see red. If blood inside the eye isconfirmed on examination, these soldiers shouldbe evacuated to a hospital with verbal reassur-ance that they may RTD soon. If the soldier isseeing red but no blood is confirmed on ophthal-moscopic examination, treat as BF.

(2) If the laser does not hit a bloodvessel, the soldier may see only flashes of light,followed quickly by some painless loss of vision.If the damage is peripheral vision, the soldier maynever know it. However, if he was looking exactlyat the laser source, there will be major loss ofvisual clarity with no pain. These symptoms mayresemble visual forms of BF.

(3) With simple retinal burns, mostof the visual symptoms are due to the swellingaround the very tiny burns. Much of the visionmay recover within hours to days with rest, re-assurance, and nonspecific treatment, the sameas for BF. The only permanent result may be a

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constellation of small black dots in the soldier’svisual field or a peripheral visual field defect ofwhich the soldier is unaware.

(4) Treatment following a sus-pected laser injury is extremely important, Calm,professional treatment at each echelon of medicalcare is mandatory. Assurance that the injury isnot life threatening and that chances for some, ifnot total, recovery is good. The potential psychol-ogical effects of lasers could be enormous. It isimperative that secondary gain for these patientbe minimized. This is accomplished by promptRTD of those individuals with temporary flash-blindness, noncritical (nonfoveal) burns of theretina without hemorrhage, and those who areexperiencing purely psychogenic visual loss. Ifan error is to be made, it should be to RTDquestionable injuries, provided the risks areminimal for further injury or accident. Medicalmanagement of stress reactions for patientssuffering from real or imagined laser injuries islike stress management of other injuries. Repeatthe reassurance that symptoms will improve withrest, nutrition, hygiene, and the expectation ofan early return to the soldier’s unit.

(5) Future development of lasersas deliberate antipersonnel weapons may producemore pain and permanent effects. A high-energylaser weapon could cause the unprotected eye toboil and burst. It could cause burns to exposedskin and set clothes on fire. This would be aconsiderably more fearsome weapon, althoughone which makes differential diagnosis of realfrom psychogenic injury much easier. If theseare encountered as a surprise, without adequatepreparation and training of the troops, the psy-chological impact will be magnified. That mayproduce more cases of BF, some with visualsymptoms. Laser-protective eyewear has beenfielded; getting soldiers to wear it is an importantissue for command and NCO emphasis.

(6) For more information on thethreat of laser to the eye, see FM 8-50.

m. Middle Ear Injuries/Diseases. Tem-porary’ loss of hearing can be caused by adecreased acoustic sensitivity following a briefextremely intense noise (explosive) or less intense,longer duration noise. Tinnitus (ringing in theears) can also result from acoustic nerve damageor irritation as well as from high doses of drugs,such as aspirin. Hearing loss or perceiving noisesin the ears can also be BF symptoms. Cumula-tively, loud noise causes permanent damage tothe cochlea, resulting in hearing loss especiallyfor the higher frequencies. This is why routineuse of earplugs and ear covers in noisy situationsis so important for many (if not all) militaryoccupations. However, there are other combatsituations where acute hearing is essential andearplugs cannot be worn. Distinguishing physio-logic from psychogenic hearing loss may requirethat the patient be evaluated by an otolaryn-gologist (ear, nose and throat specialist).

n. Peripheral Neuropathies. These in-clude compression neuropathies which are espe-cially likely in military settings (for example,rucksack palsy). Depending on severity, they mayrequire temporary job reclassification duringconvalescence. As they are not life threatening,a hasty diagnosis should not precede a trial ofrestoration treatment.

o. Uncommon but Endemic NeurologicDisorders. These are physical diseases whosesymptoms (at least initially) are primarily mentalor behavioral (although eventually documentableby neurological or laboratory examination). Ex-amples include:

(1) Guillain-Barre syndrome (mus-cle paralysis, usually without sensory loss, whichascends the legs and arms, then the trunk, overhours to days). It is sometimes triggered byimmunizations, as might be given to troops de-ploying overseas. It often progresses to a life-threatening situation as the muscles of respira-tion become involved. This requires evacuation

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to COMMZ and CONUS. Fortunately, recoveryis usually complete, but it takes months to years.

(2) Multiple sclerosis. This diseasecan mimic many types of BF with its sometimestransitory, shifting motor, sensory, speech, andcognitive/emotional symptoms. It is made worseby stress and may be difficult to diagnose. Onceconfirmed, true multiple sclerosis cases should beevacuated to CONUS, as should other rare,progressive diseases like Lou Gehrig’s disease(amyotrophic lateral sclerosis). Multiple sclerosison the battlefield is not likely to be more commonthan in any other population of young to middle-aged adults.

(3) True convulsive seizure disor-ders. This may be a rare sequela of prior RTDhead injury or a common sequela of sublethal orchronic nerve agent exposure. These are treatedwith the normal anticonvulsant medications. Ifsoldiers who are anxious about nerve agent attackobserve someone having a seizure, that maytrigger an epidemic of purely psychogenic sei-zures. Pseudoseizure (becoming unconscious,falling down, and shaking all over) sometimesoccurs as a BF symptom. The extremely anxioussoldiers may also have urinal and fecal incon-tinence during the pseudo seizure, as loss ofbladder and bowel control at times of extremedanger is common. In a civilian setting, incon-tinence during pseudoseizure is unusual.

P. Substance Misuse/Abuse. Thesemay be examples of misconduct combat stressbehaviors but are not necessarily reactions tocombat stress. Drug and alcohol abuse areepidemic in US civilian society, especially amongadolescents and young adults, and continue to bea problem in the Army in spite of preventionprograms.

(1) Heavy habitual use of alcohol,even by otherwise capable officers and NCOs, maygo unnoticed in peacetime. However, it may

degrade the increased levels of mission perform-ance demanded by combat or may result in with-drawal symptoms when access to alcohol is inter-rupted by deployment. Minor alcohol withdrawalis identical to the normal common signs of BFand requires no special treatment. However, it isimportant to prevent the onset of major alcoholwithdrawal if the history or physical findings ofchromic heavy drinking suggest that is likely.

(2) Intoxication or withdrawal fromalcohol, barbiturates, and tranquilizers may bemistaken for BF; however, these conditions re-quire special treatment. Withdrawal seizures orimpending or ongoing delirium tremens needemergency treatment with diazepam, anotherbenzodiazepine, or phenobarbital to stabilize forevacuation and detoxification in a corps hospital.Dosage will be determined by the treatingphysician.

(3) Overuse of stimulants (such asdeliberate abuse or the desire to stay alert) maycause panic attacks, manic hyperactivity, rageattacks, or a condition which closely mimics acuteparanoid schizophrenia. Those patients withparanoid psychosis can be treated with standardantipsychotic drugs such as chlorpromazine orhaloperidol but may take 7 to 10 days to fullyrecover. Cessation of amphetamines after pro-longed use causes a “crash” (extreme sleepiness,lethargy, overeating) and perhaps even a “crashand burn” with possible serious depression andsuicidal thinking. This condition may require1 to 2 weeks of hospitalization to assure saferecovery,

(4) Hallucinogenic drugs causesensory distortion, panic, bizarre thoughts, andpotentially dangerous actions. These may beemployed by the enemy as chemical or biologicalwarfare agents. Phencyclidine hydrochloride(PCP) is especially problematic since it also blockspain and tends to make those under its influenceparanoid, violent, and abnormally strong.

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Hallucinogenic drug psychosis should not betreated with antipsychotic drugs. Physicallyrestrain, sedate with diazepam or lorazepam, ifnecessary, and evacuate for stabilization andfurther evaluation.

(5) Inhalation of fumes (either byaccident or as deliberate abuse) and carbon-monoxide poisoning can cause disoriented,abnormal behavior. Supportive treatment and,in cases such as carbon monoxide poisoning,specific antidotes or medication may be needed.

q. Anticholinergic Delirium. In com-bat, atropine may be a problem since we equipour troops with atropine injectors to use as firstaid against nerve agents. Even 2 milligrams (mg)(one atropine injector) without nerve agent chal-lenge can cause rapid pulse, dry mouth, slightlydilated pupils, decreased sweating (hot, dry,flushed skin), and perhaps urinary retention. Insome individuals, 6 mg of atropine (equal to threeatropine injectors) may cause hallucination anddisorientation (without a nerve agent challenge).Such effects may be more common in sleep-deprived soldiers. Similar effects can also occurfrom eating certain plants. When soldiers areheat-stressed from exercise, clothing, or exposureto hot, desert, or tropical environments, doses ofatropine tolerated well in temperate climates maybe even more incapacitating. In the heat-stressedindividuals, doses of atropine tolerated well intemperate climates may be seriously incapaci-tating by degrading the sweating mechanism.Such situations can sharply reduce the combateffectiveness of troops who have suffered little orno exposure to a nerve agent. One dose (2 mg) ofatropine can reduce the efficiency of heat-stressedsoldiers. Two doses (4 mg) will sharply reducecombat efficiency, and 6 mg will incapacitatetroops for several hours.

(1) Stabilization is achievedthrough reassurance, physical restraints (ifrequire for combative behavior), and supportive

treatment (fluids, cooling). These measures willsustain the soldier until the atropine is cleared in6 to 18 hours. Do not give chlorpromazine ordiphenhydramine as they make the conditionworse. Diazepam may be used if sedation isessential. In hot, humid climates, individuals whohave inadvertently taken an overdose of atropineand are exhibiting signs of atropine intoxicationshould have their activity restricted. In addition,these casualties must be kept as cool as possiblefor 6 to 8 hours after injection to avoid seriousincapacitation. Usually, the casualties will re-cover fully in 24 hours or less from a significantoverdose of atropine.

(2) Physostigmine (a rapidly clearedantinerve agent) is the specific antidote for atro-pine; it must be titrated carefully over hours toavoid overdose or relapse. This may be imprac-tical in mass casualty situations. If available, itcan be used to confirm the diagnosis. Physostig-mine needs to be given in repeated doses only tothose relatively few cases of atropine overdosewho are in danger of death from excessive bodytemperature (heatstroke) or cardiovascular col-lapse due to the high pulse rate.

r. Anticholinesterases. Nerve agent isan anticholinesterase similar to many insecti-cides. Low-dose nerve agent exposure may pro-duce miosis (pinpoint pupils) without other signs;this will seriously decrease vision except in verybright light and cause eye pain when attemptingto focus. This may take hours to days to improvespontaneously, depending on the degree and typeof exposure. Giving atropine eye drops will onlyrelieve the spasm if the soldier has been takingpyridostigimine as a pretreatment; the soldier willthen have several hours with very large pupils(bothered by bright light) and will have difficultyfocusing on near objects, especially fine details.Evidence gathered from affected insecticideworkers suggests that mild personality changes,insomnia with bad dreams, and chronic persistentdepressive symptoms (similar to common BF) may

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be seen even after use of an antidote. Low-dosenerve agent exposure may lower the seizurethreshold of many soldiers. True epileptic seizurecases must be distinguished from those soldierswho may have pseudoseizures and need onlytreatment for BF.

s. Endemic “Functional” Major Psych-iatric Disorders. These (especially schizophreni-form/schizophrenic disorder, major depression,and bipolar disorder) will continue to occur atapproximately the same rate as in peacetimeActive and Reserve Component personnel. Theyshould be evacuated to CONUS as soon as theycan be distinguished from temporary BF orsubstance-related conditions with good potentialfor RTD. However, that cannot be accomplishedwithout some period of observation whichapproximates the doctrinal restoration treatmentfor BF. That stabilization must be conducted in asufficiently secure, structured setting thatassures safety for violent or self-destructivebehavior. A few soldiers who have been diagnosedwith psychiatric disorders by a civilian physicianmay deploy to the theater. These soldiers mayhide the fact that they are taking psycho-therapeutic medication to keep the diagnosis offtheir military record. Once in the theater theymay experience a relapse or self-refer themselvesto an MTF when their medication supply isexhausted. The evaluating psychiatrist mustdetermine if the soldier can function without themedication. If the soldier requires medication,can he be restabilized on a drug which can beprovided in the theater? Can the drug be givenwithout risk of harmful side effects? If thealternatives are not feasible, the soldier must beevacuated out of the theater. The followingguidelines are proposed for management of caseswith significant symptoms that suggest a majorpsychiatric disorder:

(1) Severe retarded or agitateddepression with suicidal preoccupation.

Survival guilt is commonwith BF, as are feelings that death would be arelief, would end the suspense, and is so likelythat it should be expected. Such cases are un-likely to commit suicide but may fail to takeadequate precautions for safety. They may besafer with trusted comrades who can watch outfor them (as DUTY BF) than with an unfamiliarCSS unit and categorized as REST BF. If theycannot be held in their own unit, they should betriaged as HOLD rather than REST unless theCSS unit where they are attached can provideclose supervision.

Sleep loss, emotional andphysical fatigue with apathy, and loss of appetitecan mimic retarded depression. However, thesoldier should regain energy, appetite, and per-spective quickly with sleep, hygiene, and goodA rations.

Significant anxiety on topof the depression could mimic a severe agitateddepression but should also improve quickly withrest in a relatively safe place.

Serious suicidal intent ismore likely in soldiers who have suffered severedisappointment on the home front (Dear Johnletters) or who have, in fact, committed errorsabout which they have reason to feel guilty (suchas accidental fratricide). While such cases shouldbe treated as BF, special attention should be givento ensure their safety and to work on the under-lying problem. Cases with depressive symptomswhich do not improve in 1 to 3 days go for 7 to 14days of reconditioning. Brief hospitalization onthe CSH’s NP ward with suicide precautions maybe necessary for those who are judged danger-ously suicidal. If the depression has not improvedafter being sent for reconditioning in theCOMMZ, these cases meet the Diagnostic andStatistical Manual of Mental Disorders. ThirdEdition, Revised (DSM III-R) criterion for majordepression (2-weeks duration).

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(2) Predominantly auditory verbalhallucinations and schizophrenic-type thoughtdisorder.

This could be due tostimulant misuse in a good soldier or a briefreactive BF in response to extreme stress. Thisis not a condition which can be managed in a1- to 3-day restoration program without excessivedisruption for the other BF soldiers. The poten-tial risk of an open environment with manyloaded firearms is too great. Send this case to ahospital with NP staff for stabilization. If sym-ptoms improve quickly with rest or with anti-psychotic medications, transfer the soldier for-ward to the reconditioning center to prepare forRTD. If psychotic symptoms persist, evacuate tothe COMMZ and CONUS.

Auditory but nonverbalhallucinations (such as hearing battle sounds,perhaps also with visual hallucination of battlesights) are more likely to be BF with potential forlimited RTD in the TO.

(3) Paranoid delusions withoutformal thought disorder. If this follows severesleep loss, it may clear completely with reassur-ance and sleep. If it does not, consider the natureof the delusion and the sociocultural context. Isit likely to interfere with mission performanceand/or could it lead to inappropriate violentbehavior? If yes, HOLD or REFER (evacuate) forfurther evaluation. If no, RTD with appropriateadvice to command or comrades about how tohandle to get best performance.

(4) Manic episode. This could bedue to sleep loss and stress, stimulant misuse, orbipolar disorder. The soldier may be too dis-ruptive to keep at forward locations. If sedations(with physical restraint, if necessary) result inimprovement after good sleep, consider RTD. Ifmania persists, evacuate to next echelon for fur-ther evaluation.

t. Endemic Personality Disorders.Preexisting personality disorders may make asoldier unable to adapt to military life. However,numerous studies have failed to show a relation-ship between personality disorders and the likeli-hood of breakdown in combat. Even so, oncesoldiers with personality disorders have becomeBF casualties, they may have greater difficultyrecovering and returning to duty. Those whomalinger (deliberately fake illness to avoid duty)must be detected and RTD or have administrativeaction initiated by the unit.

(1) A documented (DSM III-R)personality disorder which also interferes withthe soldier’s ability to perform duty is a basis foradministrative discharge (Chapter 5, AR 635-200). The responsibility of the evaluating psychi-atrist or psychologist is to certify that the soldier’sunacceptable behavior is part of a true personalitydisorder. This is measured by DSM III-R’s strictcriteria, specifically—

It is part of a long-stand-ing pattern that has been evident since childhoodor early adolescence.

It is present in other as-pects of the soldier’s life besides military duties.

It is inflexible and has notchanged in spite of reasonable efforts to correctit.

It interferes with militaryduty.

This diagnosis may not be appropriate for someo-ne who is still in adolescence, as may be the casewith some basic trainees and first tour soldiers.The lifelong label of a personality disorder asexplanation for military discharge must not beapplied unless all of the features are present, eventhough the soldier himself, as well as the com-mander, may wish to take this easy way out.

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(2) In the CZ, it may be difficult toget the long-term occupational and social historyneeded to truly document that a soldier’s behavioris due to a personality disorder and not just to BFor an adjustment disorder. In principle, soldiersshould not be medically evacuated from thetheater for poor performance or misconduct. Ifthe soldier’s emotional or mental state doespreclude return to useful duty and command

insists on rapid evacuation, the diagnosis ofpersonality disorder (and recommendation forchapter discharge ) may best be deferred forfurther evaluation in CONUS. In the CZ, com-mand should be unwilling to allow so easy a wayhome which might encourage malingering. Theyshould require RTD, job reclassification, ordisciplinary action, unless true BF is present anddoes not respond sufficiently to treatment.

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CHAPTER 7

COMBAT STRESS CONTROL STABILIZATION

7-1. Priority for Stabilization

Combat stress control stabilization is the acutemanagement of the small percentage of BF andNP cases who have severe behavioral dis-turbances. The behavior seriously disrupts thefunctioning of the unit and may even pose adanger to the soldier or others. In some cases,the underlying medical condition may also be adanger to the soldier’s life. Combat stress controlstabilization can be divided into initial emergencystabilization and full stabilization.

a. Initial Emergency Combat StressControl Stabilization. Initial emergency CSCstabilization has been achieved when thedisturbed soldier is in physical restraints, can begiven an adequate physical examination, andmay, if necessary, be sedated for evacuation. Thismay be all that can be done at forward echelonsby nonpsychiatric personnel or by CSC personnelin a mass casualty situation. Stabilizing severelydisturbed soldiers will always have an extremelyhigh priority, especially when they becomeagitated or combative. Such cases can causeserious harm to others as well as to themselves,especially in a presence of loaded firearms,explosives, powerful machinery, and life or deathmissions.

(1) Violent behavior is quite rarein pure BF but is one form of misconduct stressbehavior. Some NP disorders are prone toviolence, especially paranoid psychotic states.Violence is also more likely with disruptionof brain functioning due to organic factors suchas intoxication, hyperthermia, or metabolicimbalance.

(2) Increased numbers of thesesevere BF cases can be expected during highNBC threat situations. This is due to increasedorganic brain syndromes caused by antidotes(such as atropine), heat stress, the heightened

physiological stress, and the possibility of directNP effects of some NBC agents.

(3) Examples of these CSC cas-ualties requiring immediate stabilization wereprovided in paragraph 6-3.

b. Full Stabilization. Full stabilizationgoes beyond securing the safety of the patientand those around him. It prepares the patientfor an evaluation of his potential for RTD in thenear future. If RTD within the evacuation policyis not feasible, it prepares the patient for safe,long-distance evacuation. Full stabilization isnormally the responsibility of the NP ward andconsultation service (module of the hospital unitbase) in every CSH, FH, and GH.

(1) Full stabilization is desirablefor the sake of the soldier’s future treatment andfor the potential of returning some soldiers toduty. However, full stabilization is personnelintensive with a relatively low RTD payoff. Forthat reason, full stabilization has the lowestpriority of the six CSC functions. Providing onlysufficient initial stabilization to allow evacuationfrom the theater may be accepted in order tomaintain the other CSC functions.

(2) However, because of the lowpriority for evacuation of NP patients as com-pared to the large surgical caseload, it is quitelikely that NP patients will accumulate in the CZor COMMZ. Even adequate initial stabilizationwill require continued resources.

7-2. Use of Restraints in Initial (Emer-gency) Stabilization

a. Physical Restraints. Physically re-straining soldiers with presumed BF goes againstthe treatment message of normality and positiveexpectation. However, some NP and a few BFcases may be—

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fused.Seriously disoriented and con-

Paranoid.

Delusional.

Hallucinatory.

Suicidal.

Agitated and restless.

Manic and intrusive.

Threatening violence.

Restraining these soldiers may be necessary toensure safety of the soldier and other personnel.Physical restraints also minimize disruptions ofmedical or restoration activities (especially whenstaff are few). It also permits medical evacuationby ground (preferred) or air ambulance.

b. Subduing and Restraining an Agi-tated or Disruptive Soldier. The best way tosubdue and restrain agitated or disruptivesoldiers is verbally, by reassurance and re-orientation. If that fails, a nonthreatening showof strength may suffice. Otherwise, decisivecoordinated action by five helpers, one on eachlimb, one to hold the head, is preferred to get thesoldier face down on the ground. More helpersget in each other’s way. Fewer may be all thatare available but risk more injury to the stafffrom bites, blows, or kicks. The patient also ismore likely to be injured. It is inadvisable toattempt subduing an agitated case one-on-one.The restraining team should continue to talk withand provide reassurance to the resisting patientduring the take-down.

c. Methods of Restraining. Once thesoldier is face down, mechanical restraints canbe applied if sufficient personnel are available.

Lockable, padded leather cuff restraints are safestbut may be in short supply. Other methods suchas using two litters (sandwiching the patientbetween the litters and using straps for securing)or straps, sheets, improvised strait-jackets or anyother field expedients may be used. Regardlessof the method, the soldier placed in restraintsmust be checked frequently. This is done to guardagainst nerve injuries or impaired circulationleading to skin ulcers or gangrene. It is alsoimportant to check that the soldier is not secretlyescaping from restraints. The soldier is providedverbal reassurances with positive expectations forhis recovery each time he is checked.

7-3. Use of Medication in Initial (Emer-gency) Stabilization

a. Administering Medication. Admin-istering medication to an uncooperative andunrestrained severe BF soldier can be extremelydifficult; unfortunately, the effects of themedication may act too slowly to be much help.Once the soldier is in restraints, the medicationis no longer essential and serves mainly to reducethe risk of escape. Medications will reduce anagitated soldier’s resistance to the restraints, thusdiminishing the disturbance of other BF soldiersin the vicinity.

b. Observing for Reactions. The soldieris observed for any reactions. Be concerned thatthe medication does not interact badly with anybiochemical already present in the disturbedsoldier. Do not give chlorpromazine for anti-cholinergic delirium. If hallucinogenic drugintoxication is suspected, the use of anyantipsychotic drug is contraindicated. The useof diazepam for pathological intoxication withalcohol or barbiturates is also contraindicated.

c. Rapid Sedation. Rapid sedationwith antipsychotic drugs (repeating high dosesevery half hour until the patient is sedated) was

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widely practiced in the early 1980s. This methoddid not improve overall recovery time signifi-cantly and did tend to cause more side effectssuch as dystonic spasms of the neck, back, oreye muscles. Now, even in known psychiatricpatients who must be restabilized after stoppingtheir previously successful medication, it ismore common practice to build up antipsychoticdrugs gradually. To achieve an antianxiety andsedative effect, the patient is initially treatedwith a benzodiazepine (such as diazepam orlorazepam). Lorazepam, if available, has theadvantage of being more consistent when givenintramuscularly.

d. Effects of Antipsychotic Drugs. Anti-psychotic drugs can take several hours todays to take effect. Early administration ofchlorpromazine or another antipsychotic drugmay confuse the clinical picture for the nextevaluator if the soldier is evacuated. The evalu-ator will not know whether any changes in thesoldier’s behavior over the next day or two wasdue to the reassurance, sleep, hydration, andreduced anxiety (from increasing distance fromthe battle), or whether it is just due to the medi-cation. The medication must be discontinued ifthe soldier is to RTD. Therefore, the recom-mendation for most cases is to use no medicationunless it is truly necessary for management.If medication is required, use as low a doseas is effective of a benzodiazepine (usuallydiazepam or lorazepam, although a shorter actingbenzodiazepine, such as temazepam, would bebetter when available).

7-4. Full Stabilization in Combat StressControl

Full stabilization in CSC includes adequate evalu-ation of RTD potential. This requires assessmentof mental status and performance capability overtime without excessive drug effects or limitationson activity. Contact with the soldier’s unit may

be needed to get information on prior history andfunctioning. The further from the unit the soldierhas been evacuated, the more difficult it isto contact the soldier’s unit. Full stabilizationnormally takes several days.

a. Follow the Principles for TreatingBattle Fatigue. To the extent compatible withsafety, the stabilization program should adhereto the principles and methods for treating battlefatigue:

(1) PIES:

Proximity to the soldier’sunit.

Immediate initiation oftreatment.

Expectation of rapid andfull recovery.

Simplicity of approach.

(2) The four Rs:

Reassurance of normality.

Rest.

Replenishment of nutri-tion, hydration, hygiene, and sense of physicalwell-being.

Restoration of confidencethrough talk and activities.

(3)dier’s identity as

pajamas, as soon

Maintain and reinforce the sol-a soldier.

Battle-dress uniform, notas they can be allowed safely.

Rank distinctions and ap-propriate military courtesy.

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Responsible for self-careand helping others.

b. Evaluation and Treatment Modali-ties. The evaluation and treatment modalitiesinclude—

Individual interviews for ob-taining complete medical history.

as indicated.

be thorough).

cated.

7-5.

Mental status examination.

Laboratory and x-ray workup,

Physical examination (should

Specialty consultations as indi-

Group sessions.

Recreational activities.

Occupational (work) history.

Stabilization Treatment Facilities

Stabilization Facilities. Ideally, sta-bilization is conducted by qualified mental healthpersonnel in a nonhospital (medical companyclearing station ) military setting, to maximizepositive expectation and minimize chronicity.However, it must be kept separate from therestoration or reconditioning facilities, as thepresence of these dramatically symptomaticsoldiers is very disruptive to the treatment of BFcasualties. More sophisticated procedures andlaboratory and x-ray capabilities may be requiredthan is available at medical company clearingstation (for example, lumbar puncture andcerebral spinal fluid examination and analysis).

For that reason, most full stabilization will beconducted in the CSH, FH, or GH. All of thesehospitals have an inpatient psychiatric capa-bility. Those soldiers who improve and havethe potential for RTD are then transferred toa reconditioning program.

b. Neuropsychiatric Ward. Militaryhospital NP wards in the TO can be catego-rized as either in fixed/planned facilities, fixed/improvised facilities, or mobile facilities.

(1) Fixed/planned facilities are inbuildings which were designed or premodifiedto serve as psychiatric wards. These could be inUS Army fixed hospitals, allied military hos-pital, or host-nation civilian hospitals. Dependingon degree of modernity and enlightenment ofpsychiatric treatment, these should provide—

Security design for pro-tection against suicide.

Seclusion areas.

Comfortable and reason-ably civilized surroundings.

These can provide the safest setting for initialstabilization, or for holding cases until they canbe evacuated. They may already be divided intomaximum security closed wards and open wardswhich allow for more responsible self-controllingbehavior. If such facilities are to be used for thetreatment and evaluation of soldiers for possibleRTD, it requires steps to maintain a militarysetting for the wards and the treatment routine.

(2) Fixed/improvised facilities arein buildings which were not designed or pre-viously modified for use as psychiatric wards.These buildings have been taken over for thispurpose. They will require assessment andusually some modification to make them safe,including—

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Impassable screens on thewindows.

Covering of electrical out-lets.

Removal of hazard for sui-cidal or violent acting out.

Separation of wards into closed and open isdesirable if layout and staffing allows. Here,too, it is important to maintain a militaryenvironment and routine to the degree patientsafety allows, especially on the open ward.

(3) Mobile facilities are thosewhich are in tent, extendable, modular, person-nel (TEMPER) or general purpose (GP) largetents. The principal advantage of the (hospital)TEMPER tents, as assembled into DeployableMedical System (DEPMEDS) hospitals, is theirclimate control capability. This may be a sig-nificant safety advantage for treating seriouslydisturbed patients in restraints with high-dosemedication, which can disrupt normal thermalregulations. Both TEMPER and standard tentspose greater problems for security than do fixedfacilities. The staff may, therefore, have to relymore than is ideal on physical and/or chemicalrestraints. Blankets or screens can be used toisolate or segregate problem patients from others.Such partitions reduce behavioral contagion butprovide little true protection. Standard mobilehospital beds on high, lightweight metal legs mustbe replaced with standard low, stable cots to holdstrong, agitated patients in restraints. The cotsalso make a more “military” setting and can beused as seats for group activities. As in the fixedfacilities, it is best to have a separate “closed”

(high security) and “open” (moderate/minimal)security area. The latter could be a standard GPlarge tent (the same as those of the minimal carewards [MCW]) located close to the TEMPER tentof the official NP ward. The specialists (MOS91C and 91B) of the MCW could be given on-the-job-training in supervision and military groupactivities for the moderate/minimum securitycases if the NP staff is too small.

c. Mixed Neuropsychiatric/Medical Sur-gical Ward. The NP ward may be expected toadmit those NP cases with concurrent physicalillness or injury and concurrent significantmental symptoms unless the patient’s conditionrequires that he be in the intensive care unit, orin isolation because of contagious disease. Themental symptoms could be—

Caused by organic brain dis-ruption (such as drug intoxication or withdrawal).

Functional NP disorders whichare coincidental to the illness or injury.

Functional and in reaction tothe traumatic situation which caused the injury.

The NP staff must be prepared to react thera-peutically whatever the cause of the disturbedbehavior. In the event of many medical/surgicalcases, the NP ward could receive overflowmedical/surgical cases. Therefore, NP ward staffmust remain current in basic nursing and woundcare skills.

d. Combat Support Hospital Neuro-psychiatric Ward Staff. Definitive information isprovided on the CSH NP ward staff capabilitiesin FM 8-10-14.

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CHAPTER 8

COMBAT STRESS CONTROL RESTORATION

8-1. Restoration of Battle Fatigue Casu-alties

a. Restoration. Restoration is the l-to3-day treatment of BF casualties at medical unitswhich are as close to the BF casualties’ units astheir condition and the tactical situation allow.Restoration can be divided into first line (thefurthest forward, with few staff, under verylimiting and fluctuating conditions), second line(still limited, but with more expert staff and morepredictability) and third line (performed atEchelon III or Echelon IV hospital).

b. Screening and Treatment. Adequatemedical screening and treatment must be done inthe supported units by organic medical platoonsor by the supporting medical companies. The BFcasualties who enter restoration should be onlythose HOLD and REFER cases who requirecontinuous medical and/or mental healthevaluation and observation for 24 hours or more.Although still on their unit roll, they are notavailable to that unit for even limited duty andare, therefore, true casualties. DUTY (mild) caseswill have been returned to their small units andREST (moderate) cases sent to rest in their units’CSS elements.

c. Restoration Priority. Restorationusually has the fifth priority following con-sultation, reconstitution support, combat NPtriage, and minimal essential stabilization.However, when true BF casualties are numerous,or when the tactical situation makes it difficultfor forward units to manage DUTY and REST BFcases, the influx of BF cases may force restorationto take a temporarily higher priority.

(1) To the maximum extent pos-sible, restoration should be increased. Thismeans a lower priority for reconditioning andstabilization being restricted to the minimum

requirements for cases and unit safety whileawaiting (and during) evacuation.

(2) To the greatest extent possible,preventive consultation, operational planning andRTD-related coordination must continue or theinflux will worsen!

(3) Combat stress control per-sonnel should be freed up for reconstitutionsupport missions even if that means evacuatingsome BF casualties who appear likely to requiredisproportionate effort for restoration. Otherwise,more BF soldiers who could have recovered andreturned to duty in their units will just add to thealready great work load for restoration.

d. Categories of Restoration. Resto-ration can be categorized as first line, second line,or third line, depending on where it is provided.The three categories may also differ in durationof restoration which they usually provide. Thisis dependent on the level of specialized skill,experience, and knowledge of the providers.

8-2. Generic Tactics, Techniques, andProcedures of Restoration

a. Reprieve from Extreme Stress.Initial restoration begins at the most forwardechelon where the label “REFER BF” can bechanged to “HOLD. ” Normally, restorationfacilities are part of (or collocate with) the clearingstation of the supporting medical company.

(1) Criteria for when to hold casesfor restoration were discussed under combat NPtriage in Chapter 6.

(2)locations which

Restoration is not feasible atare consistently under artillery.

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air, or direct-fire attack, unless they are ex-ceedingly well fortified and resistant to damage.However, safety on the modern deep battlefieldis never complete; relative security is sufficientto provide restoration. If there is potential forattack, there should be reasonable cover anddefensive position to provide a sense of relativesafety to a jumpy combat soldier. A good workdetail for recovering BF casualties is the digging,building, and camouflaging of these positions.

(3) Ideally, the location is still“within sound of the artillery,” that is, within thesounds of the distant booms or rumble thatremind the soldier that comrades are still inbattle. Other relatively distant noises, such ashelicopters, aircraft taking off, or road traffic, arealso acceptable provided they are not so noisy asto disrupt sleep.

(4) In addition, the location shouldnot be one from which a move is likely within 24(or 48) hours. If there is a significant possibilityof a move, only those cases who can participateactively in the move with minimal supervisionshould be held for treatment at this location. Anytime the unit is given a warning order to standbyto displace, the CSC staff may have to conduct aquick sorting of the cases on hand. The staff usesmore stringent combat NP triage criteria andsends to the next-line restoration facility all thosewho are not readily transportable with the team.

(5) The specific site of the resto-ration facility should be out of immediate (close)sight of the triage area. Battle fatigue casualtiesshould not be able to see severely woundedsoldiers come into the MTF. The expectant areaor temporary morgue areas, when mass casualtysituations occur, should also not be seen from therestoration facility. It may be close to, but ideallyslightly separate from, the treatment area forRTD wounded and DNBI cases. However, thesecan merge if provision is made to stabilize overlydramatic cases elsewhere. Ideally, the restoration

area is close to the host unit’s field kitchen andother support facilities.

(6) Restoration facilities collocatedwith medical units in the BSAs and DSAs willoften be restricted by the local commander fromdisplaying the red cross on the grounds thatit reveals the entire unit’s location. This isconsistent with the principle of treating BF casesas “soldiers, not patients.” In the corps area, thereis a greater chance that the medical unit willbe allowed to display the red cross. The restor-ation (and/or reconditioning) facility leader willneed guidance on whether to display the redcross or not. If the red cross is displayed, thereis greater assurance of protection under theGeneva Conventions, For discussion of the issueof Geneva Conventions status and its limitationson CSC activities, see Appendix D.

b. Reassurance. Restoration beginsafter the initial combat NP triage evaluationdescribed in Chapter 6. Immediate reassuranceis given to BF soldiers,

(1) Tell them that they are tem-porarily joining the unit, not as patients, but assoldiers who need a couple days to recover fromBF. Emphasize that BF is a normal response toextremely abnormal conditions and that rapidrecovery is also normal.

(2) Orient the BF casualty to theprogram. Tell them that they will get plenty offood and beverages, good sleep, a chance to cleanup, and light duties for 1 or 2 days (or at most, 3days). By that time, they will have regainedstrength and confidence and will return to theirunit.

(3) Reassure them (as much as youhonestly can) about safety and what to do in theevent of an attack or march order.

(4) Personal possessions are nottaken away. These personal items remind the

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soldiers of their normal lives and are a comfort intime of stress. The soldiers are expected to takecare of their personal items. This applies even toknives or other weapons (with the exception offirearms), unless there is significant reason forconcern that this soldier might harm himself orothers. Soldiers for whom there is such concernsneed stabilization and should be segregated, atleast temporarily, from the restoration program.

(5) If the soldier arrives with afirearm, the weapon is secured by the medicalcompany supply element. Ammunition, grenades,mines, or other explosives must also be collectedand turned-in. The soldier should be told thatthis is the TSOP for all medical units. Tell theBF soldier that his weapon will be returned tohim if he is assigned guard duty or if the medicalunit is under the threat of an attack.

c. Structured Military Environment.Maintain a structured military chain of command.When the BF soldier is processed into therestoration program, he is received as a soldierperforming temporary duty and not as a patient.

(1) Assign the BF casualty to a“squad” under supervision of a specific squadleader. At larger facilities, several squads maybe organized into a platoon, under a platoonleader. In a extremely large restoration center,several platoons could be organized into a com-pany. The squad leader may be a CSC unit ormental health section officer, NCO, or sectionmember, or a member of the host medical unit’spatient-holding squad. In a pinch, a carefullyselected line NCO with a minor wound or injurythat temporarily prevents his RTD may bedetailed as a squad leader. Ideally, each squadleader should not have more than 6 to 8 BFcasualties to supervise. For brief peak periods,the squad leader may be assigned 10 to 12 BFcasualties to manage.

(2) The soldier’s FMC (filled outduring combat NP triage) is not kept attached to

the soldiers, but is kept at a central place untilthe soldier is ready to RTD or be evacuated.

(3) The initial interview and ac-tivities depend upon the symptoms of the BFcasualty and the degree of physical/psychologicstress in relation to the cognitive/emotional stress.The attitude of the interviewer should be that ofa good, caring leader. As a leader, he is gettingto know the recent experience, background, andskills of a new soldier just assigned to his unit asa combat transfer, not as a therapist doing anintake interview.

A BF casualty who is ingood physiologic shape, but who clearly has muchto talk about, should be encouraged to talk im-mediately.

More often tending to andrestoring physiologic status comes first. Theorder of priority varies with the nature of thedeprivation.

(4) The newly arrived soldier is notassigned to a ward tent as a patient but rather tothe squad’s quarters tent. In many situations, itwill be appropriate and necessary for the squadleader(s) to sleep in the same tent with the teammembers. Ponchos or blankets can be hung toscreen off areas where true patients are restingand to provide privacy.

d. Replenishment of Physiologic Status.

(1) Restore temperature regula-tion. Get the soldier under shelter and cool downif overheated, warm up if cold, dry off if wet.

(2) Replenish hydration with pal-atable beverages (cool if hot, warm or hot if cold).

Soups are ideal as theyare also foods.

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Milk, soft drinks, Kool-Aid, and fruit juices are good.

Minimize caffeine-typestimulants in coffee, tea, or beverages, unlessincreased wakefulness is desired.

Intravenous fluids maybe used in exceptional cases when speed ofdehydration is important. Effort is then requiredto reinforce the fact that the soldier is not apatient and that this is just routine.

(3) Replenish nutrition. Offer thebest possible filling meal, preferably high incarbohydrates with some protein.

(a) A-rations from the hostunit’s field kitchen are best. Hot tray-packs(especially the noodles and potatoes tray) andeven hot MREs are acceptable.If the latter areused, try to have some special seasonings orgarnishes to increase variety and palatability.Break up and stir most tray-pack selections tonormalize their texture and appearance, ratherthan serving them as a solid rectangular “brick.”

(b) Since BF casualties mayarrive at any time, day or night, a restorationfacility must have means to quickly heat food.The minimum standard is a large pot of waterready to boil at all times. If the supporting fieldkitchen cannot provide this, CSC personnelshould coordinate for other arrangements.

(c) If a BF casualty is tootired, anxious, or depressed to eat at first, providean assigned area for sleeping. “Three hots and acot” are essential throughout the period ofrestoration.

(4) Restore hygiene. Unless thesoldier is totally exhausted and already fallingasleep, institute some personal hygiene.

(a) Wash face and hands withwash cloth, warm/hot water and soap. The menshave with hot water, soap or lather, and sharpsafety razors. This may extend to a partial or fullsponge bath, if feasible. The restoration facilityneeds a supply of sundry packs plus a basin.

(b) Hot showers, if available.A quartermaster shower/bath unit may be presentin a corps base defense cluster DSA or BSA. Theshower point may be some walking or ridingdistance away, and scheduled hours of operationsshould be considered.

(c) In hot or temperateweather, CSC personnel (and/or the host medicalunit) should set up a field shower.

This could be anAustralian shower bucket, a collapsing canvasbucket with nozzle. A shower could be improvisedby perforating other large buckets or 55-gallondrums (see FM 21-10).

The shower can bescreened with poncho liners for privacy and givena wooden pallet “floor” above the water run-off.In cold weather, a tent with a heater would needto be dedicated to the shower.

Hot water from thefield kitchen or an alternate source is blendedwith cool water to give a suitable shower temp-erature. Dry, clean towels are also necessary,since most of the BF casualties will not bring theirown.

The hot shower isan excellent way for new arrivals to relax andunwind before sleep, if they are not already tooexhausted, or if harsh weather does not make ittoo difficult. Otherwise, it can be an “event” or“duty activity” for subsequent restoration days.

(d) The importance of cleanclothes (if available) depends on the condition of

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(how wet, sweaty, filthy, bloody, or torn) the BFcasualties’ own battle-dress uniforms.

In principle, BF ca-sualties should remain in combat uniform whichincludes helmet and protective mask. Reasonablycomplete load bearing equipment (LBE) and cleanuniforms are desirable. However, BF casualtiesdo not need to be in uniform while sleeping,provided adequate sleeping gear (bedding) isavailable.

A problem may arisebecause medical treatment companies, unlikehospitals, do not stock either patient pajamas(which BF casualties should not be given onprinciple), spare uniforms, or a large supply ofsleeping bags. Nor do they have an organiclaundry.

Those personnel whoare supervising BF casualties must work with themedical company’s supply element to priorityrequisition necessary clothing, bedding, andequipment items through the supporting logisticelement (the FSB, MSB, or area support bat-talion’s S4). It may be necessary to improviseuntil required items are available. In the corps,the AG replacement company will issue RTDsoldiers new clothing, as required,

A field-improvisedlaundry (hot water pots and soap) plus patchingand sewing repairs may also be a useful “workproject” for the recovering BF casualty.

(5) Restorative sleep should beas normal as possible. Most BF casualties willfall asleep quickly with only strong positivereassurance that they will be safe, provided theyhave relative comfort compared to what theyhave been used to. It is important to minimizeinterruptions to sleep. As much as possible,ensure relative quietness (facilitated by dispos-

able earplugs) and darkness (perhaps facilitatedby a cravat blindfold).

(a) Bedding may be on a cot,a ground pad, an air mattress, or field expedienthay, pine needles, or leaves. The quality of sleepis important, especially for the first night or two,so the shelter should be as comfortable as ispractical and neither too cold nor too hot.

(b) The soldier should be toldbad dreams will probably occur soon after he fallsasleep and be reassured that they are normal andthat he should go back to sleep if awakened.

(c) Muscle stretching rou-tines, massage, and other simple relaxationtechniques may help the tense or anxious soldierget to sleep. If available, audiotapes of relaxingbackground sounds can be played.

(d) Medication for sleepshould not be used if food, a hot shower, orrelaxation will do. However, BF casualties whoare too tense, depressed, or frightened to sleepcan be given just enough sleep medication to helpthem doze off. Possible sleep aids are—

Diphenhydramine, asedative antihistamine in most medication sets).

Low-dose diazepam.A dosage of 2.5 or 5 mg may be administered.The trouble with diazepam is that it and its activemetabolizes are slowly cleared from the body.Their continued presence in the body and brainmay interfere with motor coordination and taskperformance the next day. The persistence ofsome pharmacologic antianxiety effect may seemlike an advantage, but it actually interferes withthe treatment, which is based on helping thesoldier master his own anxiety himself.

Temazepam, if avail-able. This has a biological half-life under 8

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hours and should have no residual sedation,antianxiety, or motor skill deficit the next day.

Triazolam (Halcion).This sleep aid is even more rapidly cleared buthas been reported to produce some memoryproblems, especially if sleep is interrupted. Theperson may appear to be normal, but does notremember his experiences later. Some peoplehave difficulty in learning new information thefollowing day.

(e) Antianxiety drugs shouldnot be given routinely during restoration. In mostcases, soldiers should not be medicated even withtheir anxiety. Unmedicated soldiers will be betterable to participate actively in their own recoveryand perform with appropriate capability if thefacility comes under attack or must move.

(f) The duration of sleepshould be sufficient to make substantial progressin repaying the sleep debt. It should also beginthe process of restoring a reasonable sleep/wakecycle. The start time and wake-up time shouldbe flexible but tend towards sleeping most ofthe night and being awake all day (or split shift,with sleep in the graveyard shift plus an after-noon nap). Initial sleep should be 8 to 12 plushours.

e. Support the Soldier’s Military Iden-tity. Sustain the soldier’s identity as a soldier.

(1) Maintain appropriate rank dis-tinctions, titles, and military courtesies from theoutset.

(2) Expect the soldier to maintainmilitary bearing, personal appearance, uniform(to include LBE [with canteen, rolled poncho,and first-aid dressing pack as a minimum]),protective mask, and helmet when outdoorsunless under special circumstances.

(3) Conduct basic soldiering skills.See FM 8-10 and Appendix D for the limitationof the Geneva Sick and Wounded Conventionregarding who may teach what to whom.

f. Structure Activities During UnitFormations. Provide structure to the day’sactivities through regular group formations.

(1) Regularly scheduled forma-tions provide occasions to announce the day’sschedule of activities, assign tasks/details to eachsquad leader, introduce new members, and allowparticipation by BF casualties in planning how tocarry out the assigned activities.

(2) The leaders keep everyoneinformed by briefings on the “big picture” andtactical situation, with special attention to theactivities of the BF casualties’ units of origin.Obtain and circulate command information factsheets and newspapers. Radio and/or televisionmay be available in the theater which are goodsources for information.

g. Assign Duties and Work Details.

(1) Assign militarily relevant workdetails at the MTF, preferably to pairs or groupswhich include BF casualties and non-BF casu-alties. Examples include—

Digging foxholes and slittrenches.

Filling sandbags.

Erecting and garnishingcamouflage when permitted.

Providing perimeter guardor air watch.

Performing vehicle pre-ventive maintenance or repair.

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Cleaning equipment.

Work activities must be coordinated with ap-propriate commanders and subordinates well inadvance of casualty flow.

(2) Other obviously relevant andnecessary work details include assisting with foodpreparation and food service at the supportingfield kitchen. Battle-fatigue casualties may beused for loading, unloading, and moving supplies.Repairing clothing and equipment, operating thefield expedient shower, and improving or makinga new latrine are additional appropriate workdetails. Assisting with the care and movement ofother minor wounded and ill may be done and isespecially indicated for BF medical personnel.However, these and other duties must not exposethe BF soldiers to the critically injured or thoseawaiting treatment (except for those medics whoare in the final stage of recovery just before RTD).

(3) Tasks and work details are as-signed according to the status and needs of eachcase.

(a) Some BF casualties needheavy physical activity to work off energy andcomplete the unfinished stress-release process.They should be given tools which make this sat-isfying. Give them shovels and picks that canreally move dirt and show accomplishment inminutes, not little entrenching tools that justscratch away at the surface.

NOTE

Soldiers who may be violent or unstableshould not be given tools which couldbe used to harm themselves or others.

(b) Other BF casualties whoare already physically drained need light duties

that keep them moving and flexible while theyrecover strength.

(c) Tasks should be chosen toexercise relevant manual and cognitive skills andto ensure a successful and satisfying performance.

(d) Utilize soldiers’ skills toteach each other.

h. Schedule Relaxing Activities. Pro-vide enjoyable, relaxing activity.

(1) Provide physical training andensure all are involved in an exercise program.

(2) Organize cooperative/competi-tive physical team games (involving BF casualtiesand non-BF casualties). Examples include relayor cross-country races; tug-of-war; touch football,volleyball, or soccer (using a real or improvisedball); softball; or stick ball. These games shouldbe short, vigorous, and balanced with rest andreplenishment, as well as the work details.

(3) Organize cooperative/competi-tive mental games for teams or pairs of soldiers.These include card games or board games likechess and checkers.

(4) Equipment for the physical andmental games can be brought from home upondeployment. Equipment may be mailed by friendsand family on request. The equipment may beobtained from the morale/welfare/recreation setor purchased from host nation retailers. Some ofthe equipment for games may be constructed outof otherwise worthless trash as an individual orteam project.

(5) Teach relaxation techniques ingroup relaxation sessions in which the mentalhealth/CSC person talks everyone through thetechnique.

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i. Debriefing, Ventilation, and Coun-seling. Mental health/CSC personnel (or medicstrained by mental health/CSC personnel) provideindividual or small group discussion and coun-seling.

(1) Formal critical event debrief-ing or ventilation is not usually done in largeformations or group activities during brief res-toration. The turnover is too rapid to form highlysupportive relationships and a clear therapeuticmind-set. Instead, the tendency is for the highpercentage of new BF casualties (all of whom havehad different bad experiences and who arestrangers to the group and to each other) toamplify rather than resolve the distress. Whenthe group begins to move in this direction, theleader reassures the distressed soldiers that hewill talk with them later and redirects the group’sattention to the next scheduled activity.

(2) After each new arrival has set-tled in, he is interviewed in detail by the assignedsquad leader and/or by the mental health/CSC supervisor or consultant. This interviewreviews exactly what happened to bring thesoldier here. The focus is on recent events in thesoldier’s unit or back home rather than on theremote past.

(3) The process is similar to after-action or critical event debriefings. As the detailsare described, the feelings naturally come out or,at least, show enough signs that they can bereflected and validated as honest and normal.The counselor works patiently to get all the factsand feelings out, then subtly helps to put theminto a perspective that reinforces their normalityin the combat context. The counselor leads thesoldier to seeing how to handle the same or othercrisis should a similar situation recur.

(4) The counselor may bring one,two, or more other recovering BF casualtiestogether to talk with the new arrival. This is

based on the counselor’s understanding of thesoldiers’ common experiences and the way theyare coping with them. These small, focusedgroups can often confirm the message of normal,shared experiences better than the counselor canby himself.

(5) As BF casualties recover, thecounseling process shifts towards how recoveringBF casualties can return to their small units andbe accepted there. The counselor must work withthe CSC coordinator or other resources (such asthe unit chaplains) who can assist this reinte-gration. Ways to coordinate and facilitate RTDwere discussed in Chapter 4.

8-3. First-Line Restoration

a. First-Line Restoration in the Divi-sion. In the division, first-line restoration isusually provided at the FSMC. It is provided bypersonnel organic to the FSMC, usually assistedand supervised by mental health officers andNCOs from the division mental health section.The combat stress preventive teams from corps-level CSC units may also assist and superviserestoration at the FSMC (See Chapters 2 and 3).

(1) The FSMC is usually located inthe BSA which is 25 to 30 kilometers behind theforward line of own troops (FLOT) so that it isjust beyond the range of the enemy’s mainartillery support, however, not beyond range oflonger-range tube and rocket artillery, air attack,or forces for special operations.

(2) Depending on the tactical situ-ation, the BSA may have to displace forward orrearward as part of the scheme of maneuver,or have to displace very hastily to escape per-sistent bombardment or an enemy probe orbreakthrough.

(3) For these reasons, restorationin the BSA will often be limited to 2 days or even

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1 day, or may have to be temporarily suspended.At other times, when the brigade is being held inreserve, 3 days may be feasible.

(4) In OOTW (conflict), the FSMCmay be located at a relatively large and securefire base or base cluster. Since each scenariois situationally dependent, the command sur-geon will establish holding times for first-linerestoration.

b. Separate Brigades or Armored Cav-alry Regiments. In separate brigades or ACR,first-line restoration should usually be providedat the medical company, separate brigade or atthe medical troop, ACR. It is provided by per-sonnel organic to the FSMC, perhaps assisted andsupervised by a combat stress preventive teamfrom a corps-level CSC unit.

(1) In many scenarios, the sepa-rate brigade (or regiment) may be in actionsimilar to that of divisional brigades. Its medicalcompany in the BSA would share the same typesof difficulties as the division’s FSMCs.

(2) In other scenarios, the brigade/regiment may be in division or corps reserve. Itmay also be engaged in rear battle against forceswhich lack the long-range artillery capability ofthe enemy’s main force, but may be more likelyto infiltrate and harass. The squadrons of anACR may also be highly dispersed far from theregimental medical troop. They may be supportedby the organic medical platoon. This squadronmay depend on corps ASMCs for its Echelon IImedical care, including CSC.

c. Corps and Communications ZoneFirst-Line Restoration. For CS and CSS units inthe corps or COMMZ, first-line restoration shouldbe provided by ASMCs with responsibility fortheir AO. It is provided by personnel organic tothe ASMC, assisted and supervised by NCOs and

perhaps a mental health officer from the ASMBmental health section (see Section II of Chapter3). If there are large numbers of BF casualties,the ASMCs could also be reinforced by a teamfrom a corps CSC unit.

(1) The ASMC has a holding ca-pacity of 40 cots.

(2) The corps area is likely to befree from artillery attack, except for large, long-range rockets or the smaller rockets or mortarsof infiltrating unconventional forces. Air attackis still possible.

(3) Corps ASMCs will be relativelyunlikely to have to move on short notice exceptpotentially in rear battle situations. Restorationup to 3 days (and even to 4 days) should usuallybe feasible.

(4) Those ASMCs in the COMMZshould be even safer and more stable than thosein the corps, except in the theater NBC envi-ronment. However, they are also vulnerable torear battle situations.

d. Medical Company Restoration Sup-port. Support provided for restoration is a re-sponsibility of the supporting medical companies.

NOTE

Combat stress control teams bringspecialized skills and perhaps somesupplies to help with their critical RTDmission, but do not relieve the localmedical commanders of their ultimateresponsibility.

(1) When total casualties are light,patient-holding squad elements in division- and

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corps-level medical companies provide resourceswhere BF casualties can be rested, fed, andrestored. The patient-holding squad personnel(two 91Cs and two 91Bs) serve as treaters.Ideally, the treatment will be under the technicalsupervision of the mental health section or CSCteam personnel.

(2) The holding squad will havetwo GP medium or large tents with up to 40 cots.When there are few patients, the second tent canbe the “rest tent” for HOLD BF casualties andother minor DNBIs. The first tent remains readyto receive new arrivals, some of whom may beseriously injured. At some times, of course, thecompany commander may decide to keep one tentpacked on the truck, ready to "jump” if a move isordered.

(3) Those BF casualties whosesymptoms are not dramatic (primarily thoseshowing extreme fatigue, other normal/common“psychosomatic” symptoms, and simple memoryloss which could also be due to concussion andtherefore require a period of medical observation)can be mixed in with the minimally wounded andminor DNBI cases. Recovering BF casualtieswhose more dramatic symptoms have improvedcan also be billeted with true “patients” as long astheir imminent RTD is emphasized. Selectivitymay be required to ensure they do not “catch” thesymptoms of the disease patients, either throughtrue infection or unconscious imitation.

(4) Those cases who are showingmore dramatic symptoms of anxiety, depression,physical disability, memory loss, or gross dis-organization can be quartered temporarily ina separate tent or expedient shelter. Thesepatients are under the observation of trainedmedical or CSC personnel. If sufficient shelter isnot available for these BF casualties, evacuationto a second-line restoration facility is required. Iftransported by nonmedical vehicle, an attendantmust accompany these BF casualties.

(5) The medical unit’s holding re-sources are available only when WIA and DNBIrates are low. Battle-fatigue rates rise in directproportion to the intensity of combat (as reflectedin the WIA rate). It will be at times of such heavyfighting, when the holding assets are preemptedfor emergency medical and minor surgical care,that it is most important to restore BF casual-ties close to their units. At other times, mini-epidemics of gastrointestinal, upper respiratory,or other infectious diseases may fill the holdingcots to the exclusion of BF casualties. That BFcasualties are moved out into “expedient shelters”to make way for true patients is, of course,consistent with the message of treatment thatthey themselves are “not sick. ” However, ifweather is inclement and no “expedient shelter”is available, these soldiers are evacuated to asecond-line restoration center unless assets arehastily sent forward and set up for them.

(6) Obviously the medical com-pany’s patient-holding resources cannot be reliedupon for consistent first- or second-line CSCsupport at times of mass casualties. The organicmental health sections in the divisions or in theASMB in the corps are without BF casualty-holding capability of their own. If restoration isstill to continue to return the BF casualties toduty quickly, reinforcing CSC teams must bringsufficient assets. This includes lightweight/low-cube tentage, working tools, and means to heatwater to be able to provide the very basic shelter,food, and hygiene which are the minimumessentials for treatment.

8-4. Second-Line Restoration (FatigueCenter)

Location of Second-Line Restoration.Each of the forward locations listed above shouldbe backed up by a second-line restoration capa-bility at a location which is relatively less likely

a .

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to have to move on short notice. It should havesufficient NP/mental health staff expertise tomanage the more problematic cases. These mayinclude clinical psychology, psychiatric nursing,and OT, in addition to social work and psychiatry.The facility should be able to hold these casesfor 3 days and conduct a stable, well-organized“fatigue center. ” Fatigue centers may be locatedat the MSMC in the division or at the HSC of anASMB (in the corps or COMMZ).

b. Fatigue Center. The name “fatiguecenter” is suggested for this facility for tworeasons. First, it is a central place where fa-tigued soldiers are sent to rest and recover theirstrength. Second, it does not sound too attrac-tive—not as attractive and desirable as a restcenter. While there, the soldier will be assignedto work details which can be tiring and notespecially fun.

Cases Received at the Fatigue Cen-ter. The fatigue center receives all REFER BFcases who must be evacuated from the first-linemedical companies. Many of these cases may besent back for purely tactical reasons, but othersare evacuated because their symptoms are toodramatic or unstable to manage so close to thebattle. Other soldiers requiring restoration maycome from nearby units in rear battle.

c .

NOTE

Transportation of BF casualties fromBSA to DSA or from ASMC to theASMB’s HSC will be an exception tothe usual flow of WIA from the siteof initial stabilization directly tohospitals in the corps. For this reason,transportation of BF casualtiesrequires special attention and shouldbe in nonambulance vehicles, ifpossible.

d. Restoration Techniques. The tech-niques of restoration at the fatigue center areessentially the same as at the more forwardlocations. The number of cases at any one timeis likely to be larger since they may be comingfrom several forward MTFs and staying longer(up to 3 days). Dealing with the more symp-tomatic soldiers will also require more interviewand treatment skills.

e. Neuropsychiatric Disorders. Someof the soldiers sent back from the first-linemedical companies will prove to have true NPdisorders which require further evacuation to acorps hospital. The second-line fatigue center,therefore, needs to have a neuropsychiatricallytrained physician or psychiatric clinical nursespecialist to provide stabilization capability.

f. Reinforcement by Combat StressControl Teams. Combat stress control teamswhich reinforce to setup a “fatigue center” shouldbring sufficient tents and equipment to provideformal “holding” for 20 to 40 BF casualties. Thiscan then provide basic shelter” for up to twicethat number in the event of a mass casualtysituation.

8-5. Third-Line Restoration

a. Operating a Fatigue Center at anEchelon III or Echelon IV Hospital. In somescenarios, units with soldiers in need ofrestoration may be significantly closer to a CSHin the corps and a FH or a GH in the COMMZthan to any of the ASMB’s medical companies.In such cases, the principles of immediacy andproximity justify conducting a restorationprogram (fatigue center) at the hospital.

(1) Staffing would be as an addi-tional duty to the NP ward, the consultationservice, and the MCWs. These personnel could

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be reinforced by teams from the medical company,CSC.

(2) If a task-organized CSC ele-ment from the corps medical company, CSCcollocated with the CSH (usually to staff a re-conditioning program as described in Chapter 9),it could also provide restoration.

b. Considerations for Restoration at aHospital.

(1) The threat to a CSH is similaras to the ASMB. The CSH can move only aftermuch preparation with external assistance.

(2) Restoration at a CSH must bekept clearly separate from the NP ward andideally from the MCW. It should also be separatefrom any reconditioning (14 day) program.

8-6. Return to Duty or Further Referralof Restoration Cases

Battle-fatigue symptoms do not necessarilyimprove completely while the prospect of combatcontinues. The positive expectancy is for RTD ofthe soldier with sufficient confidence that he cando his job. It does not require that the soldierfeels happy, sad, or frighten about his situation.The soldier’s condition may continue as post-traumatic stress symptoms, if not necessarily asPTSDs. The symptoms/disorders may occur afterthe war is over and the soldier has returnedhome. Most BF casualties in restoration areready to RTD when they have regained sufficientconfidence in themselves and their symptomshave returned to the range of the "normal/common signs.” These normal/common signs areoutlined in Graphic Training Aid (GTA) 21-3-4.Every reasonable effort should be made to sendthese soldiers back to their original unit.

a. Recovered Soldiers in the BrigadeSupport Area. Recovered cases from units that

are present in the same BSA are returned directlyto their units. For example, a soldier from aninfantry company can return through his infantryheadquarters and headquarters company, whosefield trains are part of the BSA. The medicalcompany patient administration specialist notifiesthe unit (or equivalent) to send someone to getthe soldier.

(1) Consultation by the CSC teamwith leaders of the BF casualty’s parent unitfacilitates the recovered soldier’s acceptance andtransportation back to his unit. Some specialcases may require reassignment to another unitwhich is coordinated through the recoveredsoldier’s battalion S1.

(2) This soldier has been kept onthe rolls by his unit during the 1 to 3 days du-ration of treatment. The summary of treatmentfor medical statistical purposes is captured bycarding for record only, utilizing the FMC. Careprovided to this soldier will be considered out-patient treatment and any documentation will bedone on the FMC. A copy of the FMC is sentback to the major MEDCOM in the TO uponrelease of the soldier.

b. Recovered Soldiers in the DivisionRear. Recovered BF soldiers who have completedrestoration treatment in the DSA are returnedto duty by contacting the division personnelreplacement company. If the soldier’s unit is inthe DSA, his unit is called. Coordination forreturn of the soldier to his original unit or forreassignment to a new unit is accomplishedthrough the G1 section. Direct consultation withthe forward area unit receiving the recovered BFsoldier is coordinated with the forward deployedCSC personnel supporting the unit’s AO.

c. Recovered Soldiers in the Corps.Return to duty of recovered BF soldiers in thecorps depends on where they received theirtreatment. If an ASMC provided the treatment,

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then the ASMC calls the soldier’s unit to providetransportation. If the recovered soldier wasevacuated to the HSC of the ASMB forrestoration, his RTD must be coordinated. TheRTD of these soldiers may be complicated be-cause there may not be a routine means oftransporting personnel between the remotebase defense clusters. Either the soldier’s unitmust come the distance to collect him or othertransportation must be coordinated. Alterna-tively, he may be returned to his unit by way ofthe personnel replacement company. Main-taining accountability for such cases is crucial—otherwise, they get lost in the medical evacuationor transportation system and no one knows wherethey are.

d. Completing the Recovery. Somecases in restoration do not improve sufficiently in3 days to be ready to return to their units and fullduty. The cases which are making progress mayneed additional time to complete the recovery.Some may need only another 1 to 3 days, whichneed not be spent under full-time medical ormental health/CSC care. Soldiers who requireonly 1 to 3 days of additional rest for full recoverymay be placed in their units’ CSS trains asREST BF cases. The CSS trains in the BSA, at aDISCOM unit in the DSA, or in a corps support

command unit in the corps could be used. Thismust be coordinated with the soldier’s unit priorto his disposition.

e. Referral to Reconditioning. Thosewho need further mental health/CSC professionaltreatment are temporarily reclassified as having"REFER" BF and are sent to the supportingreconditioning program, if one is available. Thismovement should not be called an evacuation. Itshould be done without much fanfare (so as notto attract the attention of newly arrived BFcasualties). The preferred method of sending theREFER BF casualty is by ground, not air, and ina GP vehicle, not an ambulance. If ambulancesmust be used, these REFER BF casualties shouldgo as ambulatory (not litter) cases.

f. Referral to Hospital. A few casesmay be identified by the division or other psy-chiatrists as having an NP disorder whichrequires evacuation to a hospital. These may goby ground (or air) ambulance as litter patients.

g. Referral for Administrative Actions.A few cases may be identified as malingerers whodo not respond to counseling and refuse to RTD.They are turned over to their parent unit foradministrative disposition.

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CHAPTER 9

COMBAT STRESS CONTROL RECONDITIONING

9-1. Reconditioning Treatment Program

a. Overview of Reconditioning. Recon-ditioning programs are intensive efforts to returnBF casualties to duty when they have notimproved sufficiently with 1 to 3 days ofrestoration. In the corps area these programsare normally 7- to 14-days long but can be asshort as 3 days, depending on the corpsevacuation policy. Reconditioning may continueas long as 28 days in the COMMZ, depending onthe theater evacuation policy. These programsare conducted in a nonpatient care setting bymedical CSC, NP, and mental health personnel.Reconditioning also can include rehabilitation ofthose BF casualties who were evacuated to ahospital without receiving restoration treatment.It can include NP and alcohol/drug patients andminor misconduct stress cases with good potentialfor RTD. Conducting reconditioning programsis a mission of the medical company, CSC.Reconditioning can also be provided on a smallscale by the medical detachment, CSC underspecial circumstances. Reconditioning is alsoprovided by the combined NP ward and con-sultation services, the OT/PT sections, and theclinical psychologist of FHs in the COMMZ.

b. Priority of Reconditioning Pro-grams. Reconditioning programs have lowerpriority than restoration programs. This isbecause they are manpower intensive and havea lower return of RTD for the effort invested.When the number of BF cases who may need 1 to3 days of restoration treatment is high, additionalCSC personnel should be sent forward fromreconditioning programs to reinforce forwardrestoration teams. The reconstitution supportmission may also need to draw upon recondi-tioning program staff.

(1) If a shortage of reconditioningstaff is only temporary, it may not be necessaryto evacuate the excess caseload. They may be

maintained on a less-intensive program. Thisprogram would entail more work details and lessindividual and group therapy until staffing ratiocan be restored.

(2) At times when reconditioningcases far exceed the staff available to treat them,reconditioning may be limited to fewer days persoldier or may be discontinued altogether. Thischange will effect some of those soldiers in thereconditioning program who might be returnedto duty with additional treatment (and mightbe protected from subsequent PTSD). They willbe evacuated to the COMMZ and/or CONUS tomaximize RTD of those soldiers with the bestpotential.

(3) Reconditioning, like restora-tion, can be provided by successive echelons.Treatment facilities in the COMMZ or corpsrear should continue to treat the evacuees withrelentless positive expectation. This is calledsecond-line reconditioning. The program shouldcontinue as third-line reconditioning for thoseevacuated to CONUS.

9-2. Reconditioning Program Methods

a. Reconditioning Extends Restoration.Reconditioning is similar to restoration but moreorchestrated over longer periods of time, is moreintensive, and it requires a higher staff-to-caseratio. Reconditioning puts special emphasis ona highly structured military unit environmentand schedule of activities. Treatment strategiesassist recovering soldiers in regaining skillsneeded for combat duty. These skills and abilitiesinclude concentration, team work, work tolerance,psychological endurance, and physical fitness.

b. Military Unit Structure. As in res-toration, the soldiers are not treated like patients

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on a ward under the care of therapists. Rather,the BF casualties are treated like other soldiersassigned to a military unit which requires—

Assignment to a squad or teamwith a staff member as squad or team leader.

Wearing the prescribed uni-form and appropriate LBE.

c. Physical Replenishment. Recon-ditioning continues to provide physicalreplenishment (food, hydration, sleep) andhygiene (shower), especially in the first few days.Later in the program, the comfort factor may beintentionally decreased; for example, bysubstituting MREs for some A-ration meals andby assigning recovering soldiers to night duties.These duties may include fire watch, perimeteror gate guards, or radio watch.

d. Unit Formations. Unit formationsare held on a regularly scheduled basis. Thepurpose of the formation is to—

Disseminate information.

Account for all personnel.

Announce the daily work andtraining plan or changes.

Break out or cross-attach sub-elements into small groups for activities or details.

Introduce new unit members.

Brief on the tactical and worldsituation, especially as it relates to the soldiers’units of origin.

tional activities.

9-2

Assign physical and occupa-

NOTE

Display of unit emblems, mottoes,streamers, and other distinctive de-vices should be encouraged to focus thesoldier’s attention on his unit of originand his identification with it.

e. Physical Reconditioning Activities.Physical reconditioning activities may include—

Calisthenics and stretching ex-ercises.

Running in formation.

Competitive sports.

f. Individual Counseling and Therapy.Individual counseling and therapy may include—

Abreaction (redescribing andremembering the traumatic events in detail andreleasing pent-up emotions).

Working through personalgrief, guilt, and home-front issues.

For some cases, psychothera-peutic drugs for brief symptom relief, or taperingoff drugs used in stabilization or detoxification.

For some cases, hypnosis oramytol interviews to uncover repressed memories.

g. Group Sharing and Validation.Group sharing and validation of common ex-periences and issues include—

Restoration of perspectivethrough realistic reappraisal of the traumaticevents.

Cognitive reframing.

FM 8-51

h. Group Training in Relaxation Tech-niques. Group training in relaxation techniquesis provided and includes—

Abdominal breathing.

Breathing for meditation.

Progressive muscle relaxation/autogenic training.

Focused imagining of relaxingsituations.

i. Group Training in Life Skills.Group training in life skills is provided to assistwith—

Control of impulses and anger.

Appropriate assertiveness inthe military context.

j. Common Soldier Task and SuruivalSkill Drills. Common soldier task and survivalskill drills may be provided as individual and asteam competition.

k. Drug and Alcohol Abuse Counseling.Drug and alcohol abuse counseling may be pro-vided through individual or group work sessionsas indicated.

l. Reconditioning Program Work Proj-ects. Reconditioning program work projects mayinclude—

Improving and reinforcingdefensive positions such as entrenching andsandbagging.

Improving living conditionssuch as making furniture or installing packingcrate floors.

Building better showers orlatrines.

m. Work Assignments. Work assign-ments to medical units for real work details are—

Coordinated and monitored bythe reconditioning program OT staff.

Increased over the course ofthe program and gradually displace most of thetherapy and training sessions.

Considered protected statussince they are patients.

n. Tempora.y Reassignment to CombatSupport or Combat Service Support Units. Whenrecovering soldiers are temporarily assigned aspart of their reconditioning program to CS or CSSunits for work, the—

Assignment of the soldier is for24 hours of each day.

Soldiers are no longer in a pro-tected status under the Geneva protocol.

Combat stress personnel con-tinue to work with the soldier in preparing himfor RTD to his original unit, or reassignment to anew unit.

9-3. First-Line Reconditioning Centers

a. Combat Fitness Reconditioning Cen-ters. Combat fitness reconditioning centers inthe corps are staffed by task-organized CSCelements from the medical company, CSC. InOOTW, a reconditioning center could be estab-lished by a task-organized CSC element from oneor more detachments, CSC. This is done onlyif the medical company, CSC has not beendeployed. Also, if the inpatient NP work load is

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light, a small reconditioning program may bestaffed by personnel from the NP ward andconsultation service of a CSH. A reconditioningcenter usually collocates with a CSH but mustmaintain its separate, nonhospital identity.

b. Area for Establishment. While thehospital is often in the open, the combat fitnessreconditioning centers should be in or close tothe tree line or under camouflage. It should notbe situated near the morgue, triage area, orhelicopter pad. It should be placed in an areawhere incoming ambulances are not seen as theyoff load their patients. Often the best area forestablishing the combat fitness reconditioningcenters is next to the CSH staffs’ quarters tents(not among the wards). This is normally closeto the food service kitchen, the showers, andthe laundry. There the BF casualties receivereplenishment and perform work details. TheCSC unit (CSC restoration and CSC preventiveteams combine as a task-organized CSC element)can provide their own tents for staff quarters andthe operations center. They can accommodate amoderate number of soldiers in their own tentsfor reconditioning (20 per GP large tent in thetask-organized CSC element). If the recondi-tioning case census exceeds the capability of thetask-organized CSC element to provide tentage,the additional tents are requested from themedical company, CSC headquarters. If tentscannot be provided, additional shelters andsleeping facilities are requested from the hostCSH. In some situations, local buildings maybe used or other arrangement made throughhost-nation agreements. The combat fitnessreconditioning centers may be augmented by anelement from the medical company, holding. Thepatient care providers of the holding facility canalso be trained (under the supervision of mentalhealth/CSC personnel) to serve as squad leaders,each supervising six to ten BF soldiers.

c. Working with the Supporting Hos-pital. The combat fitness reconditioning center

is dependent on the supporting hospital forcommunications, food services, shower facilities,and other areas of support. The combat fitnessreconditioning center works with the supportinghospital by sending work parties of recoveringsoldiers to assist in food preparation and deliveryand cleanup chores. The recovering soldiers fromthe reconditioning center may also be used forassisting with work details throughout thehospital but must be under direct supervision ofeither hospital or mental health/CSC personnel.

d. Medical Records. The combat fit-ness reconditioning center uses the supportinghospital’s medical records section to maintain thepermanent case records.

(1) Cases who were initially ad-mitted to a hospital ward for stabilization aretransferred to the combat fitness reconditioningcenters, and the combat fitness reconditioningcenters staff continues to keep the standard hos-pital chart. The soldier is given any personaleffects that were secured by the patient adminis-tration section at the time of his initial admission.

(2) Cases who are “transferred”from a restoration facility go directly to thecombat fitness reconditioning center. Theyshould not be admitted through the supportinghospital’s admission area. However, all patientadmission steps except securing personal itemsand affixing a hospital identification wristband are done upon their arrival at the combatfitness reconditioning center. These steps areaccomplished or monitored by the patientadministration specialist assigned to the medicalcompany, CSC. The combat fitness recondi-tioning center also initiates a hospital chart oneach case.

(a) Cases in the combat fit-ness reconditioning center are counted as patientsin the reconditioning center on the daily hospitalcensus.

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NOTE coordination should be conducted to move thecombat fitness reconditioning centers to collocate

These cases are counted as patients onthe daily hospital census. The casesare not counted as occupied beds whenreporting the hospital bed occupancy.

(b) Upon disposition from thecombat fitness reconditioning center, whether forRTD, retraining for other duty, or evacuation,the combat fitness reconditioning center’spsychiatrist prepares the chart for furtherevacuation or writes the discharge summary andcloses the hospital’s chart.

e. Stabilization. Stabilization of seri-ously disturbed NP or BF casualty cases shouldbe the responsibility of the collocated hospital’sorganic NP personnel and NP care ward. Neuro-psychiatric ward cases should not disrupt or infectthe combat fitness reconditioning center’snonpatient status, RTD-oriented activities, andatmosphere. Cases can be transferred easilybetween the hospital’s inpatient NP ward and thetents of the combat fitness reconditioning center.

f. Multiple Small Reconditioning Cen-ters. The preferred option in a corps-sizedoperation is to have a separate, small recon-ditioning center collocated with a hospital behindeach division. That combat fitness reconditioningcenter treats soldiers from that division plussupporting corps units located in its AO. Thismaintains the principle of proximity and favorsimmediacy and simplicity by avoiding prolongedtransportation of cases. The maintenance of unitidentification (most soldiers wearing the samedivision patch) also aids the positive expectation.Limited resources or geography, however, mayrequire use of consolidated reconditioning centers,which would each support several divisions.

g. Mature Theater. In a mature thea-ter, once action in the corps has stabilized,

with (and receive logistical support from) a quar-termaster or personnel unit. Hospital charts/medical records would continue to be kept by thenearby CSH.

h. Division Fatigue Center. Under spe-cial circumstances in OOTW, a division “fatiguecenter” with few cases in need of restoration couldchange mission to become a small reconditioningcenter. Under these special circumstances themedical detachment, CSC personnel could staff avery small reconditioning program. Any patientadmitted to this program would be carried as anadmission to the supporting CSH. Inpatientrecords are initiated and maintained by CSCpersonnel. Upon completion of the reconditioningprogram, the inpatient record is forwarded to thesupporting CSH.

9-4. Disposition of First-Line Recondi-tioning Cases

a. Status of Reconditioning Cases.Some reconditioning cases will be able to returnto far-forward CS or CSS duty. However, manyof the soldiers who need reconditioning will beunable to return to their original unit. This couldbe a result of combat operations or the nature oftheir symptoms which prevent their return tooriginal units.

(1) Ideally, BF casualties who un-dergo a 14-day restoration program in the corpsshould not be crossed off the division’s personnelrolls (as specified in AR 40-216). However, inhigh casualty situations, the division commanderwill be unwilling to wait two weeks on the un-certain chance that he will get his old BF soldier(now improved) back again. The commander willwant to count soldiers as losses to the division ifthey are gone more than 3 days in order to req-uisition replacements. Even when BF casualties

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are no longer on the division’s rolls, every fea-sible effort should be made to return those BFcases who recover fully to their original units.This is desirable even if that unit has alreadyreceived a replacement and is technically noteligible to receive another. Most units in combatare chronically understrength and they can alsoanticipate more losses in the near future. Anoverly strict interpretation of the replacementpolicy should not prevent the mutually beneficialreturn of a recovered soldier to his unit. Thedivision psychiatrist and the CSC unit teams whoare attached to reinforce that division shouldmaintain frequent contact with the combat fitnessreconditioning centers which supports thedivision (as specifically directed in AR 40-216).Coordination efforts, through the DMOC and thepersonnel replacement system by division mentalhealth/CSC personnel, should attempt to facili-tate return of recovered soldiers to their originalunits.

NOTE

The CSC consultant should also ensurethat everyone knows that it is just asimportant (if not more so) to returnrecovered WIA and DNBI soldiers totheir original units whenever possible.

(2) More commonly, reconditionedsoldiers may need reassignment (and perhapsreclassification into new MOSS) and/or on-the-jobtraining into new combat, CS, or CSS roles. Ifrecovered BF casualties cannot be returned totheir previous small unit, they should be formedinto small (two to five persons) cohesive groupsor teams which can be reassigned to a new unittogether (or to the unit of one of those soldiers).The combat fitness reconditioning centers mustcoordinate with the personnel replacementsystem and nearby CSS units to find a suitable

9-6

assignment for these newly formed two- to five-person teams.

(3) For some cases, it may be bestto have the recovering BF casualty (as part oftheir reconditioning program) visit with nearbyunits during the day (returning to the combatfitness reconditioning center at night) beforebeing returned to duty for assignment. Any workperformed during such visits must conform tothe Geneva Conventions (see Appendix D).Alternatively, the recovering BF casualty maybe assigned to the CSS unit 24 hours/day ontemporary duty as a REST BF casualty until heis ready for reassignment (preferably in pairs orgroups) to other units.

b. Evacuation Policy.

(1) Army Regulation 40-216 speci-fies that there should be a 14-day reconditioningprogram in the corps. This recognizes the factthat the additional days substantially increase theRTD rate. At the NP clearing companies inWWII, the average length of stay was 11.4 days.The corps evacuation policy is at the discretion ofthe theater commander. In some situations, themaximum length of stay may be set by the theatercommander at 7 days.

(2) If the corps evacuation policyis less than 14 days, the mental health/CSC staffpsychiatrist of the medical brigade should requestan exception for BF casualties in reconditioningprograms. He submits the case via the com-mander, medical brigade, through the corpssurgeon to the corps commander. The followingfacts apply:

(a) The reconditioning pro-gram, because of its austerity, is not a significantlogistical burden to the corps—it requires onlyfood, water, and shelter for the cases, plus thesupplies and equipment from quartermaster units

FM 8-51

that rearm the recovered soldier for combat orother duties.

(b) Because the combat fit-ness reconditioning center maintains a militarysetting, it is not a conspicuous target. Its case-load performs useful work details and perimeterdefense, either for medical units or for alltype units, depending on its chosen GenevaConventions status (see Appendix D).

(c) The increase in RTD ofBF casualties (mostly to CSS units) frees assignedsoldiers for other duties, reduces the accu-mulation of cases with poorer prognoses in theCOMMZ, and minimizes chronic disability.

c. Evacuation. Reconditioning caseswho do not recover sufficiently to return to someduty within the designated evacuation period areevacuated from corps to COMMZ. They are besttransported in GP trucks and buses, busambulances, or an ambulance train. In the lattertwo cases, they should be assigned helper tasks.Use air evacuation if there is no other alternative.

9-5. Second-Line Reconditioning in theCommunications Zone

a. Option 1—Field Hospital. Establishreconditioning programs in the COMMZ at oneor more FH. The FH is preferred to the GHbecause it is dedicated to RTD of convalescingcases. It has a psychologist and OT personnelassigned to the hospital unit’s medical holding.These personnel are in addition to the NP wardand consultation service personnel assigned to thehospital unit base.

(1) The FH has sufficient mentalhealth staff to conduct a small reconditioningprogram, provided it is not preoccupied withNP cases. However, most of its recondition-

ing capability will be required for the estimated10 percent of the RTD wounded who also havesignificant BF. This capability could be improvedsomewhat by attaching a platoon of the medicalcompany, holding.

(2) It is still important to minimizethe hospital atmosphere and to treat the casesnot as patients but as soldiers being reconditionedfor combat-related duties. (The same is true forthe convalescing WIA with concurrent BF.) Thefacility should be in a separate building with itsown rigorous schedule of therapeutic activities,physical training, and work projects.

b. Option 2—Combat Stress ControlUnits. A medical company, CSC may be allocatedto the COMMZ and assigned to the medicalbrigade. The medical company, CSC, reinforcedwith a patient-holding capability, may establishseparate “nonhospital” reconditioning centers inthe COMMZ.

(1) In OOTW, task-organized CSCelements of a medical company or a medicaldetachment, CSC combine with a 240-cot platoonof the medical company, holding. Attach thiscombat fitness reconditioning center to a FH orGH.

(2) Limited conflict is defined hereas either—

(a) A relatively small conflictwhich does not require all CSC units in theforward areas of the corps.

(b) The late stages of a largerwar when fighting has stabilized or ceased, sothat CSC units can be withdrawn from forwardareas to provide reconditioning in the COMMZ.In the latter (late in the war) situation, someof the work load may include cases who haveaccumulated in the COMMZ. These cases may

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not have received mental health/CSC treatmentbecause there were insufficient evacuation assetsto transport them to CONUS along with thewounded and the true NP cases. These wouldmake a difficult, but still potentially rewardingcaseload.

c. Second-Line Reconditioning Cases.Most second-line reconditioning cases willno longer need much physical replenishment.The combat fitness reconditioning centerprograms continue to emphasize physical fit-ness, soldier skills, work details, and individual/group counseling/psychotherapy. Cases will beretrained for CSS duties in COMMZ and corps.As soon as the recovering soldiers are ready,the retraining site can shift to on-the-job trainingat a nearby CSS unit. This training beginsas a day job, returning each night to thecombat fitness reconditioning center. Later,the soldier may be placed full time in the newunit (as DUTY BF) while being followed-upperiodically by the combat fitness reconditioningcenter’s staff.

9-6. Third-Line Reconditioning

a. Battle Fatigue Casualties That Failto Improve. Those BF casualties who do notimprove sufficiently to RTD in the COMMZ aresent to CONUS. If these BF casualties have notbeen found to have some NP or physical disorder,they should be transferred to a third-line re-conditioning center in CONUS. If they have NPor physical disorders which warrant dischargefrom the Army, they are sent to the Departmentof Veterans Affairs for additional treatment andfollow up. The facilities for the reconditioningcenters should be located at MEDDACs or medicalcenters which are on active Army posts thatprovide the military atmosphere and theopportunity for job retraining in actual units.

b. Sending to Appropriate Recondi-tioning Center. The BF casualty should be sentto the reconditioning center which is best suitedfor the retraining to be done. This center is oftennot the one that is nearest the soldier’s home ofrecord.

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APPENDIX A

LISTING OF MAJOR ITEMS OF EQUIPMENT FORTHEATER ARMY MEDICAL COMBAT STRESS CONTROL

UNITS AND ELEMENTS

A-1. General

The major items of equipment in this listing are authorized by the base TOE and other required itemsare authorized by the common table of allowances (CTA).

A-2. Medical Company, Combat Stress Control

a. Headquarters Section.

(1) Major items authorized by the baseinclude—

Truck, cargo, tactical, 2 l/2-ton (twoTrailer, cargo, 1 l/2-ton (one each).Truck, utility, l/4-ton (one each).Trailer, cargo, l/4-ton (one each).Tow bar, motor vehicle (one each).Generator, 5 kilowatt (one each).Radio set, AN/VRC 90 (one each).

TOE and assigned to the headquarters

each); one truck has a winch.

Radio set, control group, AN/GRA-39 (one each).Tool kit, general mechanic, automotive (three each).Tool kit, carpenters (one each).Tool kit, small arms repairman (one each).Camouflage screen support system (nine each).

(2) Major items of CTA equipment assigned to the headquarters section include—

Tent, general purpose, large (one each).Tent, general purpose, medium (two each).Tent, general purpose, small (three each).Tent, vehicle maintenance (one each).Tent liner, general purpose, Iarge (one each).Tent liner, general purpose, medium (two each).Tent, general purpose, small (three each),Panel marker set, Geneva (three each).

section

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b. Preventive Section.

(l) Major items authorized by the base TOE and assigned to the preventive sectioninclude—

Truck, cargo, tactical, 5/4-ton (six each) with 3/4-ton trailers, cargo (six each).Medical equipment set, sick call, field (six each).Clinical psychologist set, field (one each).Generator, 5 kilowatt (one each).Camouflage screen systems for woodland and desert.

(2) Major items of CTA equipment assigned to the preventive section include—

Tent, general purpose, medium (six each).Tent liner, general purpose, medium (six each).Panel marker, Geneva (six each).

c. Restoration Section.

(1) Major items authorized by the base TOE and assigned to the restoration sectioninclude—

Truck, cargo, tactical, 5/4-ton (four each) with four trailers, cargo.Truck, cargo, 2 l/2-ton (four each) with trailers, 1 l/2-ton (four each).Trailer, tank, 1 l/2-ton, water, 400 gallons (two each).Generator, 3 kilowatt (four each).Medical equipment set, sick call, field (four each).Clinical psychologist set, field (four each).Tool kit, carpenters (four each).Camouflage screen systems, woodland and desert.

(2) Major items of CTA equipment assigned restoration section include—

Tent, general purpose, large (ten each).Tent, general purpose, medium (four each).Tent, general purpose, small (four each).Tent liner, general purpose, large (ten each).Tent liner, general purpose, medium (four each).Tent liner, general purpose, small (four each).Panel marker, Geneva (four each).

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A-3. Medical Detachment, Combat Stress Control

a. Detachment Headquarters.

(1)include—

(2)

Major items authorized by the base TOE and assigned to the restoration section

Truck, cargo, tactical, 5/4-ton with trailers, cargo, 3/4-ton.Generator, 3 kilowatt (one each).Radio set, AN/VRC 90.Telephone set, TA312 (one each).Camouflage screen systems, woodland and desert.

Major items of CTA equipment assigned to the headquarters section include—

Tent, general purpose, small (one each).Tent liner, general purpose, small (one each).

b. Preventive Section.

(1) Major items authorized by the base TOE and assigned to the preventive sectioninclude—

Truck, cargo, tactical, 5/4-ton (three each) with 3/4-ton trailer, cargo (three each).Medical equipment set, sick call, field (three each).Clinical psychologist set (three each).Telephone set, TA 312 (three each).Tool kit, carpenter (three each).Camouflage screen systems, woodland and desert.

(2) Major items of CTA equipment assigned to the preventive section include—

Tent, general purpose, medium (three each).Tent liner, general purpose, medium (three each).

c. Restoration Team.

(1) Major items authorized by the base TOE and assigned to the restoration sectioninclude—

Truck, cargo, tactical, 5/4-ton (two each) with trailers 3/4-ton, cargo (two each).Truck, cargo, 2 l/2-ton with trailer, 1 1/2-ton (one each).Trailer, tank, 1 l/2-ton, water, 400 gallons (one each).Medical equipment set, sick call, field (one each).Tool kit, carpenters (two each).

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Camouflage screen systems, woodland and desert.Clinical psychologist set (one each).Telephone set, TA 312 (one each).

(2) Major items of CTA equipment assigned to the restoration section include—

Tent, general purpose, large (two each).Tent, general purpose, medium (one each).Tent, general purpose, small (one each).Tent liner, general purpose, large (two each).Tent liner, general purpose, medium (one each).Tent liner, general purpose, small (one each).Panel marker set, Geneva (two each).

A-4. Division Mental Health Section

a.

b.

Major items authorized by the base TOE and assigned to the mental health section include—

Truck, utility, 5/4-ton (three each).Clinical psychologist set (one each).Camouflage screen support system (thirteen each).Telephone set, TA-312/PT (one each).

Major items of CTA equipment assigned to the division mental health section include—

Tent, general purpose, medium (one each).Tent liner, general purpose, medium (one each).Panel marker set, Geneva (one each).

A-5. Area Support Medical Battalion Mental Health Section

a. Major items authorized by the base TOE and assigned to the mental health section include—

Truck, cargo, tactical, 2 l/2-ton (one each),Truck, utility, 3/4-ton (three each).Camouflage screen support system (thirteen each).Telephone set, TA-312/PT (one each).

b. Major items of CTA equipment assigned to the headquarters section include—

Tent, general purpose, medium (one each).Tent liner, general purpose medium (one each).Panel marker set, Geneva (one each).

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APPENDIX B

COMBAT STRESS CONTROL ESTIMATES

Section I. GUIDE FOR THE DEVELOPMENT OF

AND PLAN

THE COMBATSTRESS CONTROL ESTIMATE OF THE SITUATION

B-1. Combat Stress Control Estimate

The CSC planner must prepare the CSCestimate in cooperation with the senior staffsurgeon who is responsible for preparing theoverall CHS estimate. The overall CHS esti-mate, and especially the PVNTMED estimate,provide important information (see FMs 8-55 and8-42).

a. Some issues may require the CSCplanner to work directly with the staff sections ofthe combat command: S1/Gl, S2/G2, S3/G3, S4/G4, and, G5 when appropriate. The staff chap-lains (unit ministry teams), JAG, and ProvostMarshal and MP units are also important sourcesof information.

b. The level of detail of the CSC esti-mate depends upon which echelon is preparingit.

(1) The division mental health sec-tion works with the division surgeon and thePVNTMED section. The division mental healthsection is concerned with brigades which arelikely to have the most BF cases or other combatstress and NP problems. This may determinehow many assets are pre-positioned and at whichBSAs. Within the brigades (and in the DISCOM),the division mental health section may need toidentify specific battalions, companies, and pla-toons in order to focus preventive consultation orreconstitution support activities.

(2) The CSC units which providebackup support and reconditioning in the corpsare concerned with divisions, separate brigades/regiments, and other corps units which are likely

to generate the most stress casualties. The medi-cal detachment or CSC company—

Receives the CSC esti-mates from the division mental health section orASMB mental health section and coordinatesdirectly with each.

Develops its CSC estimatein conjunction with its higher medical C2 unit.

Prepares to receive recon-ditioning cases at different regions of the battle-field.

Sends CSC augmentationteams or personnel to reinforce the forward unitsthat have the greatest need.

NOTE

The medical group and medical brigadeheadquarters will have a small mentalhealth staff section to help coordinatethese activities.

c. The primary objective of the CSCestimate is—

To predict where and whenthe greatest need is likely to arise among the sup-ported units.

To initiate preventiveefforts early.

To develop contingencyplans so that limited resources can be allocatedand prepared for their reallocation as needed.

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(1) Quantification of the projectedrestoration and reconditioning caseloads will notbe precise. Absolute values should not be giventoo much weight. However, quantification pro-vides a useful analytical tool for estimating rela-tive risk. The historical ratios of the incidence ofBF casualties to the incidence of WIAs provide abaseline for estimates in future operations.

(2) This analysis is most validwhen applied to specific units in a specific combatoperation. It is less precise when applied tolarger, composite units. The analyst must esti-mate what percentage of subunits of differenttypes (combat, CS, and CSS) will encounter parti-cularly negative factors (stressors). He must alsoestimate what percentage will be protected bybeneficial protective factors.

(3) The prediction for the incidenceof WIA requiring hospitalization in the CHS esti-mate provides a starting point. In moderate toheavy conventional fighting (mid-intensity con-flict), the CSC planner can begin with the averageratio of one BF casualty for five WIA (1:5). Thenhe can examine the nature of the mission for eachof the specific units involved and use protective(Positive) and risk (Negative) factors to judgewhether 1:5 is likely to be an overestimate or anunderestimate.

(4) For discussion later in thisappendix (paragraph B-2), the protective and riskfactors for BF are referred to by their parentheticsubparagraph numbers and are identified aseither (Positive ) or (Negative).

(5) Each of these factors could begiven a numerical weight (0, +1, +2 for positivefactors; 0, -1, -2 for negative factors). The factorscores are added algebraically to give a roughtotal score. The weight must be based on subjec-tive expert judgment and experience.

(6) The same analyzing processused to estimate BF casualties in relation to WIAs

can be applied to estimating the potential forsubstance misuse/abuse patients and other mis-conduct stress behaviors compared with theirnormal rates of occurrence in the troop popula-tion.

(7) The protective (Positive ) andrisk (Negative) factors for misconduct stressbehaviors in paragraph B-3 will be similarlydesignated, but with a letter "m" (for "miscon-duct”) after the parenthesis. Each factor will beidentified as either Positive or Negative.

B-2. Estimating Battle Fatigue CasualtyWork Load

a. Protective Factors. The followingprotective (Positive) factors reduce BF casualtiesrelative to WIA:

(1) High unit cohesion (Positive).Troops and their leaders have trained together(and, ideally, have been in successful combat)with little continual turnover of personnel. Forexample. Operational Readiness Training comp-anies and battalions are presumed to have highunit cohesion provided the leaders have had timeand training to develop “vertical cohesion” withpositive factors (5) and (6), below.

(2) History of very tough, realistictraining (for example, militarily sound and dan-gerous preparation to prepare troops for war)(Positive). Successful combat with few casualtiesis good training. Airborne and Ranger train-ing and realistic live-fire exercises (both smallarms and artillery) also help to "battle proof"soldiers.

(3) Unit leaders and medical per-sonnel are trained to recognize BF (Positive).They can manage DUTY and REST cases at unitlevel and reintegrate recovered HOLD and REFERcases back into units.

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(4) Units are withdrawn from com-bat periodically to rest, refit (reconstitute if nec-essary), and absorb new replacements (Positive).Replacements arrive and are integrated as cohe-sive teams, not as individual soldiers.

(5) Leaders demonstrate compe-tence, courage, and commitment (Positive). Lead-ers care for their soldiers and make provisionsfor physical and mental well-being as the tacticalsituation permits. Noncommissioned officersknow and are given responsibility for sergeant’sbusiness (taking care of their troops). Commandalso shows concern for soldiers’ families.

(6) Leaders keep troops informedof commander’s intent and the objectives of theoperation and the war (Positive). If necessary,they focus the soldiers’ appraisal of the situationalstressors to maintain positive coping.

(7) Victorious pursuit of a retreat-ing enemy (Positive). This reduces BF casualtiesbut may release misconduct stress behaviors un-less command retains tight control.

(8) Hasty withdrawal (Positive).During hasty withdrawals, few BF casualtiesenter medical channels. However, BF soldiersmay be lost as KIA, missing in action (MIA), orcaptured instead of becoming medical patients,and other soldiers who are stressed may desertor surrender.

(9) Beleaguered friendly unit whichcannot evacuate any (or only the most severelywounded) casualties (Positive). Here, too, somesoldiers may be combat ineffective due to BF orgo AWOL without becoming medical patients.

b. Assessment of the Positiue ProtectiveFactors.

(1) Positive factors (1) through(6), above, can be assessed using standard

questionnaire surveys of unit cohesion andmorale, such as the Unit Climate Profile found inDA Pam 600-69.

(2) Many leaders and soldiers wantto believe that their unit is elite and will have farfewer than one BF casualty for ten WIA, even inthe most intensive battles. The CSC plannershould not discourage this belief since it may be anecessary first step toward becoming true. How-ever, the CSC estimator should not make planson the strength of the belief alone. Remember,CSC expertise is managed wisely if it is far for-ward, assisting command in proactive preventionrather than reactive treatment of BF casualties.

(3) Even if tough realistic training,high cohesion, and fine leadership can be inde-pendently verified (as with unit survey question-naires), the BF casualty estimate should not betoo much less than the average until the unit hasproved itself in successful combat. Even then,estimates should continue to consider the poten-tial negative impact of cumulative attrition, newreplacements, and other adverse factors whichmay eventually overcome the positive factors.

(4) Positive factors (8) and (9),above, are, of course, not truly “Positive. "Whilethey decrease the expected requirement to evac-uate BF casualties for treatment, they indicate aneed to redouble efforts for prevention of mis-conduct stress behavior. Positive factor (7), above,also should alert command to the need to main-tain firm control to prevent misconduct stressbehavior.

c. Risk Factors. Increases in thefollowing risk (Negative ) factors add to the pro-portion of BF casualties in relation to WIA:

(1) Combat intensity—indicatedby the rate of KIA and WIA (percent of battlecasualties [out of the total troops engaged] perhour or day) (Negative).

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(2) Duration of continuous opera-tions—the number of days which the troops (smallunits) have been in action without respite, espe-cially if there is little opportunity for sleep (Nega-tive ). The operation may begin well before theactual shooting. Preparation time and rapid de-ployment (jet lag) effects should also be con-sidered.

(3) Cumulative combat duration—the total number of days (cumulated over days,weeks, months) in which the small units (platoons,companies) have suffered casualties (Negative).

(4) Sudden transition to the horrorsof war—many new troops with no prior combatexperience being confronted with surprise attackor new weapons of mass destruction (Negative).

(5) Extent to which the troops aresubjected to artillery and air attack (with someallowance for the strength of their defensive forti-fication, dispersion, and concealment) (Negative).This is especially true if they involve sudden massdevastation.

(6) Casualties from friendly fire(including direct fire, artillery, and air attack)(Negative). This, of course, is not part of the planof operation but is a special hazard of the fast-moving battle. When such incidents are reported,CSC teams should respond immediately.

(7) High NBC threat—a state ofalertness requiring periods in MOPP Levels 1through 4, frequent false alarms, and concernsand rumors about escalation (Negative). ActualNBC use: What type agents? (Persistent con-tamination? Potential for contagion?) Whatcasualties? What are the implications for in-creased MOPP levels, rumors, concerns of escala-tion, and worries about home?

(8) Being on the defensive, espe-cially in static positions (unless the fortifications

are very strong and comfortable, complacencymay be a problem) (Negative).

(9) Attacking repeatedly over thesame ground against a stubborn, strong defense(Negative).

(10) Casualties among armor ormounted infantry crews, such as when armor mustoperate in highly restrictive terrain (Negative).

(11) Casualties from mines or boobytraps (Negative).

(12) Extent and intensity of the rearbattle (Negative). The introduction of CS/CSSsoldier to the stress of battle when attacked.These soldiers are confronted with dangers andhorrors of war for which they may not have beenadequately trained or mentally prepared.

(13) Failure of expected support,such as fire support, reinforcement, or relief;inadequate resupply; inadequate CHS support(Negative).

(14) High personnel turbulence, re-sulting in low unit cohesion and inadequate unittactical training (Negative).

(15) Loss of confidence in leaders,in supporting or allied units, and in equipmentas compared to the enemy’s (Negative).

(16) Popular opposition to the warat home; lack of understanding or belief in thejustness of the effort (Negative).

(17) Families left unprepared byrapid mobilization and deployment (Negative).Lack of a believable plan for evacuating familiesfrom the theater; lack of plans for keeping themsecure under a reliable authority if they cannotbe evacuated. This can also contribute tomisconduct stress behaviors, especially AWOL.

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(18) Home front worries (Negative).Lack of visible command program for ensuringsupport to Army families.

(19) Inadequate water available fordrinking (Negative ).

(20) Adverse weather, especiallycold-wet; any harsh climate if troops are notproperly trained, equipped, and acclimatized(Negative).

(21) Unfamiliar, rugged terrain (jun-gle, desert, mountain, or urban) if troops are notspecifically trained and equipped (Negative).

(22) High prevalence of endemicminor illnesses, especially if this reflects inade-quate command emphasis on self-aid and buddyaid preventive measures (Negative).

(23) Last operation before units (ormany soldiers in them) rotate home, or if the waris perceived as already won, lost, or in final stagesof negotiation (Negative).

(24) Many civilian women and chil-dren casualties resulted from the fighting (Nega-tive). This may be a stronger factor in briefOOTW (conflict) than in war where the magni-tude of the horror and the preoccupation withpersonal and unit survival may quickly hardensoldiers to these casualties.

B-3. Estimating Substance Abuse andMisconduct Stress Behaviors

a. Protective Factors. Positive Factors(1) through (6), above, reduce alcohol/drug misuseand other misconduct stress behaviors (Positive).They can also become misconduct behaviors asshown in (b), below.

(l)m High unit cohesion is positiveif the unit’s "identity" forbids abuse of substances

and emphasizes adherence to the Law of LandWarfare, United States Code of Military Justice,and tolerance for cultural differences (Positive).

(2)m History of tough and realistictraining is positive if it includes faithful adher-ence to rules of engagement which support theLaw of Land Warfare and cultural issues (Positive).

(3)m Unit leaders, medical person-nel, and chaplains are trained to recognize BFand early warning signs of misconduct stress(Positive).

(4)m Units are withdrawn fromcombat periodically to rest, refit (reconstitute, ifnecessary), and absorb new replacements whoarrive and are integrated as cohesive teams, notindividuals (Positive).

(5)m Leaders have demonstratedcompetence, courage, candor, and commitment(Positive). Leaders show caring for the soldiersand make provisions for their physical, mental,and spiritual well-being as the tactical situationpermits.

(6)m Leaders keep troops informedof the objectives of the operations and war (includ-ing psychological operations and diplomatic,political, and moral objectives) (Positive). Theyfocus the soldiers’ appraisal of the situation tomaintain positive coping against the temptationsto misconduct stress behaviors.

NOTE

These preventive factors will protectonly if leaders and troops maintain andenforce a unit’s self-image that regardsthe misconduct behaviors as unaccept-able. If this unit’s self-image is lacking,these factors may even contribute tosubstance abuse and violations of thelaws of war.

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b. Risk (Negative) Factors WhichIncrease Substance Misuse and Other HarmfulCombat Stress Behauiors.

(1)m Permissive attitude and avail-ability and use of drugs in the TO and also in theUS civilian community, especially around posts/garrison areas and in the regions and age groupsfrom which recruits are drawn (Negative).

(2)m Inadequate enforcement ofthe unit’s ADAPCP before deployment in iden-tifying and treating (or discharging) misusers(Negative).

(3) Availability and distributionnetworks (both legal and illegal) for alcohol anddifferent types of drugs in the theater (Negative).Some drugs are- more available and cheaper insome foreign countries or regions.

(4)m Unsupervised use of amphet-amines and other strong stimulants to remainawake in continuous operations (Negative). Thiscan produce dangerous (usually temporary)neuropsychiatric illness. Also, it may lead todependency and addiction in originally well-intentioned, good soldiers, including leaders.

(5)m Boredom and monotonousduties, especially if combined with chronic frus-tration and tension (Negative).

(6)m High threat of nerve agent usewith false alarms that result in self-admin-istration of atropine causing mental symptomsand perhaps temporary psychosis (Negative).

(7)m Victorious pursuit of a re-treating enemy. This reduces BF casualties, butmay not inhibit commission of atrocities (thecriminal acts of killing of EPWs, raping, looting)or alcohol/drug misuse (as supplies are “liberat-ed”) unless command retains tight moral control(Negative),

(8)m Hasty withdrawal. Here,too, soldiers may loot or abuse substances “to keepthem from falling into enemy hands” (Negative).Rape, murder, and other reprisal atrocities(criminal acts) can occur if retreating troops feelhindered by EPWs, or if the civilians being leftbehind are hostile. Leaders must not encouragetoo zealous a scorched-earth policy. This meansthat only those items except medical that wouldbe of potential use to the enemy are destroyed. Ifleaders lose tight control, overstressed soldiersmay desert or surrender.

(9)m Beleaguered units whichcannot evacuate any (or only the most severelywounded) casualties. Here, too, some soldiersmay commit misconduct stress behaviors due toBF or go AWOL without becoming medical pa-tients (Negative).

(10)m Commission of atrocities bythe enemy, especially if against US personnel butalso if against local civilians (Negative).

(ll)m Racial and ethnic tension inthe civilian world and in the Army (Negative).Major cultural and physical/racial differencesbetween US and the local population,

(12)m Local civilian populationperceived as hostile, untrustworthy, or “sub-human” (Negative). This is more likely to resultwhen soldiers have little knowledge or under-standing of cultural differences.

(13)m Failure of expected support,such as reinforcement or relief; inadequate re-supply; inadequate CHS (Negative). Soldiers whofeel abandoned and on their own may resort toillegal measures to get what they think they need.Combat soldiers naturally tend to feel “entitled toclaim what they have earned,” and this may leadto looting and worse.

(14)m High personnel turbulence,lack of unit cohesion, especially “vertical cohesion”

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between leaders and troops (Negative). A“substance-of-choice” can become a “ticket” forinclusion into a group.

(15)m Loss of confidence in leaders,in supporting or allied units, and in equipmentas compared to the enemy’s (Negative). Theseproduce the same effects as negative factors(13)m, above, and (16)m, below.

(16)m Popular opposition to thewar at home; lack of understanding or belief inthe justness of the effort (Negative). Somesoldiers will find this an excuse to desert or refuselawful orders. Others who continue to do theirduty may show their resentment by lashing outat the local population or by using drugs andalcohol.

(17)m Lack of a believable plan forprotecting families in the theater, either byevacuating them or keeping them secure underreliable authority (Negative). Some soldiers maygo AWOL to stay with them.

c. Estimate of Substance Abuse andMisconduct Stress Behavior. The purpose of thisestimate of potential substance misuse and othermisconduct stress behaviors is the same as forthe estimate of BF casualties. It is to predictwhen and where (in which units) problems aremost likely to occur so that preventive actionscan be focused. Also, provisions can be made forthe medical/psychiatric treatment of substanceabuse cases in the TO. The CSC estimator mustwork closely with the JAG staff, MP, and thechain of command to compare the projections withwhat is actually being found.

Section II. THE COMBAT STRESS CONTROL PLAN

B-4. Format

The format for the CSC plan is the standardoutline (see FM 8-55). The CSC planner mustanalyze the operations order and CHS estimatefor direct or implied CSC missions. He mustassess the available CSC resources and analyzealternative ways of using them to accomplish themissions. Frequently, it is necessary to prioritizethe missions and recommend to higher commandwhich of the alternate courses should be taken.

B-5. Combat Stress Control PlanningConsiderations in Deployment andConflict

a. The requirements for each of theCSC program functions (consultation, reconstitu-tion support, NP triage, restoration, recondition-ing, and stabilization) and the ability of CSC units

to satisfy those requirements will be influencedby the factors listed below:

(1) The nature, mobility, and in-tensity of combat operations which influence thenumber of BF soldiers; the severity of symptoms;and the feasibility of resting cases in or near theirunits.

(2) The type of threat force, espe-cially the threat to CSC activities themselves. Forexample, the likelihood of air and artillery attack;the security of “rear areas” for rest; the electronicwarfare threat and target detection capabilityfor concentrations of troops; and the NBC anddirected-energy threat.

(3) The availability of other healthservice units on which the CSC elements can relyfor local logistical/administrative support and forpatient transportation or evacuation.

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(4) The geographical AO, terrain,and climatic conditions which limit mobility ofCSC units and require additional shelter for pa-tients.

(5) The disease, drug, alcohol, andenvironmental hazards of the region whichthreaten resting BF cases and produce otherpreventable nonbattle injuries which, histori-cally, resulted from there being a complicationof BF.

b. The CSC planner must determinethe actual strengths of the CSC resources inorganic unit mental health sections and spe-cialized units. They may not be at the authorizedlevels for personnel or equipment. The level oftraining, degree of familiarity, and cohesion withthe supported units must be assessed.

B-6. Combat Stress Control PlanningConsiderations for War

a. The more intense the combat, thehigher the rate of WIA and the higher the ratio ofBF casualties to WIAs. If the WIA rate doublesthere will be four times as many BF cases re-quiring treatment. Furthermore, high-intensitycombat causes a shift towards more severe sym-ptoms and slower recovery.

b. The CSC organization must achievea balance between pre-positioning elements farforward and having other elements further to therear that can take the overflow of cases and beredeployed to areas of special need.

c. In Army operations, each maneuverbrigade covers a larger and more fluid area andhas greater firepower and responsibility than dida WWII division. Winning the first battle will becritical andstitution oftemporarily

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can be accomplished only by recon-attrited units and rapid return ofdisabled soldiers to their units. The

division mental health section must be reinforcedif cases are to be restored in the BSA and DSA.

d. Small CSC teams must be pushedforward to reinforce the maneuver BSA wellbefore the fighting starts. Although BF casualtieswill not be evenly distributed among all brigades,those cases which occur must be evaluated andtreated immediately at that level.

(1) At critical times, this will beunder mass casualty conditions. Other logisticalrequirements and enemy activity may make itimpossible to respond quickly with CSC personnelonce the battle has begun. Any newly arrivingCSC personnel who join a new unit under suchcircumstances will take critical hours to days tobecome efficient.

(2) The purpose of these CSC"preventive” teams is NOT to hold BF casualtiesfor treatment in the highly fluid BSA. Theirpurpose is to prevent the evacuation of DUTYand REST BF casualties who could remain withtheir units. These teams also ensure correctinitiation of treatment and evacuation of the refercases to the division fatigue center in the DSA. Ifcircumstances allow, they could hold a smallnumber for overnight observation/restoration.

(3) Combat stress control teamswhich are with a brigade not in action will usethis time productively in consultation activities.These activities will reduce the incidence of stresscasualties and better enable the unit to treat itscases far forward when the time comes.

e. Combat stress control elements inthe DSA provide NP triage and prevent anyunnecessary evacuation. They staff the divisionfatigue center which assures 2- to 3-days restora-tion within the division. They provide preventiveconsultation and reconstitution support through-out the division rear. They can send personnel,tents, and supplies forward to reinforce the teamsat the BSA.

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f. Combat stress control elements inthe corps area must provide the back-up "safetynet” to catch the overflow from hard-pressed divi-sions, as well as providing reconstitution supportto units which are withdrawn from battle andpreventing and treating local rear-area BF cases.Those in the corps area can be transferredlaterally within the corps or temporarily sentforward to divisions which are in greatest need.With somewhat greater difficulty, these assetscan be transferred from one corps to another.

g. Combat stress control teams need100 percent ground mobility and communicationscapability to function in their local areas. Theyneed a small vehicle to visit the units in the BSA,DSA, or corps support area and to deploy toreconstitution sites with other CS/CSS teams.Combat stress control teams should not wonderaround the battlefield alone. When they moveoutside the defensive areas, they should be inconvoy with other CSS vehicles or be providedsecurity by the echelon commander.

h. Combat stress control units providethe expertise of their personnel with little require-ment for heavy equipment. Therefore, if time,distance, or the tactical situation prevents a CSCelement from traveling by ground to reinforceanother CSC element which is already in place,the key personnel and light specialized equipmentcan be moved by air.

NOTE

Combat stress control personnel can besent forward in air ambulances that aregoing to the forward medical companiesto evacuate the wounded.

Additional supplies, equipment, and vehicles canfollow as sling-loaded or air-droppable cargos.The key requirement is that a familiar CSC team

with vehicle and preestablished contacts are al-ready at the destination expecting to be re-inforced.

i. If the division mental health sectionor CSC unit is given the mission to support aseparate brigade or ACR, it is important to estab-lish contact and send a liaison officer or NCO toits medical company as early as possible beforethe battle.

NOTE

Because of their unique missions,armored cavalry units have specialneed for consultation, preventiveeducation, and staff planning.

Because of their elite self-image, it is importantthat the liaison is someone who has trained withthe unit and is known by personnel. In somescenarios, cavalry units suffer extreme attritionin the first days of continuous operations, yet theyare cited as prime candidates for reconstitutionto return the survivors quickly to battle.

j. Combat stress control support is in-expensive and offers great potential pay-off inRTD soldiers at critical times and places in thebattle and for reconstitution support after thebattle.

(1) If not required to treat BFcasualties and attrited units, the same few per-sonnel will be active in consultation to unitleaders. This preventive consultation could re-duce BF and improve the potential RTD of unitmembers if anyone should become a BF casualty.

(2) Combat stress control assetsalso assist with treatment of other WIA and DNBIcases who have rapid RTD potential. Many ofthese will also have severe BF symptoms whichrequire treatment.

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(3) Finally, CSC personnel have acrucial role in preventing PTSD in troops(including those who did not become casualties)by assisting command with after-action de-briefings.

B-7. Combat Stress Control PlanningConsiderations in Operations OtherThan War

a. In OOTW, the total requirement forCSC support is significantly less than in war.There is less need to pre-position CSC elementsfar forward except during specific operationswhich approach war.

(1) The total ratio of BF cases toWIA cases may still be high, but the averagenumber of WIA cases is less than two perthousand per day, so there are fewer cases. MostBF cases can be managed in their units as DUTYor REST cases.

(2) Few of the cases are HOLD orREFER casualties who need to be held undermedical observation, so the BF casualty: WIAratio is usually less than 1:10. However, rela-tively more of those who are casualties will needstabilization on a hospital ward.

(3) Reconstitution support is stillimportant for units following battle, but theunits will usually be small (squad, platoon,company).

b. Contingency operations pose specialproblems if they involve rapid deployment to anundeveloped theater.The CHS plan for care ofall wounded and sick who cannot return imme-diately to full duty may be to evacuate them asquickly as possible to the nearest COMMZ- orCONUS-based MTFs. The tendency will be toerr on the side of caution and evacuate anyonewhose status is in doubt.

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(1) This zero-day evacuation policymay continue for the duration of a brief operationor until formal medical-holding facilities can bedeployed behind the forward area surgical teams.

(2) Early deploying medical per-sonnel, as well as CSC planners and treaters,must make a concerted effort to encourage unitsto keep soldiers with DUTY BF in small unitsand to keep REST cases in their own CSSelements for a day or two of light duty, thenreturn them to full duty.

(3) If at all possible, the planshould also hold BF casualties at the forwardmedical facilities for 1 to 3 days of restoration asan exception to the usual evacuation policy. Thisholding can be done under very austere conditionsand need not add significant additional logisticalburden to the system. Failure to provide suchinexpensive, proximate treatment will greatlyincreased chronic psychiatric disability amongsoldiers.

c. In OOTW, while the need for res-toration of BF casualties is less than during war,the incidence of misconduct stress behaviors in-creases, specifically—

Behavior disorders, includingindiscipline and violations of the Law of LandWarfare and the UCMJ.

Drug and alcohol abuse.

Other disorders of boredom andloneliness.

There is still a need for a reconditioning programin the corps to salvage those cases who do notimprove in the divisions. In conflict, it may bepractical to increase the evacuation policy forthese cases, extending the policy from 7, 14, or 30days; this maximizes RTD and minimizes thedevelopment of an evacuation syndrome, where

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stress symptoms, misbehavior, or drug andalcohol misuse become a “ticket home.”Increasing the length of stay increases thereconditioning program census. The preventiveconsultation programs remain important forcorps-level CSS units with no mental healthsections.

d. Conflict requires rigorous preventiveprograms and after-action debriefings to minimizesubsequent PTSD. These are especially impor-tant because of the ambiguous and often viciousaspects of enemy tactics and their effects on oursoldiers.

B-8. Considerations When Units or Indi-vidual Soldiers Redeploy Home (AfterMilitary Operations)

a. Unit mental health personnel andsupporting mental health/CSC units assistleaders in preparing soldiers for the transitionback to garrison or civilian life. A period ofseveral days should be scheduled for memorialceremonies, group debriefings, and discussionsof—

What has happened in combat,especially working through painful memories.

What to expect in the soldiers’own reactions on returning to peacetime.

How family and society mayhave changed since deployment and how to dealwith these changes constructively.

b. More intensive programs are sched-uled for individuals or units with prolonged in-tensive combat or other adverse experiences.Coordination with the rear detachment andfamily support groups is required to schedulesimilar education briefings and working-throughsessions at the home station, both before the unit

returns and in combined sessions after the return.The debriefings should also address—

How the service member, spouse,children, and society may have changed.

How to cope with those changespositively.

Welcome home ceremonies and memorial servicesprovide a sense of completion and closure.

B-9. Combat Stress Control Planning Con-siderations in Peacetime

a. To be effective, CSC must form acontinuum with the Army mental health services.The peacetime utilization and training of mentalhealth personnel must prepare them for theirmobilization missions and develop strong unitcohesion among themselves and with supportedunits. Future operations may leave little time foron-the-job-training or to develop familiarity andcohesion before the crucial battle starts.

b. Army Regulation 40-216 states thatpatient care duties must not interfere with thedivision mental health section’s training with itsdivision.

c. Echelon III psychiatric and mentalhealth personnel who will provide CSC supportshould have peacetime duties which bring theminto close working relationships with the organicmental health sections, chaplains, line command-ers, and NCOs of the units they will support inwar.

(1) Active Component CSC person-nel should be assigned to MEDDACs. They willwork in the following areas:

Community mental health/community counseling centers.

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Drug and alcohol abuseprevention and control programs.

Family advocacy and ex-ceptional family member programs.

The CSC personnel should be working at the postsor garrisons of the Active Component divisions,brigade, regiments, and corps units they willsupport during war and OOTW. They shouldalso participate with those units in field trainingexercises.

(2) Reserve Component CSC per-sonnel should train with units they will supporton mobilization. They should also use availabletraining time to establish and implement CSCprograms in those units.

B-10. Briefing the Combat Stress ControlPlan

a. Depending on the echelon, the CSCplan may be briefed to a senior medicalcommander or line commander for approval. In

some headquarters, the CSC planner may givethe briefing. In others, it may be given by theunit surgeon as part of the overall CHS plan.

b. In any case, the CSC briefing mustbe short and simple. The senior commander doesnot need all the details which went into theanalysis (although those details should be avail-able, if asked for). The commander needs to knowthe “bottom line.” What will it cost? What is thereturn, especially in reduced casualties and rapidRTD? What is the risk if it is not done?

c. Many commanders are highlyknowledgeable about the nature and importanceof combat stress reactions and home front issues.However, many others are not. The CSC briefingmay have to overcome the prejudice that mentalhealth (CSC) interventions are things that pam-per the troops and ruin them for combat or justburden the unit with weaklings who would bebetter purged from the Army.

d. Educating the senior commander,using language he knows and understands, is thefirst essential step of CSC.

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APPENDIX C

MENTAL HEALTH PERSONNEL IN MILITARY POLICECONFINEMENT FACILITY TEAMS

C-1. Confinement Facility Teams

Military Police Confinement Facility Teams LAthrough LF have the mission to provide com-mand, staff planning, and administrative andlogistical support to a confinement facility formilitary prisoners. The guards for the facilityare provided by an MP Guard Company (TOE19667L000); one squad is sufficient to guard 50prisoners.

C-2. Teams LA, LB, LC, and LD

Teams LA, LB, LC, and LD (administrativeoverhead teams) are designed to provide admin-istration for facilities of 50, 150, 300, and 450prisoners, respectively. They contain mentalhealth officers, NCOs, and enlisted personnel asshown in Table C-1. The medical specialists(MOS 91B) shown are also listed as being part ofthe TOE section for mental hygiene.

C-3. Mental Health Personnel hygiene activities; conducts prisoners’ counselingfunctions; performs prisoner evaluations; assists

The duties of the mental health and medical in the development of training programs; andpersonnel are listed below: supervises the behavioral science specialist. He

is responsible for monitoring the correctional a. Social Work Officer, MAJ, AOC treatment program for the prisoners. Each pris-

73A67. The social work officer directs mental oner is evaluated and a correctional treatment

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program is devised with continuous reevaluationas additional information becomes available.The following aspects of correctional treatmentare considered and closely monitored: employ-ment, training, education, medical condition,religious participation, off-duty activities, andfamily and financial problems. The social workofficer identifies prisoners who need psychiat-ric evaluation and refers them to the clinicalpsychologist.

b. Clinical Psychologist, CPT, AOC73B67. The clinical psychologist applies psy-chological principles through direct patientservices to help prisoners adjust to theconfinement environment; evaluates emotionaldisturbances and mental and behavioral dis-orders; and promotes effective mental health.

c. Behavioral Sciences Noncommiss-ioned Officers and Specialists. The behavioralscience specialists help prisoners adjust tothe confinement environment, learn problem-solving techniques, and develop productive andacceptable behavior. They meet with the pris-oner within 48 hours of in-processing, completenecessary records, and initiate a follow-up plan.They provide advice concerning the prisoners’record, conduct, attitude, and progress. Theymake recommendations concerning clemency,parole, restoration, custody, and job assignments.

d. Emergency Treatment Noncommis-sioned Officer and Medical Specialist. Theyprovide routine sick call and emergency treat-ment to prisoners. They coordinate CHS formedical activities beyond their capabilities.

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APPENDIX D

THE GENEVA CONVENTIONS AND COMBATSTRESS-RELATED CASUALTIES

D-1. Special Relevance to Medical CombatStress Control

a. This appendix reviews the relation-ship of the Geneva Conventions to CSC andtreatment of combat stress-related casualties.

b. The provisions of the Geneva Con-ventions afford the wounded and sick, medicalpersonnel, and medical units protected status.The time-proven principles of treating BFcasualties is to treat them as soldiers, not aspatients. The BF casualties are treated in anonpatient care tactical setting. This arguablycreates a clear tension, perhaps even a contra-diction.

c. The issue of the right to GenevaConventions protection depends not upon whatthe CSC treater tells the BF soldier but rather onseveral issues:

(1) Does the BF soldier’s behaviorand duty status, in fact, meet the standards setby Geneva Convention for the Amelioration of theCondition of Wounded and Sick in Armed Forcesin the Field (GWS)? A patient who meets thesestandards is considered a privileged patient, thatis, one who is not contributing to the combatefforts by virtue of disability.

(2) Does the CSC staff’s behaviorconform to the GWS standard as personnel whoare solely engaged in the care of the sick andwounded?

(3) Does the physical appearanceof the CSC personnel, tents, vehicles, and so forth,sufficiently identify them as medical and entitledto GWS protection for this to be more than a mootpoint on the dispersed, fast-moving, long-rangebattlefield?

d. The CSC commander and the chainof command will have to decide whether—

(1) TO risk the loss of protectedstatus of specific personnel, activities, or facilitiesin the CSC program by having them strictlyadhere to the nonpatient treatment principlesand operate the CSC unit as a truly nonmedicalactivity.

(2) To accept the possible loss ofprotected status by not marking the unit asmedical or by camouflaging the unit. Even if theunit is in technical compliance with the GWS,protection status may be lost.

(3) To seek the full benefit of pro-tected status by limiting the application of thetreatment principles and instead operating theCSC unit as a visibly obvious medical facility.This is done at perhaps the price of somereduction in therapeutic effectiveness.

e. Whether the CSC activity is oper-ated as either a visibly obvious medical facility oris camouflaged, CSC personnel and soldiers beingtreated must adhere to the provisions of the GWS.This is required for them to maintain theirprotected status and the protected status for othermedical units with which they are associated.

f. The remainder of this appendix willdiscuss special considerations for CSC activitiesand the application of these options based on thedefinitive Geneva Conventions information foundin FM 8-10.

D-2. Special Considerations for MedicalCombat Stress Control Activities

a. We will now reconsider the threequestions raised in paragraph B-1(c) relating to

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whether CSC activitiesConventions protection.

b. Issue #1:soldiers comply withpatients?

are

Dothe

entitled to Geneva

the battle-fatiguedGWS criteria for

(1) DUTY and REST cases of BFare clearly still combat soldiers and are notentitled to GWS status. They are still solely ontheir own unit’s rolls. They can, therefore,perform any soldierly task, including offensiveoperations, without losing a protected statuswhich they do not have. The treatment principleof treating them as soldiers is fully satisfied.

(2) HOLD and REFER BF casesmay be told that they are “soldiers, not patients,”but they are, in fact, medical patients. They areabsent from their units because of a temporarydisability that makes them unable to do theircombat duties. They are receiving medical careand are under the control of medical personnel/units. As long as they are not set to performingtasks which contribute to the war effort, they fullymeet the vague GWS criteria for a “sick andwounded” patient.

(3) To stay within the letter ofthe Geneva Conventions rules, the followinglimitations apply:

(a) Recovering BF casualtyperform work projects only at and for medicalunits; for example—

digging trenches for theprotection only.

Filling sandbags andmedical unit’s own

Moving medical sup-plies, maintaining medical vehicles, and helpingin the medical mess facility and laundry.

D-2

Providing perimeterand air guard security for the medical unit only,not for the total base cluster.

(b) Round trip prerecoveryvisits to the unit are theoretically allowed, pro-vided the visitors perform no combat-relevantwork but only assist the CSC personnel in theirrounds.

c. Issue #2: Does the CSC staff complywith the GWS criteria for protected medicalpersonnel? That depends on what they do or donot do.

(1) To retain personal entitlementto Geneva Conventions privilege, CSC personnel,like medics, PVNTMED teams, and battalion aidstations, must—

(a) Not use weapons except todefend themselves and their patients when thatdefense is made necessary by enemy attackspecifically directed at the medical facility.

(b) Not transport weapons orammunition (except for the permissible personalsmall arms), nonmedical equipment, or combat-effective (nonpatient) troops.

(c) Not transport DUTY orREST BF cases or fully recovered BF casualtiesback to their units in CSC (medical) vehicles.Instead, call the unit to come for them.

(d) Not initiate offensive ac-tions against the enemy.

(e) Not engage in labor whichdirectly supports combat operations (as distinctfrom protecting or restoring health).

(2) If CSC personnel are rumoredto do the above, that may endanger the GenevaConventions status for all CSC personnel, if the

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captors identify them specifically as CSC ratherthan simply as medical personnel.

d. Issue #3: Does the physical ap-pearance of the CSC element sufficiently identifyit as medical for it to benefit from theoreticalprivileged status? Combat stress control activitiescan be divided into—

(1) Combat stress control activitieswhich take place in nonmedical units. Examplesare—

A CSC consulting team inits truck, visiting a line unit.

A CSC reconstitutionsupport team camped at the reconstitution site.

A CSC reconditioning“cell” (team) attached to a corps CSS unit,providing ongoing treatment to the “REST BFcasualty” who are performing limited therapeuticduty at that unit.

(a) The BF soldiers are, infact, “soldiers” on DUTY status (however limited)and not “patients.” The BF casualty couldperform work details for CS, CSS, and combatunits in the vicinity under directions from thoseunits (not CSC personnel). This includes pullingperimeter defense duty. They could be trans-ported to and from work details in nonmedicalvehicles.

(b) In this situation, the CSCunit provides the best “military tactical” thera-peutic setting for the “REST” BF cases. The CSSvehicle, tents, and personnel themselves are nota legitimate target and, if captured, would still beeligible for the Geneva Contentions status of“retained personnel” rather than “prisoners ofwar,” provided they (collectively) have adhered tothe rules for being medical noncombatants.

However, they do not confer immunity fromattack to the legitimate target with which theyare collocated, so they have no grounds forcomplaint if they suffer casualties.

(2) Combat stress control activitieswhich are functioning as or with medical units,but under tactical circumstances where they areusing camouflage, light discipline, perimeterwatch, and not showing the distinctive emblem(red cross). Examples are—

Combat stress control teamtents/vehicles at a FSMC, under camouflage.

The division fatigue cen-ter or a corps reconditioning center, separatedsomewhat from its supporting medical companyor CSH, and camouflaged.

(a) Although the fatigue orreconditioning centers technically are “holdingpatients,” the tactical setting supports thetherapeutic message that they are still soldiersreceiving temporary rest and performing for atactical medical unit, not a hospital.”

(b) The CSC personnel wouldnot be legitimate targets and, if captured, wouldstill have the status of “retained personnel,”provided they did not violate the limitation onmedical noncombatants.

(c) They have little groundsto complain, however, if a fast-moving or distantenemy fails to recognize their protected status.

(3) Combat stress control activitieswhich are collocated with medical units showingthe red cross (as red on white and not undercamouflage). Example: A corps reconditioningcenter which is intermixed with a CSH or medicalholding company and well separated from anynonmedical units.

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(a) To avoid possibly creatingan appearance which might compromise theGeneva status of the other medical units whichare under the red cross, the CSC units shouldshow the red cross on all their tents and refrainfrom using camouflage.

(b) In this case, the BFsoldiers can still be told that they are not“patients” but rather are on temporary fatigue orreconditioning duty. This duty is with the CSCunit as temporary medical soldiers. They couldbe provided with the armbands showing the smalldistinctive emblem which is given to litter bearersor other soldiers who are temporarily detailed tomedical duties.

(c) Everyone must, of course,comply fully with the Geneva Conventionsrestrictions.

(d) Because of the substantialloss of military tactical atmosphere, thisalternative is less desirable than locating slightlyfurther away, closer to the nonmedical CSS units,and erecting camouflage. Issuing the armbandsmay still be helpful. The CSC personnel wouldalso wear them in these situations.

e. In a conflict where the enemy doesnot respect the Geneva Conventions, the chainof command may decide that CSC activities willforego the claim to Geneva Conventions pro-tection altogether.

(1) The distinctive emblem wouldnot be shown at all.

(2) Recovering BF casualty couldperform any military tasks they are capable of,under direct supervision of CSC personnel.

(3) Combat stress control vehiclescould, if available, transport DUTY, REST, and

recovering and recovered BF casualties to theirunits.

(4) Combat stress control per-sonnel could, when necessary, contribute directlyto the general defense.

(5) They should still respect theGeneva status of enemy medical units whichare identified as such and of enemy sick andwounded.

f. Combat Stress Control and GenevaPrisoners of War (GPW).

(1) Prisoners of war will not nor-mally be brought to the attention of CSC elementsat forward medical facilities unless they also haveeither wounds or disease, obvious signs of majorNP disorders, or BF symptoms which resembleone of the above.

(a.) In WWI, it was noted thatPOW and EPW rarely showed dramatic “shellshock” symptoms. As with the wounded, there isa natural (if relative) relief from anxiety thatcomes from being relieved of the responsibilityand danger of combat. Just being alive (havinghad your willingness to surrender be accepted)and having someone else make all decisions aboutwhere you go and what you receive is a big relief.

(b) It is also probable thatlanguage barriers and lack of concern for EPW“feelings” have left many psychiatric problemsamong EPW unreported. Probable symptomsinclude:

Anxiety over howthey will be treated.

Shame, guilt, anddepression at having failed their country by beingcaptured (or “voluntarily” surrendered).

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Post-traumatic stressdisorders related to the deaths of comrades, closecalls with death, and horrible sights seen.

Major psychiatric ill-ness.

(2) If EPW are brought to CSCpersonnel for evaluation or are encountered byCSC, mental health section, or NP ward andconsultation service personnel in the course oftheir consultation mission, the GPW requiresthat—

(a) The EPW receive thesame stabilization for major, potentially life- orfunction-threatening mental illness as friendlysoldiers receive. This will normally be providedon the NP ward of hospitals, with guards pro-viding security as needed. Physical restraintscan be used as needed, provided routine nursingcare is protecting against injury and unnecessarydiscomfort.

(b) Treatment of EPW withadjustment disorders or PTSD symptoms will, ofcourse, not aim to return them to combat dutybut rather to help them adjust to their statusas prisoners and minimize life-long disabilityfollowing repatriation.

(c) Combat stress control/mental health personnel will not provide directassistance to prisoner interrogation. This is theresponsibility of military intelligence personnel.Combat stress control involvement could jeop-ardize Geneva-protected status.

(3) Combat stress control unitsshould provide routine mental health consulta-tion to EPW confinement facilities. This shouldinclude—

Stress control advise tothe command regarding the stressors of US

Army MP personnel and any allied or coalitionpersonnel working at the confinement facility.

Advise regarding thestressors and stress manifestation of the prisonersand how to best control them.

Individual evaluation andintervention for guards or prisoners when in-dicated.

(4) If CSC personnel are them-selves taken prisoner and are granted “retainedpersonnel” status, they will—

Provide NP/mental healthsupport to the POW.

Provide life-saving assis-tance, as requested, to enemy personnel.

Remain true to the codeof conduct for POW and not provide other aid,comfort, assistance, or propaganda to the enemy.

D-3. The Law of War

The conduct of armed hostilities on land is regu-lated by the law of land warfare. This body oflaw is inspired by the desire to diminish the evilsof war by: protecting both combatants andnoncombatants from unnecessary suffering;safeguarding certain fundamental human rightsof persons who fall into the hands of the enemy,particularly prisoners of war, the wounded andcivilians; and facilitating the restoration of peace.The law of war places limits on the exercise of abelligerent’s power in the interest of furtheringthat desire. It requires that belligerents refrainfrom employing any kind or degree of violencewhich is not actually necessary for militarypurposes, and that they conduct hostilities withregard for the principles of humanity andchivalry.

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a. Sources of the Law of War. The lawof war is derived from two principal sources:treaties (or conventions), such as the Hague andGeneva Conventions; and customs, practiceswhich by common consent and long established,uniform adherence have taken on the force of law(see FM 27-10). Under the Constitution of theUnited States, treaties constitute part of thesupreme “Law of the Land” and thus must beobserved by both military and civilian personnel.The unwritten or customary law of war is alsopart of the law of the United States and is bindingupon the United States, citizens of the UnitedStates, and other persons serving this country(see DA Pam 27-l).

b. The Geneva Conventions. TheUnited States is a party to numerous conventionsand treaties pertinent to warfare on land.Collectively, these treaties are often referredto as the Hague and Geneva Conventions.Whereas it may generally be said that the HagueConvention concerns the methods and meansof warfare, the Geneva Conventions concernthe victims of war or armed conflict. The GenevaConventions are four separate internationaltreaties, signed in 1949, and are respectivelyentitled: “Geneva Convention for the Amelio-ration of the Condition of the Wounded andSick in Armed Forces in the Field”; “GenevaConvention for the Amelioration of the Condi-tion of Wounded, Sick and Shipwrecked Membersof Armed Forces at Sea” (GWS Sea); “GenevaConvention Relative to the Treatment ofPrisoners of War”; and “Geneva ConventionRelative to the Protection of Civilian Personsin Time of War” (GC). The Conventions, withamendments, are extremely detailed and containmany provisions which are tied directly to theCHS mission.

D-4. Protection of the Wounded and Sick

The essential and dominant idea of the GWS isthat the person of the soldier who has been

wounded or who is sick, and for that reason isout of combat, is from that moment protected.Friend or foe must be tended with the same care.From this principle, numerous obligations areimposed upon parties to a conflict.

a. Protection and Care. Article 12 ofthe GWS imposes several specific obligationsregarding the protection and care of the woundedand sick.

(1) The first paragraph of Article12, GWS, states "Members of the armed forcesand other persons mentioned in the followingArticle, who are wounded or sick, shall berespected and protected in all circumstances.”

(a) The word “respect” means“to spare, not to attack,” whereas “protect” means“to come to someone’s defense, to lend help andsupport.” These words make it unlawful toattack, kill, ill-treat, or in any way harm a fallenand unarmed enemy soldier while at the sametime imposing an obligation to come to his aidand give him such care as his condition requires.

(b) This obligation is appli-cable “in all circumstances.” The wounded andsick are to be respected just as much when theyare with their own army or in no-man’s-land aswhen they have fallen into the hands of theenemy.

(c) Combatants, as well asnoncombatants, are required to respect thewounded. The obligation also applies to civilians,in regard to whom Article 18 specifically states:“The civilian population shall respect thesewounded and sick, and in particular abstain fromoffering them violence.”

(d) The GWS does not definewhat is meant by “wounded or sick”; nor has thereever been any definition of the degree of severity

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of a wound or a sickness entitling the wounded orsick combatant to respect. Any definition wouldnecessarily be restrictive in character and wouldthereby open the door to misinterpretation andabuse. The meaning of the words “wounded andsick” is thus a matter of common sense and goodfaith. It is the act of falling or laying down ofarms because of a wound or sickness whichconstitutes the claim to protection. Only thesoldier who is himself seeking to kill may bekilled.

(e) The benefits afforded thewounded and sick extend not only to members ofthe armed forces but to other categories of personsas well, classes of whom are specified in Article13, GWS. Even though a wounded person is notin one of the categories enumerated in the Article,we still must respect and protect that person.There is a universal principle which says thatany wounded or sick person is entitled to respectand humane treatment and the care which hiscondition requires. Wounded and sick civilianshave the benefit of the safeguards of the GenevaConventions.

(2) The second paragraph ofArticle 12, GWS, provides that the wounded andsick “. . . shall be treated humanely and cared forby the Party to the conflict in whose power theymay be, without any adverse distinction found onsex, race, nationality, religion, political opinions,or other similar criteria. . . .“

(a) Adverse distinctions ofany kind are prohibited. Nothing can justify abelligerent into making any adverse distinctionbetween wounded or sick who require hisattention, whether they be friend or foe. Bothare equal in their claims to protection, respect,and care. The foregoing is not intended toprohibit concessions, particularly with respect tofood, clothing, and shelter, which acknowledgethe different habits and background of thewounded and sick.

(b) The wounded and sickshall not be made the subjects of biological,scientific, or medical experiments of any kindwhich are not justified on medical grounds anddictated by a desire to improve their condition.

(c) The wounded and sickshall not willfully be left without medicalassistance; conditions exposing them to contagionor infection shall not be created.

(3) The only reasons which canjustify prioritized treatment are reasons ofmedical urgency. This is the only justifiedexception to the principle of equality of treatmentof the wounded. For example, this means thatEPW who are triaged as “immediate” must becared for before our own wounded who have beentriaged as “delayed”.

(4) Paragraph 5 of Article 12,GWS, provides that, if we must abandon woundedor sick, we have a moral obligation to, “as far asmilitary considerations permit,” leave medicalsupplies and personnel to assist in their care.This provision is not related to the absoluteobligation imposed by paragraph 2 to care for thewounded. A belligerent can never refuse to carefor enemy wounded he has captured becauseadversary has abandoned them without medicalpersonnel and equipment.

b. Enemy Wounded and Sick. Theprotections accorded the wounded and sick applyto friend and foe alike without distinction.Certain provisions of the GWS, however,specifically concern enemy wounded and sick.There are two provisions in the GPW which alsoapply to enemy wounded or sick because theygenerally apply to POW.

(1) Article 14 of the GWS statesthat persons who are wounded and then cap-tured have the status of POW. However, thatwounded soldier also needs treatment. Therefore,

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a wounded soldier who falls into the hands ofan enemy who is a party to the GWS and theGPW will enjoy protection under both Conven-tions until his recovery. The GWS will takeprecedence over the GPW where the two overlap.

(2) Article 16 of the GWS requiresthe tabulation and sending of information re-garding enemy wounded, sick, or dead.

c. Search For and Collect Casualties.Article 15 of the GWS imposes a duty on com-batants to search for and collect the dead andwounded and sick as soon as circumstancespermit. It is left to the tactical commander tojudge what is possible and to decide to commithis medical personnel to this efforts. If circum-stances permit, an armistice or suspension offire should be arranged to permit this effort.

d.. Assistance of the Civilian Popu-lation. Article 18, GWS, is the only one thereinwhich addresses the civilian population. It allowsa belligerent to ask the civilian to collect and carefor wounded or sick of whatever nationality. Thisprovision does not relieve the military authoritiesof their responsibility to give both physical andmoral care to the wounded and sick. The GWSalso reminds the civilian population that theymust respect the wounded and sick and must notinjure them.

e. Enemy Civilian Wounded and Sick.Certain provisions of the Geneva Conventions arerelevant to the CHS mission.

(1) Article 16 of the Geneva Con-ventions provides that enemy civilians who are“wounded and sick, as well as the infirm,and expectant mothers, shall be the object ofparticular protection and respect,” The Articlealso requires that, “As far as military consider-ations allow, each Party to the conflict shallfacilitate the steps taken to search for the killedand wounded [civilians], to assist . . . other

persons exposed to grave danger, and to protectthem against pillage and ill-treatment [emphasisadded].”

(a) The "protection and re-spect” to which wounded and sick enemy civiliansare entitled is the same as that accorded towounded and sick enemy military personnel.

(b) While Article 15 of theGWS requires parties to a conflict to search forand collect the dead and the wounded and sickmembers of the armed forces. Article 16 of theGeneva Conventions states that the parties must“facilitate the steps taken” in regard to civilians.This recognizes the fact that saving civilians isthe responsibility of the civilian authorities ratherthan that of the military. The military is notrequired to provide injured civilians with medicalcare in a CZ. However, if we start providingtreatment, we are bound by the provisions of theGWS. Provisions for treating civilians (enemy orfriendly) will be addressed in COMMZ regula-tions.

(2) In occupied territories, theOccupying Power must accord the inhabitantsnumerous protections as required by the GenevaConventions. The provisions relevant to medicalcare include—

The requirement to bringin medical supplies for the population if theresources of the occupied territory are inadequate.

A prohibition on requisi-tioning medical supplies unless the requirementsof the civilian population have been taken intoaccount.

The responsibility ofensuring and maintaining, with the cooperationof national and local authorities, the medical andhospital establishments and services, publichealth, and hygiene in the occupied territory.

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The requirement thatmedical personnel of all categories be allowed tocarry out their duties.

A prohibition on requi-sitioning civilian hospitals on other than atemporary basis and then only in cases of urgentnecessity for the care of military wounded andsick and after suitable arrangements have beenmade for the civilian patients.

The requirement to pro-vide adequate medical treatment to detainedpersons.

The requirement to pro-vide adequate medical care in internment camps.

D-5.

Article

Protection and Identification ofMedical Personnel

24 of the GWS provides special protectionfor “Medical personnel exclusively engaged in thesearch for, or the collection, transport, ortreatment of the wounded or sick, or in theprevention of disease, [and] staff exclusivelyengaged in the administration of medical unitsand establishments . . . [emphasis added].” Article25 provides limited protection for “Members ofthe armed forces specially trained for employ-ment, should the need arise, as hospital orderlies,nurses, or auxiliary stretcher-bearers, in thesearch for or the collection, transport, ortreatment of the wounded and sick . . . if theyare carrying out those duties at the time whenthey come into contact with the enemy or fall intohis hands [emphasis added].”

a. Protections. There are two forms ofprotection, and they are separate and distinct.

(1) The first is protection fromintentional attack if medical personnel areidentifiable as such by an enemy in a combat

environment. Normally, this is facilitated bymedical personnel wearing an arm band bearingthe distinctive emblem (a red cross or red crescenton a white ground) or by their employment in amedical unit, establishment, or vehicle (includingmedical aircraft and hospital ships) that displaysthe distinctive emblem. Persons protected byArticle 25 may wear an arm band bearing aminiature distinctive emblem only while exe-cuting medical duties.

(2) The second protection providedby the GWS pertains to medical personnel whofall into the hands of the enemy. Article 24personnel are entitled to “retained person” status.They are not deemed to be POW, but other-wise benefit from the protection of the 1949Geneva Convention Relative to the Treatment ofPrisoners of War. They are authorized to carryout medical duties only, and according to Article28, GWS, “shall be retained only in so far asthe state of health . . . and the number of pris-oners of war require.” Article 25 personnel arePOW, but shall be employed on their medicalduties in so far as the need arises. They maybe held until a general repatriation of POW isaccomplished upon the cessation of hostilities.

b. Specific Cases. Some medical per-sonnel may fall into each of the categoriesidentified in Articles 24 and 25, depending ontheir duties at the time.

(1) While only Article 25 refers tonurses, nurses are Article 24 personnel if theymeet the “exclusively engaged” criteria of thatArticle.

(2) The AMEDD officers and non-commissioned officers serving in positions thatdo not meet the “exclusively engaged” criteria ofArticle 24 are not entitled to its protection but,under Article 25, are entitled to protection fromintentional attack during those in which they areperforming medical support functions. Examples

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of medical personnel who would not meet the“exclusively engaged” criteria of Article 24 are—

(a) The AMEDD officers serv-ing as commanders of FSBs with responsibilityfor base/base cluster defense as well as commandand control of medical and nonmedical units.

(b) The AMEDD officers andnoncommissioned officers serving in staff posi-tions within the FSB with responsibility forplanning and supervising the logistics support fora combat maneuver brigade.

(c) A medical company com-mander, a physician, or the executive officer, anMS officer, detailed as convoy march unitcommander with responsibility for medical andnonmedical unit routes of march, convey control,defense, and repulsing attacks.

(d) Medical Service officersand other Army officers and warrant officers whoare qualified helicopter pilots but who are notpermanently assigned to a dedicated medicalaviation unit. These officers devote part of theirtime to flying medical evacuation missions butprimarily fly helicopters not bearing red crossmarkings on standard combat missions.

(e) The GWS does not pre-clude the use of AMEDD personnel in perimeterdefense of nonmedical units. While manning theperimeter defense of nonmedical units, AMEDDpersonnel would forfeit their special protectedstatus under Article 24 of the GWS. They wouldbe subject to being intentionally attacked, and ifcaptured, would be POW and not necessarilyallowed to perform any medical duties. If theyhad returned to their medical duties, they wouldpossibly be entitled to the protection of Article25, GWS. That is, if identifiable as performingmedical duties, they would not be subject tointentional attack, and if captured, would beallowed to perform medical duties as needed.

c. Identification Cards and ArmBands. Medical personnel who meet the “exclu-sively engaged” criteria of Article 24, GWS, areentitled to wear an arm band bearing thedistinctive emblem of the red cross and carry themedical personnel identification card authorizedin Article 40, GWS (in the US armed services,DD Form 1934). Article 25 personnel and medicalpersonnel serving in positions that do not meetthe “exclusively engaged” criteria of Article 24are not entitled to carry the medical personnelidentification card or wear the distinctive emblemarm band. Such personnel carry a standardmilitary identification card (DD Form 2A) andunder Article 25, may wear an arm band bearinga miniature distinctive emblem when executingmedical duties.

D-6. Protection and Identification ofMedical Units and Establishments,Buildings and Material, and MedicaITransports

a. Protection. There are two separateand distinct forms of protection.

(1) The first is protection from in-tentional attack if medical units, establishments,or transports are identifiable as such by an en-emy in a combat environment. Normally, this isfacilitated by medical units or establishmentsflying a white flag with a red cross and bymarking buildings and transport vehicles withthe emblem.

(a) It follows that if wecannot attack recognizable medical units, estab-lishments, or transports, we should allow themto continue to give treatment to the wounded intheir care, as long as this is necessary.

(b) All vehicles employed ex-clusively on medical transport work are protectedon the field of battle. Vehicles being used for

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both military and medical purposes, such asambulances being used to move woundedpersonnel during an evacuation and carryingretreating belligerents as well, are not entitled toprotection.

(c) Medical aircraft, likemedical transports, are protected from inten-tional attack but with a major difference: Theyare protected only “while flying at heights, timesand routes specifically agreed upon between thebelligerents concerned.” Article 36, GWS. Suchagreements may be made for each case or may beof a general nature, concluded for the duration ofhostilities. If there is no agreement, belligerentswill be able to use medical aircraft only at theirown risk and peril.

(d) The second paragraph ofArticle 19 imposes an obligation upon belligerentsto “ensure that the said medical establishmentsand units are, as far as possible, situated in sucha manner that attacks against military objectivescannot imperil their safety. ” Hospitals should besited alone, as far as possible from militaryobjectives. The unintentional bombardment of amedical establish or unit due to its presenceamong or proximity to valid military objectivesis a violation of the GWS. Legal protection iscertainly valuable but it is more valuable whenaccompanied by practical safeguards.

(2) The second protection providedby the GWS pertains to medical units, estab-lishments, material, and transports which fallinto the hands of the enemy.

(a) Captured mobile medicalunit material is to be used first to treat thepatients in the captured unit. If there are nopatients in the unit, or when those who werethere have been moved, the material is to be usedfor the treatment of other wounded and sickpersons.

(b) Generally the buildings,material, and stores of fixed medical establish-ments will continue to be used to treat woundedand sick. However, after provision is made tocare for remaining patients, tactical commandersmay make other use of them. All distinctivemarkings must be removed if the buildings are tobe used for other than medical purposes.

(c) The material and stores offixed establishments and mobile medical units arenot to be intentionally destroyed, even to preventthem from falling into enemy hands. The actualbuildings may in certain extreme cases have tobe destroyed for tactical reasons.

(d) Medical transport whichfalls into enemy hands may be used for anypurpose once the medical care of the woundedand sick they contain is otherwise provided for.The caveat as to removal of distinctive markingapplies here also.

(e) Medical aircraft are sup-posed to obey a summons to land for inspection.If it is performing its medical mission, it issupposed to be released to continue its flight. Ifexamination reveals that an act “harmful to theenemy” (such as if the aircraft is carryingmunitions) has been committed, it loses theprotections of the Conventions and may be seized.If a medical aircraft makes an involuntarylanding, all aboard, except the medical personnel,will be POW. A medical aircraft refusing asummons to land is a fair target.

b. Identification. The GWS containsseveral provisions regarding the use of the redcross emblem on medical units, establishments,and transports (the identification of medicalpersonnel has been previously discussed inparagraph D-5).

(1) Article 39 of the GWS reads asfollows: "Under the direction of the competent

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military authority, the emblem shall be displayedon the flags, armlets, and on all equipmentemployed in the Medical Service. ”

(a) There is no obligation ona belligerent to mark his units with the emblem.Sometimes a commander (generally no lower thana brigade commander for US forces) may orderthe camouflage of his medical units in order toconceal the presence or real strength of hisforces. The enemy must respect a medical unitif he knows of its presence, even one which iscamouflaged or not marked. The absence of avisible red cross emblem, however, coupled witha lack of knowledge on the part of the enemy asto the unit’s protected status, may render thatunit’s protection valueless.

(b) The distinctive emblem isnot a red cross alone: it is a red cross on whiteground. Should there be some good reason, how-ever, why an object protected by the Conventionscan be marked only with a red cross without awhite ground, belligerents may not make the factthat it is so marked a pretext for refusing torespect it.

(c) Some countries use thered crescent or the red lion and sun on a whiteground in place of the red cross. Those emblemsare recognized as authorized exceptions underArticle 38, GWS.

(d) The initial phrase of Arti-cle 39 shows that it is the military commanderwho controls the emblem and can give or withholdpermission to use it; moreover, he alone can ordera medical unit to be camouflaged. He is at alltimes responsible for the use made of the emblemand must see that it is not improperly used bythe troops or by individuals.

(2) Article 42 of the GWS specifi-cally addresses the marking of medical units andestablishments:

(a) "The distinctive flag ofthe Convention shall be hoisted only over suchmedical units and establishments as are entitledto be respected under the Convention, and onlywith the consent of the military authorities,”paragraph 1, Article 42, GWS. Although theConvention does not define “the distinctive flagof the Convention,” what is meant is a white flagwith a red cross in its center. Also, the word“flag” must be taken in its broadest sense. Hos-pitals are often marked by one or several redcross emblems painted on the roof. Finally, themilitary authority must consent to the use of theflag (Article 39) and must ensure that the flag isused only on buildings entitled to protection.

(b) "In mobile units, as infixed establishments, [the distinctive flag] maybe accompanied by the national flag of the Partyto the conflict to which the units or establishmentbelongs,” paragraph 2, Article 42, GWS. Thisprovision makes it optional to fly the nationalflag with the red cross flag. On a battlefield, thenational flag is a symbol of belligerency and istherefore likely to provoke attack.

D-7. Loss of Protection of Medical Unitsand Establishments

Medical assets lose their protected status by com-mitting acts "harmful to the enemy,” Article 21,GWS. If such an act occurs, a warning must begiven to the offending unit and a reasonable timeallowed to cease such activity.

a. Acts Harmful to the Enemy. Thephrase “acts harmful to the enemy” is not definedin the Conventions but should be considered toinclude acts the purpose or effects of which are toharm the enemy, by facilitating or impedingmilitary operations. Such harmful acts wouldinclude the use of a hospital as a shelter for able-bodied combatants, as an arms or ammunitiondump, or as a military observation post. Another

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instance would be the deliberate siting of amedical unit in a position where it would impedean enemy attack.

b. Warning and Time Limit. Theenemy has to warn the unit to put an end to theharmful acts and must fix a time limit, at theconclusion of which he may open fire or attackif the warning has not been complied with. Thephrase “in all appropriate cases” recognizes thatthere might obviously be cases where a timelimit could not be allowed. A body of troopsapproaching a hospital and met by heavy fire fromevery window would return fire immediately.

D-8. Conditions Not Compromising Medi-cal Units and Establishments ofProtection

a. Article 22 of the GWS reads asfollows: “The following conditions shall not beconsidered as depriving a medical unit or es-tablishment of the protection guaranteed byArticle 19:

"(1) That the personnel of the unitor establishment are armed, and that they usethe arms in their own defense, or in that of thewounded and sick in their charge.

"(2) That in the absence of armedorderlies, the unit or establishment is protectedby a picket or by sentries or by an escort.

"(3) That small arms and ammu-nition taken from the wounded and sick and notyet handed to the proper service, [sic] are foundin the unit or establishment.

"(4) That personnel and materiel ofthe veterinary service are found in the unit orestablishment, without forming an integral partthereof.

"(5) That the humanitarian activi-ties of medical units and establishments or oftheir personnel extend to the care of civilianwounded or sick. ”

b. These five conditions are not to beregarded as acts harmful to the enemy. Theseare particular cases where a medical unit retainsits character as such and its right to immunity,in spite of certain appearances which might haveled to the contrary conclusion or at least createdsome doubt.

c. A medical unit is granted a privi-leged status under the laws of war. This status isbased on the view that medical personnel are notcombatants and that their role in the combat areais exclusively a humanitarian one. In recognitionof the necessity of self-defense, however, medicalpersonnel may be armed for their own defense orfor the protection of wounded and sick undertheir charge. To retain this “privileged status,”they must refrain from all aggressive action andmay employ their weapons only if attacked inviolation of the Conventions. They may notemploy arms against enemy forces acting inconformity with the laws of war and may not useforce to prevent the capture of their unit by theenemy. (It is, on the other hand, perfectlylegitimate for a medical unit to withdraw in theface of the enemy.) Medical personnel who usetheir arms in circumstances not justified by thelaw of war expose themselves to penalties forviolation of the law of war and, provided theyhave been given due warning to cease such acts,may also forfeit the protection of the medical unitor establishment which they are protecting.

(1) Medical personnel may carryonly small arms, such as rifles or pistols or autho-rized substitutes.

(2) The presence of machine guns,grenade launchers, booby traps, hand grenades.

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light antitank weapons, or mines in or around amedical unit or establishment would seriouslyjeopardize its entitlement to privileged statusunder the GWS. The deliberate arming of amedical unit with such items could constitute anact harmful to the enemy and cause the medicalunit to lose its protection regardless of the locationof the medical unit. See the previous discussionof loss of protection of medical units.

d. Guarding of medical units, as a rule,is performed by its own personnel. However, itwill not lose its protected status if the guard isperformed by a number of armed soldiers. Themilitary guard attached to a medical unit mayuse its weapons, just as armed orderlies may, inorder to ensure the protection of the unit. But,as in the case of orderlies, the soldiers may actonly in a purely defensive manner and may notoppose the occupation or control of the unit by anenemy who is respecting the unit’s privilegedstatus. The status of such soldiers is that ofordinary members of the armed forces. The mere

fact of their presence with a medical unit willshelter them from attack. In case of capture,they will be POW.

e. Wounded arriving in a medical unitmay still be in possession of small arms andammunition, which will be taken from them andhanded to authorities outside the medical unit.Should a unit be visited by the enemy before it isable to get rid of these arms, their presence is notof itself cause for denying the protection to beaccorded the medical unit under the GWS.

f. The presence with a medical unit ofpersonnel and material of the Veterinary Corpsis authorized, even where they do not form anintegral part of such unit.

g. Establishments protected by theGWS may take in civilians as well as militarywounded and sick without jeopardizing theirprivileged status. This clause merely sanctionswhat is actually done in practice.

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«APPENDIX E

MEDICAL REENGINEERING INITIATIVE FOR MENTALHEALTH AND COMBAT STRESS CONTROL ELEMENTS

IN THE THEATER OF OPERATIONS

Section I. OVERVIEW OF CHANGES

E-1. Unit Mental Health Sections

a. Divisions.

(1) Comparison. The Medical Force 2000 (MF2K) had a consolidated division mentalhealth section assigned to the MSMC of the MSB. The division mental health section was staffed with apsychiatrist, a social work officer, a clinical psychologist, and enlisted mental health specialists. Doctrinefor MF2K specified that the division mental health section send a mental health officer/NCO team to eachmaneuver brigade upon deployment. The MRI decentralized the division mental health section, making abehavioral science officer and a mental health specialist organic to each FSMC. Under the MRI, thepsychiatrist and the NCOIC remain in the MSMC and will continue to have staff responsibilities to thedivision surgeon. The psychiatrist and the NCOIC provide mobile consultation in the division rear, tech-nical supervision to the brigade-level sections and medical personnel, and clinical expertise at the MSMC.

(2) Implications. Division assignment policy, not TOE structure, must ensure that the FSBmedical companies supporting the three maneuver brigades receive one social work officer and one clinicalpsychologist as brigade mental health officers. The third brigade can receive either AOC. Doctrine andpolicy must ensure that the division psychiatrist, the mental health NCOIC, the brigade behavioral scienceofficers, and the mental health specialists continue to function in an integrated and coordinated CSCprogram. This ensures that all three mental health disciplines/expertise are available throughout thedivision. This is facilitated in garrison where all division mental health assets will work together andprovide clinical care for division soldiers and their families. On deployment, division mental healthpersonnel will continue to work together using telecommunication, electronic transmission, and automateddata processing (�telemedicine�).

b. Area Support Medical Battalion.

(1) Comparison. The MF2K had a centralized mental health section assigned to theheadquarters and support company. This section was similar to the division mental health section except itonly had two officers (a psychiatrist and a social worker). The reorganization of the ASMB under MRIreplaces the headquarters and support company with a headquarters detachment. The headquartersdetachment provides C2 for the battalion. Under this MRI design, the headquarters detachment can locatewith any of its four ASMCs. Each ASMC will have a behavioral science officer and a mental healthspecialist assigned. The behavioral science officer position may be filled with either a social worker or aclinical psychologist. The ASMC mental health section provides mobile support to all units in its area ofresponsibility, as well as clinical expertise for the ASMCs. Assigned to the ASMB headquarters detachmentis a psychiatrist and two mental health specialists. The psychiatrist continues to provide staff advice to thebattalion headquarters and technical supervision and clinical expertise for all the ASMCs (mental healthsections). All of the enlisted mental health specialists assigned to the battalion are E-4 or below.

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(2) Implications. When deployed, the ASMB psychiatrist and the ASMC behavioral scienceofficers may not have the opportunity for close contact depending on the ASMB�s mission and the size of theAO. All ASMB mental health sections must be proactive by providing consultation and by teaching stressreduction techniques. Battalion medical personnel must understand the principles of CSC prevention,treatment, and the different medical/surgical diagnoses that must be ruled out. The absence of mental healthNCOs in the battalion to supervise and mentor the enlisted mental health specialists makes it essential thateach section�s behavioral science officer and mental health specialist work together in peacetime. Theyshould work together in a field training environment as well as a clinical environment in garrison. All themental health personnel assigned to the battalion must learn to make good use of telemedicine amongthemselves and with supported units.

c. Armored Cavalry Regiment and Separate Brigades.

(1) Comparison. In MF2K, the ACR had no organic mental health personnel. Separatebrigades had only enlisted mental health personnel in their medical company. The MRI gives these units amental health section which is the same as those found in division medical companies. The behavioralscience officer (AOC 67D00) assigned to the ACR or separate brigade FSMCs may be either a social workeror a clinical psychologist.

(2) Implications. These mental health sections will receive technical training and supervisionfrom a psychiatrist only when they come under the operational control of a division or are located in thecorps under the ASMB psychiatrist�s area of responsibility. The behavioral science officer assigned to theACR should actively seek out training assistance from the ASMB or the division psychiatrist. He shouldseek this assistance to ensure that regiment/brigade mental health and other medical personnel are fullytrained in the medical aspects of CSC triage and stabilization.

E-2. Combat Stress Control Units

a. Medical Detachment, Combat Stress Control.

(1) Comparison. In MF2K, the 23-person CSC detachment was designed to be the corps-level package to augment the organic mental health section of a division during war. Although highly mobileand designed to break up into widely dispersed teams, the detachment was totally dependent on the divisionand/or its higher medical headquarters for administrative and logistical support. Assigned to the headquarterssection was a psychiatrist who was also a full-time clinician in one of the forward-deployed teams and anNCOIC with a clinical rather than an administrative background. A light-wheeled vehicle mechanic wasadded later. Since the first CSC detachment was activated, these units have provided CSC support to theirhome posts. They have supported field training exercises while concurrently deploying teams or entiredetachments on 5- to 12-month rotations to Somalia, Haiti, Guantanamo (Cuba), Bosnia, and Hungary.These missions demonstrated the need for additional clinical and headquarters personnel to conduct highlyflexible, split-based operations. In MRI, the CSC detachment increases to 43 persons (without increasingtotal CSC personnel in the corps) by transferring from the CSC companies some of the corps-level CSCmission support requirements and the assets to accomplish them. Each CSC detachment gains one 4-personCSC preventive team (for a total of four), one 10-person CSC fitness team (for a total of two), and five newheadquarters personnel.

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(2) Implications. The MRI CSC detachment retains the mission of providing direct supportto a division�s maneuver brigades and general/reinforcing support to the DSA, including corps units in thoseareas. In addition, the detachment now augments area support in the corps immediately behind the division.It can provide reconstitution support for a brigade- or smaller-sized unit; it can conduct the corps-levelreconditioning program, when needed, for the division and corps slice. The bill payer is a reduced numberof CSC companies and detachments in the force structure. The detachment must function with its elementswidely dispersed, some working in and for the supported division and others working in the corps for themedical group/brigade. The CSC detachment headquarters must coordinate these CSC support operations.In the corps, the MRI CSH no longer has a 15-person NP ward and consultation service. Under MRI, it hasa small 4-person NP consultation section (psychiatrist, psychiatric nurse, two mental health specialists) toprovide psychiatric stabilization on medical wards; to provide triage and outpatient psychiatry; and toprovide stress control support (including debriefings) for all the hospital patients and staff. The CSCdetachment will have an increased requirement to provide CSC support at the CSHs. Under somecircumstances, the CSC detachment may be required to provide a CSC fitness team to conduct ward-levelstabilization, in addition to other higher priority CSC mission requirements.

b. Medical Company, Combat Stress Control.

(1) Comparison. In MF2K major regional conflicts, the 85-person CSC companies hadresponsibility for all CSC support in the corps area, plus major responsibility for supporting and reinforcingthe CSC detachments. The detachments were usually entirely within the division areas, although �spareteams� might come under the CSC company�s C2 for reallocation to areas of special need. There was noCSC unit allocation to support the COMMZ. In the COMMZ, the field hospital�s 15-person NP ward, OT,and psychology personnel provided the required Level 4 reconditioning. The general hospital�s NP wardpersonnel provided NP stabilization or detoxification to assure safe air evacuation of psychiatric patients orRTD for recovered patients. The MF2K COMMZ hospitals could reinforce the COMMZ ASMB�s mentalhealth section in the event of serious rear battle or disaster. Under the MRI, the hospitals retain only the4-person NP consultation section. While the MRI CSC detachments take over the forward corps and Level 3reconditioning mission, the one remaining CSC company is still responsible for the corps rear and hasadditional mission responsibilities for the echelons above corps (COMMZ). Each remaining CSC company,therefore, increases to 88 persons with the gain of two 4-person CSC preventive teams and the retention ofits four CSC fitness teams (previously labeled restoration teams in MF2K). Each CSC company loses five2½- or 5-ton trucks from its CSC fitness and headquarters sections, plus three maintenance personnel. Thetrucks and maintenance personnel were lost because of Armywide rules for vehicles in rear area units. Twomore of the headquarters section�s personnel were also deleted. The CSC company loses 50 percent of itsweapons for self-defense.

(2) Implications. The CSC company still has a high-mobility multipurpose wheeled vehiclewith trailer for each preventive and fitness team and the commander to perform daily consultation missions.It is dependent on other units to move its large tents and cots. This could be time-urgent in somereconstitution support missions. The CSC company should use the one remaining large truck in itsheadquarters to practice load planning and to develop loading plans for unit equipment being transported byother units. All the CSC sections could use this vehicle for training and familiarization of loading planswhich would enhance their movement operations. The CSC company still provides CSC preventive teamsfor direct support of corps-level brigades (National Guard enhanced readiness brigades, ACRs, field artillery,

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aviation, combat engineers, military police, and so forth) which may deploy as far forward as the divisions�brigades. The company augments the ASMB/ASMC mental health mission in the corps rear and providesroutine support to brigade-sized units refitting in or transitioning through the corps. The company mustremain able to assemble task-organized elements quickly to provide reconstitution support for a division- orsmaller-sized unit. If Level 4 reconditioning is indicated after several weeks of intensive battle, the CSCcompany can provide a CSC fitness team and perhaps a CSC preventive team. One inpatient NP ward in thetheater may be judged more efficient to stabilize psychiatric patients for air evacuation at a time of heavycasualties. This would prevent their presence from disrupting the functions of the busy medical/surgicalwards. This capability could be achieved by attaching at least one CSC fitness team to a hospital. However,this should only be a temporary measure because the fitness team will have other CSC support requirements.The capability of staffing a psychiatric ward, which is no longer organic to any deploying MRI hospital, canalso be required in stability operations and support operations, as it was at Guantanamo for 11 months.Finally, a new mission for the CSC company and hospital NP personnel is the DOD (Health Affairs)requirement to screen all US soldiers for mental health problems prior to redeployment from a TO. This canrequire brief interviews of up to 20 percent of the redeploying population.

c. Medical Companies and Detachments, Combat Stress Control.

(1) Comparison.

(a) In MF2K, the command positions were officially open only to psychiatrists, althoughexceptions were made in practice. In MRI, the TOE specifies that command is now open to �best qualified�officers of the other mental health disciplines (65A, 66C, 73A, 73B) as well as the psychiatrists (60W).This is in keeping with the general trend within the Army Medical Department. Number constraints stillrequire the commander of the CSC detachment to be dual-hatted as a practicing clinician in one of theteams.

(b) In MF2K, psychiatrists were in the preventive section, usually deployed furtherforward, while clinical psychologists were in the restoration (now fitness) section, usually employed furtherto the rear. The commander could transfer personnel between sections to meet mission needs. In MRI, theclinical psychologists are in the preventive section and the psychiatrists are in the fitness section. Thisresults in a net decrease in psychiatrists and a larger proportional increase in psychologists.

(2) Implications. The switching of the psychiatry and psychology positions was made as an�economy of force measure,� rather than because of any change in the mission demands at each echelon. Itis projected that the Army will not have sufficient psychiatrists to fill all CSC unit positions. The CSCmission still recognizes the FSMC as the key point for making the differential triage between combat stress/BF cases and similar-appearing patients with significant medical or surgical conditions. Putting triageexpertise as far forward as feasible is especially important in chemical warfare scenarios or on a widelydispersed and mobile high-technology battlefield. The psychiatrists in the CSC units must now make specialeffort to train the psychologists and social workers in the preventive section on basic physical/neurologicalexaminations and to convey relevant findings or suspicions to the physicians and physician assistants. Thepsychiatrists must use telemedicine to support their forward deployed CSC preventive teams and must beprepared to deploy forward themselves when needed. The division psychiatrists must increase training to all

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the forward-deployed physicians and physician assistants, as well as the brigade behavioral science officers,as there will be fewer psychiatrists forward to assist in combat NP triage.

Section II. UNIT MENTAL HEALTH SECTIONS IN THETHEATER OF OPERATIONS

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

Mental health sections are located in the divisions, the corps, and echelons above corps. In the divisions, amental health section is assigned to each medical company. In the corps and echelons above corps, mentalhealth sections are assigned to each of the ASMCs. In ACRs and separate brigades, they are assigned to themedical company.

E-4. Utilization in Garrison

In garrison, mental health personnel assigned to the division or brigade units should be employed as mentalhealth care providers. They should provide their consultation skills and specialty clinical expertise todivision personnel and their families. When the medical company and its supported units deploy on trainingexercises or are in the field, assigned mental health personnel will deploy with them to provide CSC trainingand support. In addition, they will train to perfect their own technical and tactical skills. In garrison,referrals to the hospital or its clinics should be reduced. This is accomplished by having each of the mentalhealth sections working closely with units leaders and chaplains as consultants. In this capacity, they canprovide intervention and teach stress management. They can evaluate and treat distressed soldiers at theirduty stations or unit areas. However, the mental health sections of the division must continue to operate aconsolidated division mental health activity in which all division mental health officers and enlisted personnelwork together. The consolidated division mental health activity ensures that case management of problemsoldiers/patients receive the benefit of all three mental health disciplines (psychiatrist, psychologist, andsocial worker) represented in the division for diagnosis, treatment, and referral. The consolidated divisionmental health activity provides the environment for cross training and building of team cohesion.Additionally, enlisted mental health personnel receive multidisciplinary training and supervision. All threemental health disciplines contribute fully in operational planning and in the division preventive psychiatryprogram, to include family support group development, drug and alcohol prevention and control, andpersonnel reliability screening. On some posts, the division mental health assets may augment table ofdistribution and allowances personnel in the Community Mental Health Activity. This would be the usualmode for the behavioral science officers and mental health specialists/mental health sections of the ASMBand companies of ACRs or separate brigades.

NOTE

In accordance with AR 40-216, clinical responsibilities in garrisonmust not interfere with participation in field exercises, deploymentexercises, and maintenance of combat readiness.

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E-5. Division Mental Health Sections

One CSC/mental health section as stated above is organic to each medical company assigned to the division.The medical companies are a DISCOM asset (see FMs 8-10-1, 8-10-3, and 63-21). The FSMCs are unitsassigned to the FSBs which support the maneuver brigades. The MSMC in the MSB is located in theDSA.

NOTE

The responsibilities of the division mental health section extends to alldivision elements and provides a mental health/CSC presence at thecombat maneuver brigades.

The mental health sections are the medical elements in the division with the primary responsibility forassisting the command with controlling combat stress. Combat stress is controlled through sound leadership,assisted by CSC training, consultation, and restoration programs conducted by these sections. Division andbrigade mental health sections enhance unit effectiveness and minimize losses due to BF, misconduct stressbehaviors, and NP disorders. All mental health sections assigned or attached to the division work under thetechnical control and direction of the division psychiatrist. The division psychiatrist, acting for the divisionsurgeon, has staff responsibility for establishing policy and guidance for the prevention, diagnosis, treatment,and management of NP, BF, and misconduct stress behavior cases within the division AO. He also hastechnical responsibility for the psychological aspect of surety programs. The staff of the division mentalhealth sections provides training to unit leaders and their staffs, chaplains, medical personnel, and troops.The staff monitors morale, cohesion, and mental fitness of supported units. Other responsibilities for themental health sections located in divisions include�

� Monitoring indicators of dysfunctional stress in units.

� Evaluating NP, BF, and misconduct stress behavior cases.

� Providing consultation and triage as requested for medical/surgical patients exhibiting signs ofcombat stress or NP disorders.

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

� Coordinating support activities of attached corps-level CSC elements.

The division psychiatrist normally uses the DSA clearing station as a base of operations. A behavioralscience officer (AOC 67D00) is assigned to each medical company except those which have the psychiatristassigned. Each behavioral science officer assigned to a FSMC is designated as the brigade behavioralscience health officer. The mental health specialist (MOS 91X00) assigned to each FSMC is designated asbrigade CSC coordinator. The division psychiatrist oversees the activities of all mental health sections in thedivision and provides consultation, as necessary.

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a. Mental Health/Combat Stress Control Support. The division psychiatrist provides input to thedivision surgeon on CSC-related matters. He works with the division medical plans and operationspersonnel to monitor and prioritize mental health support missions in accordance with the division CHSOPLANs or OPORDs. Coordination for mental health personnel augmentation is accomplished through thedivision surgeon.

b. Mental Health Sections. When the brigades are tactically deployed, the mental health sectionsuse the division clearing stations operated by the FSMCs as the center of their operations but are mobilethroughout the AO. The section�s priority functions are to sustain combat effectiveness, prevent unnecessaryevacuations, and to coordinate RTD, not to treat cases. The mental health section provides technicalsupervision for the attached CSC preventive team from the corps CSC detachment. Through the brigadesurgeons, this section keeps abreast of the tactical situation and plans and projects requirements for CSCsupport when units are pulled back for rest and recuperation.

c. Division Mental Health Staff Activities. Mental health sections will coordinate their activitieswith the division psychiatrist. The division psychiatrist synchronizes mental health/CSC activities for thedivision�s prevention, training, and treatment responsibilities. Behavioral science officers using theirmultidisciplinary mental health professional expertise will�

� Supervise and train the mental health specialists.

� Provide mental health/CSC staff input to the commands within the division AO.

� Guarantee clinical evaluation and supervision of treatment for all NP and problematic BFcases before they leave the division.

� Maintain communications and unity of efforts for the division and brigades.

� Provide points of contact to integrate reinforcing CSC teams throughout the division.

(1) Psychiatrist. The division psychiatrist (MAJ, MC, AOC 60W00) is the officer responsiblefor overseeing the division mental health program. The psychiatrist is also a working physician who appliesthe knowledge and principles of psychiatry and medicine in the treatment of all patients. He examines,diagnoses, and treats, or recommends courses of treatment for personnel suffering from emotional or mentalillness, situational maladjustment, BF (combat stress reactions), and misconduct stress behaviors. Hisspecific functions include�

� Directing the division�s mental health (combat mental fitness) program.

� Being a staff consultant for the division surgeon on matters having psychiatricaspects, which include�

� The personnel reliability program.

� Security clearances.

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� Alcohol and drug abuse prevention and control programs.

� Planning CSC support for supported units.

� Conducting mental health/CSC operations.

� Providing staff consultation for the MSMC commander and for supportedcommands within the division.

� Being responsible for assuring the diagnosis, treatment, restoration, anddisposition of all NP and problematic BF cases.

� Participating in the diagnosis and treatment of the sick, injured, and wounded,especially those who can RTD quickly.

� Providing consultation and training to physicians, physicians assistants, unitleaders, chaplains, and other medical personnel regarding diagnosis, treatment, and management of BF,misconduct stress behavior, and NP disorders.

� Prescribing treatment and disposition for soldiers with NP conditions.

� Providing supervision and training of assigned and attached mental healthpersonnel.

(2) Behavioral science officer. A behavioral science officer (CPT, AOC 67D00) is assignedto the mental health section of each FSMC. He serves as brigade behavioral science officer for thesupported brigade and the BSA. The behavioral science officer participates in staff planning to representand coordinate mental health/CSC activities throughout the brigade. The behavioral science officer isespecially concerned with assisting and training�

� Small unit leaders.

� Unit ministry teams.

� Battalion medical platoons.

� Patient-holding squad and treatment squad personnel of the FSMC.

The behavioral science officer provides training and advice in the control of stressors, the promotion of posi-tive combat stress behaviors, and the identification, handling, and management of misconduct stress behaviorand BF soldiers. He coordinates training and support to the brigade through the FSMC commander anddivision psychiatrist. He collects and records social and psychological data and counsels personnel with per-sonal, behavioral, or psychological problems. The general duties of the behavioral science officer include�

� Assisting in a wide range of psychological and social services.

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� Compiling caseload data.

� Providing counseling to soldiers experiencing emotional or social problems.

� Referring soldiers to specific mental health officers, physicians, or agencies whenindicated.

� Assisting with group debriefings, counseling, and therapy sessions, and leading groupdiscussions.

� Providing individual case consultation to commanders, NCOs, chaplains, battalionsurgeons, and physician assistants within the supported brigade.

� Collecting information from units regarding unit cohesion and morale whichinclude�

� Obtaining data on disciplinary actions.

� Collecting information with questionnaires.

� Conducting structured interviews.

� Collecting information on individual BF cases pertaining to the prior effective-ness of the soldier, precipitating factors causing the soldier to have BF, and the soldier�s RTD potential.

NOTE

Behavioral science officer positions, AOC 67D00, may be filled by aclinical psychologist, AOC 73B67, or a social work officer, AOC73A67.

(3) Clinical psychologist. The clinical psychologist (CPT, MS, AOC 73B67) assists in thedevelopment, management, and supervision of the division�s mental health (combat mental fitness) program.His specialty responsibilities apply to the knowledge and principles of psychology, to include�

� Evaluating the psychological functioning of soldiers.

� Conducting surveys and evaluating data to assess unit cohesion and other factorsrelated to prediction and prevention of both BF casualties and misconduct stress behaviors.

� Performing psychological and neuropsychological testing to evaluate psychologicalproblems and psychiatric and organic mental disorders, and to screen misconduct stress behaviors andunsuitable soldiers.

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� Apprising unit leaders, primary care physicians, and other clinical personnelregarding the assessment of individual and unit mental health fitness programs.

� Providing consultation for unit commanders and CSC/mental health personnelworking at the brigade level regarding problem cases.

� Counseling and providing therapy or referral for soldiers with psychologicalproblems.

� Serving as the brigade mental health officer for one maneuver brigade (normallyteamed with a behavioral science NCO).

(4) Social work officer. The social work officer (CPT, MS, AOC 73A67) assists in thedevelopment, management, and supervision of the division�s mental health (combat mental fitness) program.He applies the mental health principles and his knowledge of social work in the performance of his duties.His responsibilities include�

� Evaluating the social integration of BF and misconduct stress behavior soldiers intheir units and families.

� Coordinating and ensuring the RTD of recovered stress casualties and theirreintegration into their original or new units.

� Identifying and resolving organizational and social environmental factors whichinterfere with combat readiness.

� Ensuring support for soldiers and their families from Army and civilian communitysupport agencies.

� Apprising unit leaders, primary care physicians, and other clinical personnel ofavailable social service resources.

� Providing consultation to unit commanders and to division mental health sectionpersonnel regarding problem cases.

� Counseling and providing therapy or referral for soldiers with emotional disordersand psychological problems.

� Serving as brigade behavioral science officer for one maneuver brigade as a memberof the mental health section of the FSMC.

(5) Senior mental health noncommissioned officer. The mental health NCO (E-7, MOS91X40) is located with the division psychiatrist in the DSA. This senior NCO assists the division psychiatristwith the accomplishment of his duties. He is the CSC coordinator for the DSA. His specific dutiesinclude�

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� Keeping the division psychiatrist informed on the status of the mental health sectionsand on the mental fitness of soldiers supported in the DSA.

� Monitoring, facilitating, and coordinating training activities of the division mentalhealth personnel.

� Monitoring and coordinating situation reports from division mental health sections.

� Coordinating with the supporting CSC medical detachment for additional mentalhealth support, as required.

� Supervising restoration of BF casualties in the DSA.

� Conducting classes on selected mental health topics for senior NCOs within thedivision.

(6) Mental health specialist. The mental health specialist (E-4, MOS 91X10) is assigned tothe mental health section of each FSMC. He works under the supervision of the behavioral science officer.The mental health specialist assists the behavioral science officer with the accomplishment of his duties.The mental health specialist is the CSC coordinator for the supported maneuver brigade and the BSA. Hisspecific duties include�

� Keeping the behavioral science officer informed on the status and mental fitness ofsoldiers in the supported brigade and in the BSA.

� Assisting the behavioral science officer with facilitating and coordinating trainingactivities of the ASMB mental health personnel.

E-6. Area Support Medical Battalion Mental Health Sections

The ASMB�s mental health sections are the medical elements with primary responsibility for assisting unitsin the corps support area to control combat stress. As in the division, combat stress is controlled throughvigorous prevention, consultation, and restoration programs. These programs are designed to maximize theRTD rate of BF soldiers by identifying combat stress reactions and providing rest/restoration within or neartheir unit areas. Also, the prevention of post-traumatic stress disorders is an important objective in bothdivision and corps CSC programs. Under the direction of the ASMB psychiatrist, the mental health sectionsprovide mental health/CSC services throughout the ASMB�s AO. The battalion mental health sections areassigned to the headquarters and headquarters detachment of the ASMB. Also, each ASMC has a mentalhealth section. The battalion psychiatrist has staff responsibility for establishing policy and guidance for theprevention, diagnosis, and management of NP, BF, and misconduct stress behavior cases seen by ASMBphysicians and the mental health sections. He also has technical responsibility for the psychological aspectof surety programs. He provides and oversees mental health and stress control training for unit leaders andtheir staffs, chaplains, medical personnel, and troops. Through the battalion and company mental healthsections, the battalion psychiatrist monitors morale, cohesion, and mental fitness of supported units. He has

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technical control over all mental health personnel assigned to the ASMB and provides guidance as requiredfor the successful accomplishment of their responsibilities. These responsibilities include�

� Providing command consultation and making recommendations for reducing stressors.

� Evaluating NP, BF, and misconduct stress behavior cases.

� Providing consultation and triage, as requested, for patients exhibiting signs of combat stressreactions or mental disorders.

� Providing selective short-term restoration for HOLD category BF cases.

� Coordinating support activities with the medical company and detachment and CSC elements,when attached or in support of the ASMB.

a. Mental Health Support. The ASMB S3 and battalion mental health sections monitor andprioritize mental health support missions in coordination with the MEDCOM/brigade headquarters.

b. Battalion Mental Health Section Staff. The ASMB mental health section is staffed as shown inFigure E-1. The dispersion of multidisciplinary mental health professionals throughout the battalion ensuresthat expertise is present to�

� Train and supervise the mental health specialists.

� Provide staff input to supported commands.

� Provide clinical evaluation and appropriate treatment or referral for all NP and problematicBF cases.

� Provide a mental health professional for interface with supported brigades, groups, andcorps resources.

� Provide rapid assistance with critical incident/events debriefing for the ASMB�s area ofresponsibility.

MENTAL HEALTH SECTION STAFF

Psychiatrist (MAJ, AOC 60W00)Mental Health Specialist (E-4, MOS 91X10)Mental Health Specialist (E-3, MOS 91X10)

Figure E-1. Area support medical battalion mental health section.

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(1) Psychiatrist. The psychiatrist (MAJ, MC, AOC 60W00) is the section leader. Thepsychiatrist is also a working physician who applies the knowledge and principles of psychiatry and medicinein the treatment of all patients. He examines, diagnoses, and treats, or recommends courses of treatment forpersonnel suffering from emotional or mental illness, situational maladjustment, combat stress reaction, BF,and misconduct stress behaviors. His areas of responsibility include�

� Implementing CSC support according to the battalion�s area CHS plan.

� Coordinating and conducting mental health/CSC operations.

� Providing staff consultation for the ASMB commander and for supported commandswithin the supported AO. This includes the personnel reliability program, security clearances, andADAPCPs.

� Training and mentoring ASMC medical and mental health personnel in neurologicaland mental status examinations and differential diagnosis of stress and psychiatric disorders from generalmedical/surgical conditions.

� Diagnosing, treating, and determining disposition of NP, BF, and misconduct stressbehavior cases.

� Participating in the diagnosis and treatment of the sick, injured, and wounded,especially of those who can RTD quickly.

� Providing consultation and training to unit leaders, chaplains, and medical personnelregarding identification and management of BF (combat stress reaction), misconduct stress behaviors, andNP disorders.

� Providing therapy or referral for soldiers with NP conditions.

� Providing supervision and training of assigned and attached mental health and CSCpersonnel.

� Coordinating with the supporting CSC medical detachment for additional mentalhealth support as required.

(2) Mental health specialists. The mental health specialists (E-4 and E-3, MOS 91X10) arelocated with the ASMB psychiatrist at the ASMB headquarters. These mental health specialists assist theASMB psychiatrist with the accomplishment of his duties. They may perform as CSC coordinators forselected units in the corps support area. Their specific duties include�

� Keeping the ASMB psychiatrist informed on the status of the mental health sectionsand on the mental fitness of soldiers supported in the corps support area.

� Assisting the psychiatrist with facilitating, and coordinating training activities of theASMB mental health personnel.

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� Monitoring and coordinating situation reports from ASMC mental health sections.

� Conducting initial screening evaluations of patients.

c. Area Support Medical Company Mental Health Section. Each ASMC mental health staffconsists of a behavioral science officer and a mental health specialist (Figure E-2). The mental healthspecialist assists the behavioral science officer with the accomplishment of his duties. The behavioralscience officer participates in staff planning to represent and coordinate mental health/CSC activitiesthroughout the AO. The behavioral science officer and mental health specialist are especially concernedwith assisting and training�

� Small unit leaders.

� Unit ministry teams and staff chaplains.

� Battalion medical platoons.

� Patient-holding squad and treatment squad personnel of the ASMC.

AREA SUPPORT MEDICAL COMPANYMENTAL HEALTH SECTION STAFF

Behavioral Science Officer (CPT, AOC 67D00)Mental Health Specialist (E-3, MOS 91X10)

Figure E-2. Area support medical company mental health section.

The ASMC mental health section provides training and advice in the control of stressors, the promotion ofpositive combat stress behaviors, and the identification, handling, and management of misconduct stressbehavior and BF soldiers. It coordinates CSC training for supported units through the ASMC commanderand battalion psychiatrist, as required. The section collects and records social and psychological data andcounsels personnel with personal, behavioral, or psychological problems. General duties for personnelassigned to this section include�

� Assisting in a wide range of psychological and social services.

� Providing classes in stress control.

� Compiling caseload data.

� Providing counseling to soldiers experiencing emotional or social problems.

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� Referring soldiers to specific hospital NP services or CSC unit facilities, physicians, oragencies when indicated.

� Conducting or facilitating group debriefings, counseling, and therapy sessions, and leadinggroup discussions.

� Providing individual case consultation to commanders, NCOs, chaplains, battalionsurgeons, and physician assistants within the supported AO.

� Collecting information from units regarding unit cohesion and morale which include�

� Obtaining data on disciplinary actions.

� Collecting information with questionnaires.

� Conducting structured interviews.

� Collecting information on individual BF cases pertaining to the prior effectivenessof the soldier, precipitating factors causing the soldier to have BF, and the soldier�s RTD potential.

The company mental health section uses the ASMC clearing station as the center for its operations but ismobile throughout the AO. The section�s priority functions are to promote positive stress behaviors, preventunnecessary evacuations, and coordinate RTD, not to treat cases. Through the ASMC commander, thesection keeps abreast of the tactical situation and plans and projects requirements for CSC support whenunits are pulled back for rest and recuperation.

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

In the ACRs, active components, and National Guard-enhanced separate brigades, both light and heavy,mental health personnel are assigned to the medical company, separate brigade. A behavioral science officerand a mental health specialist are assigned to the mental health section of each FSMC. They serve as thebehavioral science officer and CSC coordinator for the brigade and the BSA. Their duties and responsibilitiesare the same as described for the division FSMC mental health section described above. They receivetechnical supervision from the division psychiatrist, when attached to a division, or from the ASMBpsychiatrist in their units� AO in the corps and echelons above corps.

Section III. COMBAT STRESS CONTROL COMPANY

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

The CSC medical company is employed in the corps and echelons above corps. The basis of allocation isone CSC medical company per corps or theater. The CSC medical company is task-organized, METT-T

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dependent for stability operations and support operations. Medical company, CSC, TOE 08467A000 replacesMedical Company, CSC, TOE 08467L000.

a. Mission. A CSC medical company provides comprehensive preventive and treatment servicesto a corps and echelons above corps during war. It provides this support to all services on an area supportbasis. The CSC medical company provides direct support to separate maneuver brigades or CS brigades, asneeded. It reinforces or reconstitutes other CSC assets in the corps or divisions as needed. The CSCmedical company provides CSC/mental health services to indigenous populations as directed in stabilityoperations or support operations, to include domestic support operations, humanitarian assistance, disasterrelief, and peace support operations. The comprehensive support provided by the CSC medical companyentails all of the six CSC functional mission areas. The CSC functional missions areas are discussed inChapter 1.

b. Capabilities. At TOE Level 1, the CSC medical company provides�

� Advice, planning, and coordination for CSC to commanders.

� Combat stress control reconstitution support for units up to division size.

� Preventive and CSC fitness teams (4 to 10 personnel) for consultation, treatment services,and reconstitution support for up to battalion-sized organizations.

� Restoration or reconditioning programs for up to 50 soldiers per CSC fitness team on anarea basis.

� Deployment of CSC elements to forward areas for support of contingency operations.

c. Assignment. The Medical Company, CSC (TOE 08467A000) is assigned to a corps ortheater MEDCOM. Elements of this TOE may be further attached to a corps medical brigade or to anASMB.

d. Organization. The CSC medical company is organized into a headquarters section, a preventivesection, and a CSC fitness section. The company is dependent on appropriate elements of the MEDCOM ormedical brigade for administrative and medical logistical support, medical regulating, BF casualty delivery,and medical evacuation. The company is dependent on appropriate elements of the corps or COMMZ forfinance, legal, personnel and administrative services, food service, supply and field services, supplementaltransportation, and local security support services. When CSC medical company elements or teams aredeployed to division areas, they are dependent on the division medical companies (such as the MSB medicalcompany or the FSB medical company) for patient accounting, transportation, food service, and fieldservice support.

e. Employment. The CSC medical company is employed in all intensities of conflict when acorps with two or more divisions is deployed. Task-organized CSC elements are deployed for division-sizecombat operations, stability operations and support operations, and other contingency operations which areMETT-T dependent.

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(1) The CSC preventive and CSC fitness sections together provide all five mental healthdisciplines. These resources are flexibly task-organized in a variety of combinations to meet the fluid CSCthreat at different phases in the operations. Personnel may be quickly cross-attached from one section toanother to accommodate the shifting work load and to provide reconstitution support packages.

(2) The CSC preventive and CSC fitness sections both organize into teams. Combat stresscontrol preventive or CSC fitness teams deployed forward of the corps boundaries in support of tacticaloperations come under operational control of the CHS operations element in the supported units. Theseteams will also come under technical control of the division or brigade CSC teams.

(3) One or more of the CSC medical company�s eight CSC preventive teams may locate atthe FSMC when deployed in direct support of separate brigades or ACRs.

(4) One or more of the four (10-person) CSC fitness teams may reinforce ASMCs which aredeployed to locations throughout the corps and echelon above corps. These teams provide a basis for CSCprevention and intervention. The teams may conduct restoration programs at the ASMCs, as required.These teams may also be deployed forward to provide temporary augmentation/reinforcement, as required.

(5) Based on work load, one or more of the four CSC fitness teams, plus one or more CSCpreventive teams, locate with a echelon above corps hospital where they conduct Level 4 CSC reconditioningprograms, as required. A hospital located in the corps rear or the COMMZ is the best location to conductthe theater CSC reconditioning program. When deployed with a hospital, these teams provide mobileconsultation in the vicinity of the hospital. These teams are also prepared to restrict reconditioningprograms and deploy forward in support of higher priority missions on very short notice. These teams canalso augment hospital NP services by staffing a temporary NP ward.

(6) The CSC medical company is divisible into four functionally emulative increments forsplit-based operations, stability operations and support operations, as assigned.

(7) Nonstandard task elements for specific missions can be organized using any combinationof the CSC preventive section and CSC fitness section personnel to meet specific mental health needs. Forstability operations and support operations, the minimum is an officer/NCO team to supplement a brigadeCSC team or a CSC preventive module/team of two officers, one NCO, and one enlisted. These modulesmay be augmented with personnel from the CSC fitness section to add additional specialty expertise.

E-9. Headquarters Section

The headquarters section provides C2 and unit-level administrative and maintenance support to its sub-ordinate sections when they are collocated with the company. The headquarters section may also provideassistance to detached elements by making site visits if the elements are within a feasible distance forground transportation. The CSC medical company elements normally deploy with limited maintenancecapability. When these CSC elements deploy, they are dependent on the supported units for patientaccounting, transportation, food service, and field services. The personnel assigned to the headquarterssection includes a�

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� Company commander.

� Chaplain.

� Medical operations officer.

� First sergeant.

� Mental health NCO.

� Supply sergeant.

� Patient administrative NCO.

� Nuclear, biological, and chemical NCO.

� Decontamination specialist.

� Personnel administrative specialist/unit clerk.

� Administrative specialist.

� Unit supply specialist/armorer.

� Patient administrative specialist.

� Light-wheeled vehicle mechanic.

� Power generation equipment repairman.

� Cook.

Personnel from the headquarters section are deployed with teams or task-organized CSC elements, asrequired.

a. Company Commander. The company commander, a psychiatrist or other clinical officer (LTC,MC/MS/AN/SP, AOC 60W00/73A67/73B67/66CTT/65A00) performs normal C2 and supervisoryfunctions. The commander is also responsible for the training, discipline, billeting, and security of thecompany. He provides daily reports to his higher headquarters as established by the TSOPs and corpsreporting procedures. He serves as the NP consultant on the staff of the medical group. As a psychiatrist,he coordinates with command and unit physicians regarding care and disposition of BF casualties and NPpatients. He exercises clinical supervision over all treatment provided by the CSC sections and detachments.He performs physical and mental status evaluations in emergency or command evaluation situations; thisincludes diagnosing, prescribing initial treatment, and determining disposition. The commander interfaceswith higher and supported headquarters and with supported CSC medical detachments, ASMB mental

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health sections, and division mental health sections. He keeps informed on CSC operations through dailyreports and by frequent visits to task-organized CSC elements deployed from his company.

b. Chaplain. The chaplain (CPT, CH, AOC 56A00) provides religious/ethical education andperspective to the dispersed sections for the prevention and treatment of BF and misconduct stress behaviors.He interfaces CSC activities with unit ministry teams in maneuver units, with hospital chaplains, and withstaff chaplains at each headquarters level. The chaplain usually accompanies the CSC medical companycommander when he visits supported units and task-organized CSC elements deployed in support of thoseunits. The chaplain has a chaplain�s kit to conduct services but is without a chaplain�s assistant. Thechaplain�s primary role is to aid other chaplains and CSC personnel in preventing stress control and inworking with BF casualties and misconduct stress behaviors. In addition to his coordination, liaison, andtraining duties, he provides religious support to BF casualties and to staff as available time and supportrequirements permit.

c. Medical Operations Officer. The medical operations officer (CPT, MS, AOC 70B67) is theprincipal assistant to the company commander on all matters pertaining to the tactical employment ofcompany assets. He is responsible for overseeing operations and administrative, supply, and maintenanceactivities within the company. His responsibilities also include�

� Coordinating administrative activities with the staff of the higher medical headquarters.

� Ensuring unit operations and communications security.

� Keeping the commander current on the corps� and supported divisions� tactical situations.

� Assisting the commander with development of CSC support estimates and plans.

� Planning and scheduling unit training activities.

� Coordinating movement orders and logistical support for deployed company elements.

d. First Sergeant. The first sergeant (E8, MOS 91B5M) serves as the principal enlisted assistantto the company commander. He manages the administrative activities of the CP. He supervises thecompany activities of the unit clerk and maintains liaison between the commander and assigned NCO. Heprovides guidance to enlisted members of the company and represents them to the commander. He plans,coordinates, supervises, and participates in activities pertaining to organization, training, and combatoperations for the company. He assists the company commander in the performance of his duties. The firstsergeant also assists the medical operations officer and performs the duties of an operations NCO.

e. Mental Health Noncommissioned Officer. The mental health NCO (E7, MOS 91X40) assiststhe commander and chaplain as required. He performs surveys and collects information on stress andstressors in supported units. He also checks the status of recovered stress casualties.

f. Supply Sergeant. The supply sergeant (E-6, MOS 92Y30) requests, receives, stores,safeguards, and issues general supplies. He determines methods of obtaining relief from responsibility for

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lost, damaged, and destroyed supply items. He maintains the company supply records, supervises unitsupply operations, and maintains accountability for all equipment organic to the company.

g. Patient Administration Noncommissioned Officer. The patient administration NCO (E-5, MOS71G20) is responsible for managing patient statistics of all BF casualties seen by the company element. Heis normally located with the company headquarters but makes visits to task-organized CSC elements asrequired to ensure company elements are complying with patient administrative requirements. He isresponsible for forwarding the Medical Summary Report (RCS Med-302 [R3]) in accordance with AR 40-400 and ensures that all BF casualty accountability and status reports are forwarded as directed by higherheadquarters. He initiates the FMC (DD Form 1380) on all BF casualties seen for consultation and medicaltreatment and those placed in the center for restoration or reconditioning programs. He ensures that allrestoration and reconditioning centers maintain the Daily Disposition Log. He supervises subordinatepatient administrative specialists. He coordinates transportation and evacuation, as required, for BF casualtiessent rearward for additional restoration or reconditioning and for recovered BF casualties returning to theirunits.

h. Nuclear, Biological, and Chemical Noncommissioned Officer. The NBC NCO (E-5, MOS54B20) coordinates NBC defense operations for the company. He supervises the training that pertains toprocedures and techniques of NBC defense. The NBC NCO predicts the effects of weather and terrain onchemical operations. His responsibilities also include preparing predictions on nuclear fallout and on NBCdownwind hazards. He prepares and evaluates NBC reports and computes expected radiation effectsaffecting personnel, equipment, and operations. This NBC NCO is the technical advisor to the unitcommander on matters pertaining to NBC functions. He provides expertise and training in the operation andmaintenance of NBC equipment. He supervises decontamination of unit equipment, supplies, and personnel(not patients). At a time of heavy caseloads (unless the unit is in an active NBC environment), the NBCNCO may serve as a squad leader for up to ten BF casualties in reconditioning or restoration.

i. Decontamination Specialist. The decontamination specialist (E-4, MOS 54B10) assists theNBC NCO with the accomplishment of his duties. The decontamination specialistmay serve as squad leader for up to ten BF casualties in reconditioning or restoration.

j. Personnel Administrative Specialist/Unit Clerk. The unit clerk (E4, MOS 75B10) providesand coordinates personnel and administrative support to company personnel and maintains unit admin-istrative records. He advises the commander and coordinates personnel actions for recovering BF casualtiesor RTD soldiers that require other administrative actions. He prepares and processes recommenda-tions for awards and decorations and arranges for awards ceremony. For complete description of duties, seeAR 611-201.

k. Administrative Specialist. The administrative specialist (E-4, MOS 71L10) prepares militaryand nonmilitary correspondence in draft and final copy. He employs basic principles of English compositionand grammar in preparing correspondence. He prepares registered or certified mail for dispatch. Heopens, sorts, routes, and delivers incoming correspondence and messages. He prepares suspense controldocuments and maintains suspense files. The administrative specialist prepares and maintains functionalfiles according to Modern Army Record-keeping System. He receives publications and establishes andmaintains the publications library. He requisitions and stocks blank forms.

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l. Unit Supply Specialist/Armorer. The unit supply specialist/armorer (E-4, MOS 92Y10)performs duties involving general supply, including inventorying, requisitioning, distribution, and storage.He assists the supply sergeant with the accomplishment of his duties. In addition to general supply duties,the supply specialist maintains the weapons storage area, issues and receives munitions, and performs smallarms unit maintenance. He assists the supply sergeant with general supply activities and operates thevehicle assigned to the supply element.

m. Patient Administration Specialist. The patient administration specialist (E-4, MOS 71G10)participates in the in-processing of BF casualties into restoration and reconditioning centers. He isresponsible for initiating reports and forms identified in the preceding paragraph. He maintains the DailyDisposition Log. When deployed with a CSC fitness team or task-organized CSC elements, he works withthe patient administration section of the medical unit to which the task-organized CSC element or CSCfitness team is attached. Through the patient administration section of the unit they are attached to, theycoordinate BF casualty evacuation and transportation requirements. He maintains his assigned vehicles andoperates company radios. He coordinates the disposition of BF casualties through supporting unitcommunications assets. Patient administration specialists deploy with CSC fitness teams or task-organizedCSC elements.

n. Light-Wheeled Vehicle Mechanic. The light-wheeled vehicle mechanic (E-4, MOS 63B10)performs organizational maintenance, PMCS, and repairs on gasoline and diesel-fueled, light-wheeledvehicles. Light-wheeled vehicles include prime movers designated as 5 tons or less and their trailers andassociated items. Duties of the light-wheeled vehicle mechanic include�

� Diagnosing malfunctions of light-wheeled vehicles and associated items.

� Troubleshooting engine/equipment problems using TMs, TMDE, and other equipment,as required.

� Applying applicable safety precautions.

� Performing scheduled maintenance and repairs on vehicles and equipment assisted by thevehicle operator.

� Maintaining and accounting for tools and equipment issued to him.

� Deploying with company element (task-organized CSC element) to provide maintenancefor company or attached vehicles.

� Maintaining and requisitioning repair parts as required.

� Initiating and maintaining records on equipment use, operations, history, maintenance,modifications, and calibration.

� Requesting, receiving, recording, and storing parts and tools.

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The light-wheeled vehicle mechanic is also responsible for�

� Providing input for the materiel readiness report.

� Assisting in the scheduling of maintenance and repair services.

NOTE

When the light-wheeled vehicle mechanic deploys, he works with themaintenance section/element of the unit to which the task-organizedCSC element is attached.

o. Power Generation Equipment Repairman. The power generation equipment repairman (E4,MOS 52D10) performs unit maintenance functions. The major functions and tasks of the repairmaninclude�

� Applying applicable safety precautions.

� Inspecting equipment, determining category of maintenance and extent of repairs, andrecording results.

� Classifying unserviceable components and assemblages as required.

� Performing PMCS on shop equipment.

� Maintaining and accounting for tools issued.

� Training unit personnel on how to properly operate and perform user maintenance onassigned generators.

p. Cook. One cook (E3, MOS 92G10) provides food service (tray-pack heating) for the companywhen it is assembled. More often, he is deployed with a task-organized CSC element and further attachedwith the food service section of the supported medical unit. He also trains CSC personnel on food taskswhich may be used as a part of a CSC restoration or reconditioning program. He may serves as work groupleader for BF casualties performing food service tasks as part of the BF casualty�s treatment.

E-10. Combat Stress Control Preventive Section

Personnel of this section are task-organized to prevent stress, misconduct, and prevent post-traumatic stressdisorders. The CSC preventive section accomplishes this through command consultation, preventiveeducation, critical events/incidences debriefings, staff planning, case evaluation, and triage, and counselingintervention at supported unit. Section personnel also supervise and participate in restoration and

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reconditioning programs conducted by Echelon II medical unit and the CSC fitness section. Personnel fromthis section may be task-organized with personnel of the CSC fitness section into CSC elements for specificmissions of the company. This section can divide into eight CSC preventive teams. The section (and team)leader position may be held by any of the officers assigned to the section. The CSC preventive section hassix clinical psychologists, eight social work officers, two behavioral science officers, eight mental healthNCOs, and eight mental health specialists assigned to the section. This section can divide into eight 4-person CSC preventive teams. Elements of the section may also be task-organized with elements of therestoration section to form task-organized CSC elements for deployment to conduct CSC operations. Thecompany commander will appoint the CSC preventive team or task-organized CSC element leaders,considering rank, professional qualifications, and especially, experience. The preventive section�sresponsibilities include�

� Providing preventive consultation.

� Assisting units with REST category BF cases and RTD of recovered BF casualties.

� Providing NP triage and stabilization as required.

� Supervising restoration of category HOLD BF casualties by medical personnel.

� Providing medical, psychiatric, and social work expertise to restoration and reconditioningprograms.

� Deploying CSC preventive teams to reinforce CSC elements operating in the divisions andcorps areas.

� Providing reconstitution mental health support to physically and mentally exhausted units.

a. Clinical Psychologists. There are six clinical psychologists (MAJ [four], CPT [two], MS,AOC 73B67) assigned to the section. Their duties include�

� Providing diagnostic expertise for triage.

� Conducting psychological and neuropsychological testing.

� Providing behavioral treatment and counseling.

� Conducting and supervising surveys of unit cohesion, morale, and individual mentalreadiness for combat.

� Providing command consultation.

� Supervising subordinate personnel.

� Conducting and supervising critical event debriefings.

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b. Social Work Officers. Eight social work officers (MAJ [four], CPT [four], MS, AOC 73A67)are assigned to this section. They provide proactive consultation, give individual and group counseling,supervise restoration/reconditioning, and coordinate RTD of recovered cases. They also provide staffadvice and coordinate Army and civilian social services support. These social work officers may be dividedamong several task-organized CSC elements or be utilized as a member of a CSC preventive team. Whendeployed as a member of a CSC preventive team or task-organized CSC element, the social work officers�duties include�

� Evaluating psychosocial (unit and family) functioning of soldiers with BF and misconductstress behavior.

� Coordinating and ensuring the return of recovered BF and NP soldiers to duty and theirreintegration into their original or new unit.

� Identifying and resolving organizational and social environmental factors which interferewith combat readiness.

� Coordinating support for soldiers and their families through Army and civilian communitysupport agencies, when possible.

� Apprising unit leaders, primary care physicians, and others health care providers of availablesocial service resources.

� Providing consultation to supported unit commanders and to other mental health/CSCpersonnel regarding problem cases.

� Counseling and providing therapy or referral for soldiers with psychological problems.

� Conducting and supervising unit survey interviews and critical event debriefings.

c. Behavioral Science Officers. These two positions (CPT, AOC 67D00) are filled by AOC73A67 or AOC 73B67. These officers perform the duties of their respective AOC and in the technical andtactical operations of the section. The behavioral science officers are responsible for direct supervision ofthe mental health NCOs and specialists assigned to the section. The behavioral science officers, assisted bythe mental health NCOs, conduct the training activities of the section. They monitor and coordinatesituation reports, conduct classes on stress control, and provide consultation for leaders of supported units.

d. Mental Health Noncommissioned Officers. There are eight mental health NCOs (E-5, MOS91X20). Two of these NCOs act as assistant section sergeants and assist the behavioral science officers withthe accomplishment of their duties. When deployed as a member of a CSC preventive team or task-organized element, these NCOs assume the position of team NCOIC and assist the team leader with theaccomplishment of his duties. Their general duties include�

� Providing consultation and stress control education, especially to NCOs and enlistedpersonnel.

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� Assisting in a wide range of psychological and social services.

� Compiling caseload data and referring patients to specific mental health officers andphysicians in supporting MTFs.

� Providing counseling to soldiers experiencing emotional or social problems.

� Conducting or assisting with group counseling and debriefing sessions and leading groupdiscussions.

� Collecting data in unit survey interviews pertaining to unit cohesion, morale, andindividual mental readiness for combat.

� Conducting or assisting in critical event debriefings.

e. Mental Health Specialists. There are eight mental health specialists (E-4, MOS 91X10)assigned to the section. These specialists assist the mental health officer and NCOs in gathering social andpsychological data to support patient evaluations. Under the supervision of the mental health officer andNCOs, they provide initial screening of patients suffering emotional or social problems. In addition to theirduties, they operate and maintain assigned vehicles. Under the supervision of the mental health officer, theirspecific duties include�

� Serving as team leaders and providing supportive counseling to BF casualties andmisconduct stress behavior cases experiencing emotional or social problems.

� Assisting in the evaluation of BF casualties and misconduct stress behaviors.

� Assessing the mental status (level of functioning capacity) of BF casualties and misconductstress behaviors and their need for professional services.

� Collecting data in unit survey interviews.

� Assisting in critical event debriefings.

� Driving and maintaining team vehicles.

E-11. Combat Stress Control Fitness Section

The CSC fitness section has 4 psychiatrists, 4 OT officers, 4 psychiatric/mental health nurses, 8 OT NCOs,8 mental health NCOs, and 12 mental health specialists assigned to the section. Personnel of this section aretask-organized to provide NP triage, diagnosis, stabilization, and treatment at restoration or reconditioningcenters. Section personnel also deploy to provide mobile consultation and reconstitution support to units inthe vicinity and to reinforce the CSC preventive teams. Section personnel may be task-organized withmembers of the CSC preventive section into CSC elements for specific missions. The section personnel can

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augment a deployed CSH to staff a temporary NP ward. This section can divide into four CSC fitnessteams. Elements of this section are sometimes task-organized with elements of the CSC preventive sectionto form task-organized CSC elements which operate restoration or reconditioning centers. At these centers,they provide NP triage, diagnosis, stabilization, treatment, and disposition. Section personnel, as membersof task-organized CSC elements or CSC preventive teams, also deploy routinely to provide preventiveconsultation and reconstitution support to units in the corps area. They reinforce and may reconstitute CSCmedical detachment teams in the division support areas.

NOTE

The priority role for all CSC personnel is the prevention of BF andother stress-related casualties. This is as true for the CSC fitnesssection as it is for the CSC preventive section. The section leaderposition may be held by any of the officers assigned to the section.The company commander will appoint the section leader based onrank, professional qualifications, and experience. This same rationaleis used in selecting leaders for the task-organized CSC elements andCSC fitness team.

a. Psychiatrists. The psychiatrists (MAJ [two], CPT [two], MC, AOC 60W00) assigned to thissection examine patients and provide consultation. These psychiatrists make neuropsychological and medicaldiagnosis and prescribe and provide treatment. They also direct disposition of patients. The seniorpsychiatrist assigned to the section performs the duties of section leader and directs the activities of thesection when the section is assembled. Psychiatrists assigned to this section may be deployed in support ofCSC operations with the section, or as members of either a CSC preventive team or a task-organized CSCelement. When deployed as a member of a CSC preventive team or a task-organized CSC element, thepsychiatrists� duties include�

� Establishing and providing CSC support.

� Providing staff consultation to supported units as required. This includes nuclear surety,security clearance, and the alcohol and drug abuse preventive programs.

� Being responsible for the diagnosis, treatment, rehabilitation, and disposition of NP andproblematic BF cases.

� Participating in the diagnosis and treatment of the wounded, ill, and injured, especially ofthose who can RTD quickly.

� Consulting and providing training to unit leaders and medical personnel regardingidentification and management of NP disorders, BF, and misconduct stress behaviors.

� Providing therapy or referral for soldiers with NP disorders.

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� Providing supervision and training of assigned and attached mental health personnel.

� Conducting and supervising unit survey interviews and critical event debriefings.

b. Occupational Therapy Officers. Four OT officers (MAJ [two], CPT [two], SP, AOC 65A00)are assigned to the section. They serve as environmental managers using daily living tasks, physicalreconditioning, work, and other activities to counteract combat stress reactions. Preventive treatmentprograms include individual work assignments, organized group work projects, common soldier task review,stress management education, recreation, and physical reconditioning. Their responsibilities include�

� Providing command consultation to leaders regarding work schedules and restorative off-duty activity programs.

� Assessing and advising on ergonomically sound work practices.

� Performing functional occupational evaluations of BF casualties.

� Performing neuromuscular evaluations, especially upper extremities and hands.

� Assigning BF casualties to physical reconditioning and work groups.

� Overseeing physical reconditioning and work programs for BF casualties.

� Selecting appropriate activities based on a BF casualty�s assessment.

� Evaluating functional work capacity.

� Modifying reconditioning programs, as required.

� Maintaining records of therapy/treatment.

� Reporting status of BF casualties to psychiatrists and staff members on a daily basis, or inaccordance with the TSOPs.

� Conducting unit survey interviews and critical event debriefings.

c. Psychiatric/Mental Health Nurses. The four psychiatric/mental health nurses (MAJ [two],AOC 66C7T, and CPT [two], AOC 66C00, AN) provide specialized care, as required. They provide carefor all BF, misconduct stress behaviors, and NP casualties, especially those with severe behavioraldisturbances and/or concurrent physical illness or injury. They administer medications according to thepsychiatrist/physician�s orders. The clinical nurse specialists (AOC 66C7T), when properly trained, mayprescribe medications under the supervision of a psychiatrist/physician. In coordination with the psychiatrist,clinical psychologist, occupational therapist, and other section members, the psychiatric nurses� responsi-bilities include�

� Conducting individual and group therapy and stress control education sessions.

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� Providing preventive and command consultation, especially to medical units.

� Assisting with the development of the RTD plan for each case.

� Ensuring the BF casualty�s therapeutic program, as outlined in the RTD plan, is followed.

� Monitoring the BF casualty�s status and recording pertinent case data.

� Conducting nursing reports in accordance with TSOPs to update section members.

� Conducting and supervising unit survey interviews and critical event debriefings.

d. Occupational Therapy Noncommissioned Officers. Eight OT NCOs (E-6 [four], MOS91L30N3, and E-5 [four], MOS 91L20N3) are assigned to the section. They assist the occupationaltherapists with�

� Evaluating functional capacity and supervising physical reconditioning programs.

� Coordinating and setting up work programs with supported and supporting units andoverseeing the work programs.

� Supervising and ensuring appropriate training for subordinate OT specialists and othermental health personnel.

� Providing BF casualty status updates to the occupational therapists and other staffmembers as required.

� Providing direct supervision of BF casualties and squad leaders.

� Assisting with unit survey interviews and critical event debriefings.

� Assisting with the supervision of work programs.

� Assisting with the identification of useful work projects.

� Assisting with organizing activities which facilitate the recovery of the BF casualties.

� Serving as team leader for up to 12 BF casualties.

e. Mental Health Noncommissioned Officers. A total of eight mental health NCOs (E-6 [four],MOS 91X30, and E-5 [four], MOS 91X20) are assigned to the CSC fitness section. They assist in a widerange of psychological and social services.

(1) The NCOs, E-6, are assigned as team chiefs of the CSC fitness teams. Theirresponsibilities include�

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� Collecting and recording social and psychological data.

� Counseling soldiers with personal, behavioral, or psychological problems.

� Assisting with the management of the section.

� Deploying as members of the CSC preventive team or task-organized CSC elements.

Their general duties include�

� Assisting in a wide range of psychological and social services.

� Assisting with initial screening and assessment of new cases.

� Compiling caseload data and referring BF casualties to mental health officers andpsychiatrists.

� Providing counseling to BF casualties experiencing emotional or social problems.

� Assisting the psychologist with administration of psychological testing.

� Assisting with group counseling and therapy sessions and leading group discussions.

� Assisting with unit survey interviews and critical event debriefings.

(2) Four mental health NCOs (E-5) manage and provide supervision for BF casualty care.They deploy with either the CSC fitness teams or the task-organized CSC elements to supervise and functionas BF casualty care managers for the restoration and reconditioning centers. Other duties and responsibilitiesinclude�

� Assisting the psychiatric nurses with planning and executing the establishment,disestablishment, and movement of the reconditioning center.

� Assisting the psychiatric nurses with conducting restoration and reconditioning centeroperations and with the administration of medications and supervision of subordinates and BF casualties.

� Providing guidance and training to subordinate mental health specialists and otherBF care providers.

� Providing direct supervision for BF casualties (when assigned as their squad leader)and monitoring their progress.

f. Mental Health Specialists. Twelve mental health specialists (E-4 [eight] and E-3 [four], MOS91X10) provide BF casualty care and intervention, as required. These mental health specialists deploy witheither the CSC fitness teams or the task-organized CSC elements. Their duties include�

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� Following the RTD plans for cases placed under their supervision.

� Coordinating with the psychiatric nurses and other staff members on questions pertainingto the RTD plan.

� Providing direct supervision for BF casualties (as squad leaders) and monitoring theirprogress.

� Recording and reporting to the psychiatric nurses and other mental health staff memberson the status and any other pertinent observation of cases assigned to them.

� Assisting with unit survey interviews and critical event debriefings.

� Operating and maintaining assigned vehicles.

Section IV. COMBAT STRESS CONTROL DETACHMENT

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

The CSC medical detachment is a 43-person unit composed of a headquarters, a CSC preventive section(composed of a maximum of four CSC preventive teams), and a CSC fitness section (composed of two CSCfitness teams). The modular CSC teams found in the CSC medical detachment are similar to those found inthe CSC medical company. The CSC medical detachment provides CSC planning, consultation, training,and staff advice to C2 headquarters and the units to which they are assigned regarding�

� Combat and noncombat stressors affecting the troops.

� Mental readiness.

� Morale and cohesion.

� Potential for BF casualties.

The detachment provides NP triage, basic stabilization, and restoration for BF casualties. Under somecircumstances, it may provide reconditioning for NP and alcohol and drug abuse patients. This unit isdependent on support from appropriate elements of the corps to include�

� Religious support.

� Finance support.

� Legal support.

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� Personnel and administrative support.

� Laundry and bath services.

� Clothing exchange for unit personnel and stress casualty caseload.

� Communications and operations information support.

The detachment is dependent on units to which it is attached for support, to include�

� Food service.

� Water distribution.

� Medical treatment.

� Logistical support, including combat health logistics.

� Patient administration (assisted by its own enlisted patient administration specialist, MOS71G10).

� Unit maintenance for the detachment�s communications and power generator equipment andvehicle maintenance (assisted by its own light-wheel vehicle mechanic, MOS 63B10).

a. Mission. The CSC medical detachment provides complete preventive and treatment servicesin direct support of the division and corps personnel deployed forward. It also provides CSC support on anarea basis to all services and indigenous population as directed in stability operations or support operationswhich include domestic support operations, humanitarian assistance, disaster relief, and peace supportoperations. As the tactical situation permits, this detachment can provide all six of the CSC functionsidentified.

b. Assignment. The CSC medical detachment is normally assigned to a corps Medical Brigade(TOE 08432LXX) or a corps MEDCOM (TOE 08611LXX). It may be further attached to a MedicalCompany, CSC (TOE 08467A000), an ASMB (TOE 08456A000), or a division medical company.

E-13. Detachment Headquarters

The detachment headquarters section provides C2 for the detachment. The headquarters section isresponsible for planning, coordinating, and implementing CSC support for supported units. Personnel ofthe headquarters section provide maintenance, supply and service, and personnel administration support.The detachment headquarters is composed of the following personnel:

� Detachment commander who also works as a treating clinician with the CSC preventive orCSC fitness section.

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� Health service administrative assistant.

� Detachment NCOIC.

� Supply sergeant.

� Patient administration specialist.

� Light-wheel vehicle mechanic.

� Personnel administration specialist/unit clerk.

� Cook.

Detachment officers and NCOs from the CSC preventive team and the CSC fitness team may be assignedadditional duties which enhance the overall effectiveness of the headquarters section. Additional dutyresponsibilities may include�

� Maintenance.

� Training.

� Security, plans, and operations.

� Nuclear, biological, and chemical defense.

� Supply.

These duties may be rotated to achieve maximum cross-training.

a. Detachment Commander. The detachment commander, a psychiatrist or other clinical officer(LTC, MC/MS/AN/SP, AOC 60W00/73A67/73B67/66CTT/65A00) performs normal C2 and supervisoryfunctions, as well as serving as a treating clinician in one of the CSC preventive or CSC fitness teams. Hecoordinates with the command surgeon and mental health sections regarding care and disposition of patients.He exercises clinical supervision over treatment in all the CSC teams. He provides NP expertise tosupported unit headquarters. In conjunction with supported unit headquarters and MTFs, the detachmentcommander plans CSC support for the unit�s operations. He deploys the detachment teams separately, ortask organizes personnel across teams as needed to form task-organized CSC elements. He appoints teamleaders based on qualifications by experience as well as by AOCs.

b. Health Service Administrative Assistant. The health service administrative assistant,(1LT, MS,AOC 70B67) is the principal assistant to the detachment commander on all matters pertaining to the tacticalemployment of detachment assets. He is responsible for overseeing operations and administrative, supply,and maintenance activities within the detachment. His responsibilities also include�

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� Coordinating administrative activities with the staff of the higher medical headquarters.

� Ensuring unit operations and communications security.

� Keeping the commander current on the corps� and supported divisions� tactical situations.

� Assisting the commander with development of CSC support estimates and plans.

� Planning and scheduling unit training activities.

� Coordinating movement orders and logistical support for deployed detachment elements.

c. Detachment Noncommissioned Officer in Charge. The detachment NCOIC (E-7, MOS 91X40)assists the detachment commander in the accomplishment of his duties. He performs administrative duties;he receives and consolidates reports from deployed detachment elements and forwards them to higherheadquarters. The detachment NCOIC coordinates support for the detachment and for detachment elementsdeployed to supported units. He represents the commander at staff meetings and on-site visits to the CSCteams when the commander is occupied with clinical duties. When the detachment is divided into CSCpreventive and CSC fitness teams or task-organized CSC elements, the NCOIC normally locates with theCSC fitness team. He supervises the detachment activities of the unit clerk and maintains liaison betweenthe commander and assigned NCOs. He provides guidance to enlisted members of the detachment andrepresents them to the commander. He plans, coordinates, supervises, and participates in activities pertainingto organization, training, and combat operations for the detachment. He assists the detachment commanderin the performance of his duties. The detachment NCOIC also assists the health service administrativeofficer and performs the duties of an operations NCO.

d. Supply Sergeant. The supply sergeant (E-5, MOS 92Y20) requests, receives, inspects, stores,safeguards, and issues general supplies. He operates unit-level computers. The supply sergeant prepares allunit/organizational supply documents. He maintains the detachment supply records, supervises unit supplyoperations, and maintains accountability for all equipment organic to the detachment. He maintains andreceives small arms and controls weapons and ammunitions in security areas. The supply sergeant isresponsible for scheduling and performing preventive- and organizational-level maintenance on weapons.The supply sergeant reviews the Unit Material Condition Status Report and annotates changes. He poststransactions to organizational and installation property books and supporting transaction files. He determinesmethods of obtaining relief from responsibility for lost, damaged, and destroyed supply items. The supplysergeant is responsible for coordinating all supply activities.

e. Patient Administration Specialist. The patient administration specialist (E-4, MOS 71G10) isresponsible for managing patient statistics of all BF casualties seen by the detachment element. His dutiesare consistent with those identified above (paragraph E-9m).

f. Light-Wheeled Vehicle Mechanic. The light-wheeled vehicle mechanic (E-4, MOS 63B10)performs organizational maintenance. His duties are consistent with those identified above (para-graph E-9n).

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C 1, FM 8-51

NOTE

When the light-wheeled vehicle mechanic deploys, he works with themaintenance section/element of the unit to which the task-organizedCSC element is attached.

g. Personnel Administrative Specialist/Unit Clerk. The unit clerk (E4, MOS 75B10) provides andcoordinates personnel and administrative support to company personnel and maintains unit administrativerecords. His duties are consistent with those identified above in paragraph E-9j.

h. Cook. One cook (E3, MOS 92G10) provides food service (tray-pack heating) for thedetachment when it is assembled. More often, he is deployed with a task-organized CSC element andfurther attached for work with the food service section of the supported medical unit. He also trains CSCpersonnel on food tasks which may be used as a part of their CSC restoration or reconditioning program.He may serves as work group leader for BF casualties performing food service tasks as part of the BFcasualty�s treatment.

E-14. Preventive Section

This section has four clinical psychologists, four social work officers, four mental health NCOs, and fourmental health specialists. This section can divide into four 4-person CSC preventive teams. Three CSCpreventive teams are normally allocated, one each, to the supported division�s maneuver brigades. Thefourth CSC preventive may provide moving support to the aviation brigade, attached brigade-sized units,corps units in the division AO, or an ASMC in the corps area. When applicable, it combines with a CSCfitness team to staff the reconditioning program for the supported division and corps units, usually collocatedwith a CSH. Combat stress control preventive team leaders are selected by the detachment commanderbased on experience as well as on grade and specialty. Elements of the section may also be task-organizedwith elements of the CSC fitness team to form task-organized CSC elements for special CSC operations.The CSC preventive section�s responsibilities include�

� Preventing stress, misconduct stress behaviors, and post-traumatic casualties by providing�

� Command consultation.

� Stress prevention education.

� Debriefings (critical events and after action).

� Staff planning.

� Case evaluation and triage.

� Counseling intervention at supported units.

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C 1, FM 8-51

� Preventive consultation support to leaders, chaplains, and medical personnel.

� Assisting nonmedical units with REST category BF casualties and the RTD of recovered BFsoldiers.

� Providing NP triage and stabilization.

� Supervising restoration of HOLD category BF casualties by medical personnel and providingrestoration for selected cases.

� Deploying to units to provide reconstitution support.

a. Clinical Psychologists. There are four clinical psychologists (MAJ [two], CPT [two], MS,AOC 73B67) assigned to the section. Their duties include�

� Providing diagnostic expertise for triage.

� Conducting psychological and neuropsychological testing.

� Providing behavioral treatment and counseling.

� Conducting and supervising surveys of unit cohesion, morale, and individual mentalreadiness for combat.

� Providing command consultation.

� Supervising subordinate personnel.

� Conducting and supervising critical event debriefings.

b. Social Work Officers. Four social work officers (MAJ [two], CPT [two], MS, AOC 73A67)are assigned to this section. These social work officers provide proactive consultation and evaluatepsychosocial functioning and mission context of the supported units. They give individual and groupcounseling and debriefings, supervise restoration/reconditioning, and coordinate RTD of recovered cases.They provide staff advice and coordinate social services agency support. As a member of a CSC preventiveteam or other CSC element, in addition to those duties identified above (paragraph E-10b), the social workofficers� duties include�

� Evaluating soldiers with BF and misconduct stress behavior.

� Supervising subordinate personnel.

c. Mental Health Noncommissioned Officers. There are four mental health NCOs (E-5, MOS91X20). One of these NCOs acts as the section sergeant and the other three NCOs act as assistant sectionsergeants and assist the section sergeant with his duties. Their duties are consistent with those identified

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C 1, FM 8-51

above (paragraph E-10d). They deploy as NCOICs of teams and may be assigned as the team leader for upto 14 BF casualties in a restoration center. As stated above, the senior mental health NCO (E-5) alsoperforms as the preventive section sergeant. His duties are the same as those previously identified above(paragraph E-11e).

d. Mental Health Specialists. There are four mental health specialists (E-4, MOS 91X20)assigned to the section. These specialists perform those duties previously identified above (paragraph E-10e). In addition to their duties, they operate and maintain assigned vehicles.

E-15. Combat Stress Control Fitness Section

This section has two psychiatrists, two OT officers, two psychiatric/mental health nurses, four OT NCOs,four mental health NCOs, and six mental health specialists. The detachment NCOIC (E-7, MOS 91X40) islocated with the CSC fitness section and serves as the senior mental health NCO. The section can divideinto two CSC fitness teams. One team usually collocates with the supported division�s MSMC to providemobile CSC support to the DSA and conduct restoration programs, as required. The second CSC fitnessteam augments area support to corps units in the division AO and in forward areas of the corps. It canconduct the corps-level reconditioning program for the supported division and corps units and usuallycollocates with a CSH. The CSC fitness team provides staff and equipment for operating a restoration orreconditioning center. Personnel of this section are task-organized to provide NP triage, diagnosis,stabilization, and treatment at a restoration or reconditioning center. Section personnel also deploy toprovide mobile consultation and reconstitution support to units in the vicinity and to reinforce the CSCpreventive teams of the detachment. Section personnel may be task-organized with members of the CSCpreventive section into CSC elements for specific missions. The section personnel can augment a deployedhospital to staff a temporary NP ward. The section (and team) leader�s position may be held by any of theofficers assigned to the section. The commander will base his selection on experience as well as specialtyand grade. The commander, because of his other duties, normally appoints one of the officers assigned tothe section as the section leader.

a. Psychiatrists. The psychiatrists (LTC [one], MAJ [one], MC, AOC 60W00) assigned to thissection examine patients and provide consultation. These psychiatrists make neuropsychological and medicaldiagnosis and prescribe and provide treatment. They also direct disposition of patients. The seniorpsychiatrist directs the activities of the section when the section is assembled. Psychiatrists assigned to thissection may be deployed in support of CSC operations with the section, or as members of either a CSCfitness team or a task-organized CSC element. When employed as a member of a CSC fitness team or atask-organized CSC element, the psychiatrists� duties include�

� Establishing and providing CSC support.

� Providing staff consultation to supported units as required. This includes nuclear surety,security clearance, and alcohol and drug abuse preventive programs.

� Being responsible for the diagnosis, treatment, rehabilitation, and disposition of NP andproblematic BF cases.

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C 1, FM 8-51

� Participating in the diagnosis and treatment of the wounded, ill, and injured, especially ofthose who can RTD quickly.

� Consulting and providing training to unit leaders and medical personnel regardingidentification and management of NP disorders, BF, and misconduct stress behaviors.

� Providing therapy or referral for soldiers with NP disorders.

� Providing supervision and training of assigned and attached mental health personnel.

� Conducting and supervising unit survey interviews and critical event debriefings.

b. Occupational Therapy Officers. The OT officers (MAJ [one] and CPT [one], SP, AOC65A00) perform those duties previously identified above (paragraph E-11b).

c. Psychiatric/Mental Health Nurses. The psychiatric/mental health nurses (MAJ [one] and CPT[one], AN, AOC 66C00) provide specialized nursing care and management of BF casualties. The positionshould be filled by clinical nurse specialists (AOC 66C7T). The duties of the psychiatric/mental healthnurses are consistent with those previously identified above (paragraph E-11c).

d. Senior Mental Health Noncommissioned Officer. The senior mental health NCO (E-7, MOS91X40) is also the detachment NCOIC. He assists the CSC fitness section leader with the accomplishmentof his duties. He provides assistance with the management of technical and tactical operations of the section.His specific duties include�

� Keeping the section leader informed.

� Monitoring, facilitating, and supervising the training activities of subordinates.

� Monitoring and coordinating situation reports from deployed CSC preventive teams.

� Conducting classes on selected mental health topics for senior NCOs of supported units.

e. Occupational Therapy Noncommissioned Officers. Four OT NCOs (E-6 [two], MOS 91L30N3,and E-5 [two], MOS 91L20N3) are assigned to the section. The OT NCOs deploy with either CSC fitnessteams or task-organized CSC elements. Their duties are consistent with those listed above (paragraphE-11d).

f. Mental Health Noncommissioned Officers. A total of four mental health NCOs (E-6 [two],MOS 91X30, and E-5 [two], MOS 91X20) are assigned to CSC fitness section. They assist in a wide rangeof psychological and social services.

(1) The NCOs, E-6, are assigned as team chiefs of the CSC fitness teams. A team chiefdeploys with each CSC fitness team to supervise and function as the BF casualty care manager for arestoration center. The team chief assists with establishment, disestablishment, and movement of the team.

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C 1, FM 8-51

He also assists with conducting restoration and reconditioning center operations. The team chief may providedirect supervision for up to 12 BF casualties when assigned as their squad leader. The team chief may bedeployed temporarily to reinforce a CSC preventive team. The responsibilities of the team chief include�

� Collecting and recording social and psychological data.

� Counseling soldiers with personal, behavioral, or psychological problems.

� Assisting with the management of the section.

� Deploying as members of CSC preventive team or task-organized CSC elements.

Their general duties include�

� Assisting in a wide range of psychological and social services.

� Assisting with initial screening and assessment of new cases.

� Compiling caseload data and referring BF casualties to specific mental healthofficers and psychiatrists.

� Providing counseling to BF casualties experiencing emotional or social problems.

� Assisting the psychologist with administration of psychological testing.

� Assisting with group counseling and therapy sessions and leading group discussions.

� Assisting with unit survey interviews and critical event debriefings.

(2) The two mental health NCOs (E-5) manage and provide supervision for BF casualty care.They deploy with either CSC fitness teams or task-organized CSC elements to supervise and function as BFcasualty care managers for the restoration and reconditioning centers. Other duties and responsibilitiesinclude�

� Assisting the psychiatric nurses with planning and executing the establishment,disestablishment, and movement of the reconditioning center.

� Assisting the psychiatric nurses with conducting restoration and reconditioning centeroperations and with the administration of medications and supervision of subordinates and BF casualties.

� Providing guidance and training to subordinate mental health specialists and otherBF care providers.

� Providing direct supervision for BF (when assigned as their squad leader) casualtiesand monitoring their progress.

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C 1, FM 8-51

g. Mental Health Specialists. Six mental health specialists (E-4 [four] and E-3 [two], MOS91X10) provide BF casualty care and intervention, as required. These mental health specialists deploy witheither the CSC fitness teams or task-organized CSC elements. In addition to their duties, they operate andmaintain their assigned vehicle. Duties for the mental health specialist include�

� Following the RTD plans for cases placed under their supervision.

� Coordinating with the psychiatric nurses and other staff members on questions pertainingto the RTD plan.

� Providing direct supervision for BF casualties (as squad leaders) and monitoring theirprogress.

� Recording and reporting to the psychiatric nurses and other mental health staff memberson the status and any other pertinent observation of cases assigned to them.

� Assisting with unit survey interviews and critical event debriefings.

� Operating and maintaining assigned vehicles.

FM 8-51

GLOSSARY

ABBREVIATIONS, ACRONYMS,

AAR after-action review

ABCA American, British, Canadian, andAustralian

ACR armored cavalry regiment

ADAPCP Alcohol and Drug Abuse Preventionand Control Program

advanced trauma management This is theresuscitative and stabilizing medical or surgi-cal treatment provided to patients to save lifeor limb and to prepare them for further evac-uation without jeopardizing their well-beingor prolonging the state of their condition.

AG adjutant general

ambulance exchange point (AXP) A point in anambulance shuttle system where a patient istransferred from one ambulance to anotheren route to a medical treatment facility.

AMEDDC&S Army Medical Department Centerand School

AN Army Nurse Corps

AO See area of operations.

AOC area of concentration

AR Army regulation

area of operations (AO) That portion of an areaof conflict necessary for military operations.Areas of operations are geographical areasassigned to commanders for which they haveresponsibility and in which they have authori-ty to conduct military operations.

ASMB area support medical battalion

AND DEFINITIONS

ASMC area support medical company

assign To place units or personnel in an organi-zation where such placement is relativelypermanent, and/or where such organizationcontrols, administers, and provides logisticalsupport to units of personnel for the primaryfunction or a greater portion of the functionsof the unit or personnel. (See also attach;operational command; operational control;organic.)

attach The temporary placement of units orpersonnel in an organization. Subject tolimitations imposed by the attachment order,the commander of the formation, unit, ororganization receiving the attachment willexercise the same degree of command andcontrol as he does over units and personnelorganic to his command. However, the respon-sibility for transfer and promotion of person-nel will normally be retained by the parentformation, unit, or organization. (See alsoassign; operational command; operationalcontrol; organic. )

AWOL absent without leave

AXP See ambulance exchange point.

BAS battalion aid station

battle fatigue (BF) Also referred to as combatstress reaction or combat fatigue. Fatigue bydefinition is the distress and impaired per-formance that comes from doing something(anything) too hard and/lor too long. The termbattle fatigue is applied to any combat stressreaction which is treated the way all fatigueis treated, with the four "Rs"--Reassure ofnormality, Rest (respite from the work ),Restoration of confidence through talk andactivities, and Replenish of nutrition, andhydration, hygiene and a sense of physicalwell-being.

Glossary-l

FM 8-51

BF See battle fatigue.

brigade support area (BSA) A designated areain which combat service support elementsfrom division support command and corpssupport command provide logistics supportto a brigade. The brigade support area nor-mally is located 20 to 25 kilometers behindthe forward edge of the battle area.

BSA See brigade support area.

C2 See command and control.

camouflage The use of concealment and disguiseto minimize detection or identification oftroops, weapons, equipment, and installa-tions. It includes taking advantage of theimmediate environment as well as usingnatural and artificial materials.

casualty Any person who is lost to his organiza-tion by reason of having been declared dead,wounded, injured, diseased, interned, cap-tured, retained, missing in action, beleaguered,besieged, or detained.

CH chaplain

CHS See combat health support.

clearing station An operating field medicalfacility established by a clearing company ormedical company which provides emergencyor resuscitative treatment for patients untilevacuated and definitive treatment for pa-tients with minor illness, wounds, or injuries.

combat health support (CHS) This term is usedin current doctrine to include all servicesperformed, provided, or arranged by the ArmyMedical Department to promote, improve,conserve, or restore the mental and/or physicalwell-being of personnel in the Army and, asdirected, in other services, agencies, andorganizations.

combat neuropsychiatric triage Is the processof sorting combat stress-related casualtiesand neuropsychiatric patients into categoriesbased on how far forward they can be treated.In operations other than war, this may bereferred to as proximate neuropsychiatrictriage.

combat service support (CSS) The supportprovided to sustain combat forces, primarilyin the fields of administration and logistics.It may include administrative services,chaplain service, civil affairs, food service,finance, legal service, maintenance, medicalservice, military police, supply, transpor-tation, and other logistical services. Thebasic mission of combat service support is todevelop and maintain maximum combat powerthrough the support of weapons systems.

combat stress control (CSC) A coordinatedprogram for the prevention, triage andtreatment of each echelon of battle fatigue tomaximize rapid return to duty and minimizemisconduct stress reactions and post-trau-matic stress disorders. This program is con-ducted by unit mental health personnel plusechelon above division combat stress controlunits.

combat support (CS) Fire support and opera-tional assistance provided to combat elements.May include artillery, air defense, aviation(less air cavalry and attack helicopter), engi-neer, military police, signal, and electronicwarfare.

combat trains The portion of unit trains thatprovides the combat service support requiredfor immediate response to the needs of forwardtactical elements. At company level, medicalrecovery and maintenance elements normallyconstitute the combat trains. At battalion,the combat trains normally consist of ammu-nition and POL vehicles, maintenance/recov-ery vehicles, and crew and the battalion aidstation. (See also field trains; unit trains. )

Glossary-2

FM 8-51

combat zone (CZ) That area required by combatforces for the conduct of operations. It is theterritory forward of the Army rear areaboundary.

command and control (C2) The exercise ofcommand that is the process through whichthe activities of military forces are directed,coordinated, and controlled to accomplish themission. This process encompasses the per-sonnel, equipment, communications, facili-ties, and procedures necessary to gather andanalyze information, to plan for what is to bedone, and to supervise the execution of opera-tions.

command post (CP) The principal facilityemployed by the commander to commandand control combat operations. A commandpost consists of those coordinating and specialstaff activities and representatives fromsupporting Army elements and other servicesthat may be necessary to carry out operations.Corps and division headquarters are particu-larly adaptable to organization by echeloninto a tactical command post, a main commandpost, and a rear command post.

commander’s estimate The procedure wherebya commander decides how to best accomplishthe assigned mission. It is a thorough consid-eration of the mission, enemy, terrain, troopsavailable, time, weather, and other relevantfactors. The commander’s estimate is basedon personal knowledge of the situation andon staff estimates.

communications security The protection re-sulting from all measures designed to denyunauthorized persons information of valuethat might be derived from the possessionand study of telecommunications, or to mis-lead unauthorized person sin their interpreta-tion of the results of such possession andstudy. Includes cryptosecurity, transmission

security, emission security, and physicalsecurity of communications security materialsand information.

communications zone (COMMZ) That reararea of the theater of operations, behind butcontiguous to the combat zone, that containsthe lines of communication, establishmentfor supply and evacuation, and other agenciesrequired for the immediate support andmaintenance of the field forces.

COMMZ See communications zone.

concealment The protection from observation.

concept of operations A graphic, verbal, orwritten statement in broad outline that givesan overall picture of a commander’s assump-tion or intent in regard to an operation or aseries of operations; includes, at a minimum,the scheme of maneuver and the fire supportplan. The concept of operations is embodiedin campaign plans and operation plans,particularly when the plans cover a series ofconnected operations to be carried out simul-taneously or in secession. It is described insufficient detail for the staff and subordinatecommanders to understand what they are todo and how to fight the battle without furtherinstructions.

CONUS continental United States

CP See command post.

CPT captain

CRC combat reconditioning center

CS See combat support.

CSC See combat stress control.

CSH combat support hospital

Glossary-3

FM 8-51

CSS See combat service support.

CTA common table of allowances

corps support command elements may belocated in the division support area to providedirect support backup and general support asrequired.

CZ See combat zone.DMOC division medical operations center

DA Department of the ArmyDNBI disease and nonbattle injuries

DA PAM Department of the Army pamphletDPCA Deputy for Personnel and Civilian Affairs

DD/DOD Department of DefenseDSA See division support area.

DEPMEDS Deployable Medical Systems

direct support (1) A mission requiring a force tosupport another specific force and authorizingit to answer directly the supported force’srequest for assistance. (2) In the NorthAtlantic Treaty Organization, the supportprovided by a unit or formation not attachedto, nor under command of, the supported unitor formation, but required to give priority tothe support required by that unit or formation.(See also general support.)

DISCOM division support command

displace To leave one position and take another.Forces may be displaced laterally to con-centrate combat power in threatened areas,When a unit is advancing, its command postmust displace forward.

division support area (DSA) An area normallylocated in the division rear, positioned nearair landing facilities and along the mainsupply route. The division support areacontains the division support command,command post, the headquarters element ofthe division support command battalions,and those division support command elementscharged with providing backup support tocombat service support elements in thebrigade support area and direct support tounits located in the division rear.Selected

DSM III-R Diagnostic and Statistical Manual ofMental Disorders, Third Edition, Revised

Echelon I (Unit level) First medical care a soldierreceives is provided at this level. This careincludes immediate lifesaving measures,advanced trauma management, disease pre-vention, combat stress control prevention,casualty collection, and evacuation from sup-ported units to supporting medical treatment.Echelon I elements are located throughoutthe combat and communications zones. Theseelements include the combat lifesavers, com-bat medics, and battalion aid station. Some orall of these elements are found in maneuver,combat support, and combat service supportunits. When Echelon I is not present in aunit, this support is provided to that unit byEchelon II medical units.

Echelon II Duplicates Echelon I medical care andexpands services available by adding dental,laboratory, x-ray, and patient-holding capa-bility. Emergency care, advanced traumamanagement, including beginning resuscita-tion procedures, is continued. No generalanesthesia is available; if necessary, addi-tional emergency measures dictated by theimmediate needs are performed. Echelon IIunits are located in the combat zone brigadesupport area, the corps support area, and thecommunications zone, Echelon II medical

Glossary-4

FM 8-51

support may be provided by a clearing sta-tion; forward support medical company;medical company, forward support battalion;medical company, main support battalion;area support medical companies located inthe corps area and in the communicationszone.

Echelon III This echelon of support expands thesupport provided at Echelon II. Casualtieswho are unable to tolerate and survive move-ment over long distances will receive surgicalcare in hospitals as close to the division rearboundary as the tactical situation will allow.Surgical care may be provided within thedivision area under certain operational condi-tions. Echelon III characterizes the care thatis provided by units such as mobile armysurgical hospitals and combat support hospi-tals. Operational conditions may requireEchelon III units to locate in offshore supportfacilities. Third Country support base, or inthe communications zone.

Echelon IV This echelon of care is provided in ageneral hospital and field hospital and inother communications zone-level facilitieswhich are staffed and equipped for generaland specialized medical and surgical treat-ment. The field hospital normally operate sinthe communications zone but may be deployedto the rear boundaries of the corps, if neces-sary. This echelon of care provides furthertreatment to stabilize those patients requiringevacuation to continental United States. Thisechelon also provides area health service sup-port to soldiers within the communicationszone.

Echelon V In this echelon of care, the casualty istreated in continental United States-basedhospitals, staffed and equipped for the mostdefinitive care available within the healthservice support system. Hospitals in thecontinental United States base represent thefinal level of CHS.

echelon above corps Army headquarters andorganizations that provide the interface bet-ween the theater commander (joint or com-bined) and the corps for operational matters,and between the continental United States/host nation and the deployed corps for combatservice support. Operational echelons abovecorps may be United States only or alliedheadquarters, while echelons above corps forcombat service support will normally beUnited States national organizations.

echelon of care This is a North Atlantic TreatyOrganization term which can be used inter-changeably with the term level of care.

echeloned displacement Movement of a unitfrom one position to another without discon-tinuing performance of its primary function.Normally, the unit divides into two functionalelements (base and advance); while the basecontinues to operate, the advance elementdisplaces to a new site where, after it becomesoperational, it is joined by the base element.

echelonment An arrangement of personnel andequipment into assault, combat follow up,and rear components or group.

emergency medical treatment The immediateapplication of medical procedures to thewounded, injured, or sick by specially trainedmedical personnel.

EPW enemy prisoner(s) of war

evacuation (1) A combat service support functionwhich involves the movement of recoveredmateriel from a main supply route, mainte-nance activity collecting point, and mainte-nance activity to higher levels of maintenance.(2) The process of moving any person who iswounded, injured, or ill to and/or betweenmedical treatment facilities while providingen route medical care.

Glossary-5

FM 8-51

evacuation policy A command decision indica-ting the length in days of the maximumperiod of noneffectiveness that patients maybe held within the command for treatment.Patients who, in the opinion of an officiatingmedical officer, cannot be returned to dutystatus within the period prescribed areevacuated by the first available means,provided the travel involved will not aggravatetheir disabilities.

F Fahrenheit

FH field hospital

field trains The combat service support portionof a unit at company and battalion levels thatis not required for immediate support ofcombat elements. At company level, supplyand mess teams normally are located in thefield trains. A battalion’s field trains mayinclude mess teams, a portion of the supplysection of the support platoon, and a maint-enance element, as well as additional ammu-nition and POL. Positioning field trains isdependent on such factors as the type offriendly operations underway and availableactivity in the area. (See also combat trains;unit trains. )

FLOT See forward line of own troops.

FM field manual

FMC US Field Medical Card, DD Form 1380

forward line of own troops (FLOT) A line thatindicates the most forward position of friendlyforces in any kind of military operation at aspecific time. The forward line of own troopsmay be at, beyond, or short of the forwardedge of the battle area, depicting the nonlinearbattlefield.

Glossary-6

fragmentary order An abbreviated form of anoperation order used to make changes inmission to units and to inform them of changesin the tactical situation.

FSB forward support battalion

FSMC forward support medical company

FTX field training exercise

G1

G2

G3

G4

G5

GC

Assistant Chief of Staff (Personnel)

Assistant Chief of Staff (Intelligence)

Assistant Chief of Staff (Operations and Plans)

Assistant Chief of Staff (Logistics)

Assistant Chief of Staff (Civil Affairs)

Geneva Convention Relative to the Protectionof Civilian Persons in Time of War, 12August 1949

general support Support that is given to thesupported force as a whole and not to anyparticular subdivision thereof.

GH general hospital

GP general purpose

GPW Geneva Convention Relative to the Treat-ment of Prisoners of War, 12 August 1949

GTA graphic training aid

GWS Geneva Convention for the Amelioration ofthe Condition of Wounded and Sick in ArmedForces in the Field, 12 August 1949

GWS (Sea) Geneva Convention for the Ameliora-tion of the Condition of Wounded, Sick, andShipwrecked Members of Armed Forces atSea, 12 August 1949

FM 8-51

HHC headquarters and headquarters company

HHD headquarters and headquarters detachment

host nation A nation in whose territory theUnited States or allied forces are operating orsupporting the battle.

host-nation support Civil and military assistancerendered in peacetime and wartime to alliedforces arid organizations located in the hostnation’s territory. The bases of such assistanceare commitments arising from national agree-ments concluded among host nation(s), inter-national organizations, and nation(s) havingforces operating in the host nation’s territory.

HSC headquarters and support company

IG inspector general

JAG judge advocate general

KIA killed in action

LBE load bearing equipment

LTC lieutenant colonel

MAJ major

MASH mobile army surgical hospital

MC Medical Corps

MCW minimal care ward

MEDCOM medical command

MEDDAC medical department activity

medical equipment set(s) Chest{s) containingmedical instruments and supplies designedfor specific table(s) of organization and equip-ment units or missions.

medical intelligence That intelligence producedfrom the collecting, evaluation, and analysisof information concerning the medical aspectsof foreign areas which have immediate orpotential impact on policies, plans, andoperations.

medical treatment facility (MTF) Any facilityestablished for the purpose of providingmedical treatment. This includes aid sta-tions, clearing stations, dispensaries, clinics,and hospitals.

METT-T mission, enemy, terrain, troops, andtime available

mg milligram

MIA missing in action

mobility The percentage of organic equipmentand personnel that can be moved in a singlelift using organic vehicles. It does not includepatients in the medical treatment facility.

MOPP mission-oriented protective posture

MOS military occupational specialty

MP military police

MRE meal(s), ready to eat

MS Medical Service Corps

MSB main support battalion

MSMC main support medical company

MSR

MTF

NBC

NCO

main supply route

See medical treatment facility.

nuclear, biological, and chemical

noncommissioned officer

Glossary-7

FM 8-51

NCOIC noncommissioned officer in charge

NP neuropsychiatric

NYDN not, yet diagnosed "nervous"

OPCON See operational control.

operation order (OPORD) A directive issued bya commander to subordinate commanders foreffecting the coordinated execution of anoperation, including tactical movement or-ders. (See also operation plan.)

operation plan (OPLAN) A plan for a militaryoperation. It covers a single operation orseries of connected operations to be carriedout simultaneously or in succession. It im-plements operations derived from the cam-paign plan. When the time and/or conditionsunder which the plan is to be placed in effectoccur, the plan becomes an operations order.(See also operation order.)

operational command North Atlantic TreatyOrganization: The authority granted to acommander to assign missions or tasks tosubordinate commanders, to deploy units, toreassign forces, and to retain or delegateoperational and/or tactical control as may bedeemed necessary. It does not of itself includeresponsibility for administration or logistics.May also be used to denote the forces assign-ed to a commander. Department of Defense:The term is synonymous with operationalcontrol exercised by the commanders of unifiedand specified commands over assigned forcesin accordance with the National Security Actof 1947, as amended and revised (10 UnitedStates Code 124). (See also operationalcontrol.)

operational control (OPCON) The authoritydelegated to a commander to direct forces as-signed so that the commander may accomplish

specific missions or tasks that are usuallylimited by function, time, or location; to deployunits concerned; and to retain or assigntactical control to those units. It does not ofitself include administrative or logisticscontrol. In the North Atlantic Treaty Organi-zation, it does not include authority to assignseparate employment of components of theunits concerned. (See also assign; attach;operational command.)

operations security All measures taken tomaintain security and achieve tactical sur-prise. It includes countersurveillance, phy-sical security, signal security, and informationsecurity. It also involves the identificationand elimination or control of indicators whichcan be exploited by hostile intelligence organi-zations.

OPLAN See operation plan.

OPORD See operation order.

order A communication written, oral, or by signalthat conveys instructions from a superior toa subordinate. In a broad sense, the termorder and command are synonymous. How-ever, an order implies discretion as to the de-tails of execution, whereas a command doesnot.

organic Assigned to and forming an essentialpart of a military organization; an element -

normally shown in the unit’s table of organiza-tion and equipment. (See also assign; attach;operational control.)

OT occupational therapy

patient A sick, injured, or wounded person whoreceives medical care or treatment from medi-cally trained (MOS-or AOC-specific) per-sonnel.

PCP phencyclidine hydrochloride

Glossary-8

FM 8-51

PIES proximity, immediacy, expectancy, andsimplicity

PLL prescribed load list

PMCS preventive maintenance checks and ser-vices

POC point of contact

PW/POW prisoner(s) of war

PROFIS professional officer filler system

PVNTMED preventive medicine

QSTAG Quadripartite Standardization Agree-ment

rear area The area in the rear of the combat andforward areas. Combat echelons from thebrigade through the field Army normallydesignate a rear area. For any particularcommand, that area extending rearward fromthe rear boundary of their next subordinateformations, or units deployed in the mainbattle or defense area to their own rearboundary. It is here that reserve forces of theechelon are normally located. In addition,combat support and combat service supportunits and activities locate in this area. (Seealso brigade support area; division supportarea.)

reconstitution The total process of keeping theforce supplied with various supply classes,services, replacement personnel, and equip-ment required. This process maintains thedesired level of combat effectiveness andrestores units that are not combat effective tothe desired level through the replacement ofcritical equipment and personnel. Reconstitu-tion encompasses unit regeneration andsustaining support.

RTD return to duty

S1 Adjutant (US Army)

S2 Intelligence Officer (US Army)

S3 Operations and Training Officer (US Army)

S4 Supply Officer (US Army)

SOI signal operation instructions

SP Army Medical Specialist Corps

TEMPER tent, extendable, modular, personnel

theater of operations (TO) That portion of an

TM

area of conflict necessary for the conduct ofmilitary operations, either offensive ordefensive, to include administration andlogistical support.

technical manual

TMDE test, measurement, and diagnostic equip-ment

TO See theater of operations.

TOC tactical operations center

TOE table(s) of organization and equipment

TSOP tactical standing operating procedure

TTP tactics, techniques, and procedures

UCMJ Uniform Code of Military Justice

unit trains Combat service support personneland equipment organic or attached to a forcethat provides supply, evacuation, and mainte-nance services. Unit trains, whether or riotecheloned, are under unit control and noportion of them is released to the control of a

GIossary-9

FM 8-51

higher headquarters. Trains are normally brief, oral, or written message designed toecheloned into combat and field trains. (See give subordinates time to make necessaryalso combat trains; field trains. ) plans and preparations.

US United States WIA wounded in action

WWI World War Iwarning order A preliminary notice of an actionor order that is to follow. Usually issued as a WWII World WarII

Glossary-10

Glossary-3

C 1, FM 8-51

security, emission security, and physicalsecurity of communications security materialsand information.

communications zone (COMMZ) That rear areaof the theater of operations, behind butcontiguous to the combat zone, that containsthe lines of communication, establishment forsupply and evacuation, and other agenciesrequired for the immediate support andmaintenance of the field forces.

COMMZ See communications zone.

concealment The protection from observation.

concept of operations A graphic, verbal, orwritten statement in broad outline that givesan overall picture of a commander�sassumption or intent in regard to an operationor a series of operations; includes, at aminimum, the scheme of maneuver and thefire support plan. The concept of operationsis embodied in campaign plans and operationplans, particularly when the plans cover aseries of connected operations to be carriedout simultaneously or in secession. It isdescribed in sufficient detail for the staff andsubordinate commanders to understand whatthey are to do and how to fight the battlewithout further instructions.

CONUS continental United States

CP See command post.

CPT captain

CRC combat reconditioning center

CS See combat support.

«CSA corps support area

CSC See combat stress control.

combat zone (CZ) That area required by combatforces for the conduct of operations. It is theterritory forward of the Army rear areaboundary.

command and control (C2) The exercise ofcommand that is the process through whichthe activities of military forces are directed,coordinated, and controlled to accomplish themission. This process encompasses the per-sonnel, equipment, communications, facilities,and procedures necessary to gather andanalyze information, to plan for what is to bedone, and to supervise the execution ofoperations.

command post (CP) The principal facilityemployed by the commander to command andcontrol combat operations. A command postconsists of those coordinating and special staffactivities and representatives from supportingArmy elements and other services that maybe necessary to carry out operations. Corpsand division headquarters are particularlyadaptable to organization by echelon into atactical command post, a main command post,and a rear command post.

commander�s estimate The procedure wherebya commander decides how to best accomplishthe assigned mission. It is a thoroughconsideration of the mission, enemy, terrain,troops available, time, weather, and otherrelevant factors. The commander�s estimateis based on personal knowledge of thesituation and on staff estimates.

communications security The protection re-sulting from all measures designed to denyunauthorized persons information of valuethat might be derived from the possessionand study of telecommunications, or to mis-lead unauthorized persons in their interpreta-tion of the results of such possession andstudy. Includes cryptosecurity, transmission

C 1, FM 8-51

Glossary-4

CSH combat support hospital

CSS See combat service support.

CTA common table of allowances

CZ See combat zone.

DA Department of the Army

DA PAM Department of the Army pamphlet

DD/DOD Department of Defense

DEPMEDS Deployable Medical Systems

direct support (1) A mission requiring a forceto support another specific force andauthorizing it to answer directly the supportedforce�s request for assistance. (2) In theNorth Atlantic Treaty Organization, thesupport provided by a unit or formation notattached to, nor under command of, thesupported unit or formation, but required togive priority to the support required by thatunit or formation. (See also general support.)

DISCOM division support command

displace To leave one position and take another.Forces may be displaced laterally toconcentrate combat power in threatened areas.When a unit is advancing, its command postmust displace forward.

division support area (DSA) An area normallylocated in the division rear, positioned nearair landing facilities and along the main supplyroute. The division support area contains thedivision support command, command post,the headquarters element of the divisionsupport command battalions, and thosedivision support command elements chargedwith providing backup support to combatservice support elements in the brigade

support area and direct support to unitslocated in the division rear. Selected corpssupport command elements may be located inthe division support area to provide directsupport backup and general support asrequired.

DMOC division medical operations center

DNBI disease and nonbattle injuries

«DOD/DD Department of Defense

DPCA Deputy for Personnel and Civilian Affairs

DSA See division support area.

DSM III-R Diagnostic and Statistical Manual ofMental Disorders, Third Edition, Revised

Echelon I (Unit level) First medical care asoldier receives is provided at this level. Thiscare includes immediate lifesaving measures,advanced trauma management, diseaseprevention, combat stress control prevention,casualty collection, and evacuation fromsupported units to supporting medicaltreatment. Echelon I elements are locatedthroughout the combat and communicationszones. These elements include the combatlifesavers, combat medics, and battalion aidstation. Some or all of these elements arefound in maneuver, combat support, andcombat service support units. When EchelonI is not present in a unit, this support isprovided to that unit by Echelon II medicalunits.

Echelon II Duplicates Echelon I medical care andexpands services available by adding dental,laboratory, x-ray, and patient-holding capa-bility. Emergency care, advanced traumamanagement, including beginning resuscita-tion procedures, is continued. No generalanesthesia is available; if necessary, additional

Glossary-5

C 1, FM 8-51

emergency measures dictated by the im-mediate needs are performed. Echelon IIunits are located in the combat zone brigadesupport area, the corps support area, and thecommunications zone. Echelon II medicalsupport may be provided by a clearing station;forward support medical company; medicalcompany, forward support battalion; medicalcompany, main support battalion; areasupport medical companies located in thecorps area and in the communications zone.

Echelon III This echelon of support expands thesupport provided at Echelon II. Casualtieswho are unable to tolerate and survive move-ment over long distances will receive surgicalcare in hospitals as close to the division rearboundary as the tactical situation will allow.Surgical care may be provided within thedivision area under certain operational condi-tions. Echelon III characterizes the care thatis provided by units such as mobile armysurgical hospitals and combat support hospi-tals. Operational conditions may requireEchelon III units to locate in offshore supportfacilities, Third Country support base, or inthe communications zone.

Echelon IV This echelon of care is provided in ageneral hospital and field hospital and in othercommunications zone-level facilities whichare staffed and equipped for general andspecialized medical and surgical treatment.The field hospital normally operates in thecommunications zone but may be deployed tothe rear boundaries of the corps, if necessary.This echelon of care provides further treat-ment to stabilize those patients requiringevacuation to continental United States. Thisechelon also provides area health servicesupport to soldiers within the communicationszone.

Echelon V In this echelon of care, the casualtyis treated in continental United States-based

hospitals, staffed and equipped for the mostdefinitive care available within the healthservice support system. Hospitals in thecontinental United States base represent thefinal level of CHS.

echelon above corps Army headquarters andorganizations that provide the interfacebetween the theater commander (joint orcombined) and the corps for operationalmatters, and between the continental UnitedStates/host nation and the deployed corps forcombat service support. Operational echelonsabove corps may be United States only orallied headquarters, while echelons abovecorps for combat service support will normallybe United States national organizations.

echelon of care This is a North Atlantic TreatyOrganization term which can be used inter-changeably with the term level of care.

echeloned displacement Movement of a unitfrom one position to another without discon-tinuing performance of its primary function.Normally, the unit divides into two functionalelements (base and advance); while the basecontinues to operate, the advance elementdisplaces to a new site where, after it becomesoperational, it is joined by the base element.

echelonment An arrangement of personnel andequipment into assault, combat follow up, andrear components or group.

emergency medical treatment The immediateapplication of medical procedures to thewounded, injured, or sick by specially trainedmedical personnel.

EPW enemy prisoner(s) of war

evacuation (1) A combat service support func-tion which involves the movement ofrecovered materiel from a main supply route,

C 1, FM 8-51

Glossary-6

maintenance activity collecting point, andmaintenance activity to higher levels of main-tenance. (2) The process of moving anyperson who is wounded, injured, or ill to and/or between medical treatment facilities whileproviding en route medical care.

evacuation policy A command decision indica-ting the length in days of the maximum periodof noneffectiveness that patients may be heldwithin the command for treatment. Patientswho, in the opinion of an officiating medicalofficer, cannot be returned to duty statuswithin the period prescribed are evacuated bythe first available means, provided the travelinvolved will not aggravate their disabilities.

F Fahrenheit

FH field hospital

field trains The combat service support portionof a unit at company and battalion levels thatis not required for immediate support of com-bat elements. At company level, supply andmess teams normally are located in the fieldtrains. A battalion�s field trains may includemess teams, a portion of the supply section ofthe support platoon, and a maintenanceelement, as well as additional ammunition andPOL. Positioning field trains is dependent onsuch factors as the type of friendly operationsunderway and available activity in the area.(See also combat trains; unit trains.)

FLOT See forward line of own troops.

FM field manual

FMC US Field Medical Card, DD Form 1380

forward line of own troops (FLOT) A line thatindicates the most forward position of friendlyforces in any kind of military operation at aspecific time. The forward line of own troops

may be at, beyond, or short of the forwardedge of the battle area, depicting the nonlinearbattlefield.

fragmentary order An abbreviated form of anoperation order used to make changes inmission to units and to inform them ofchanges in the tactical situation.

FSB forward support battalion

FSMC forward support medical company

FTX field training exercise

G1 Assistant Chief of Staff (Personnel)

G2 Assistant Chief of Staff (Intelligence)

G3 Assistant Chief of Staff (Operations and Plans)

G4 Assistant Chief of Staff (Logistics)

G5 Assistant Chief of Staff (Civil Affairs)

GC Geneva Convention Relative to the Protectionof Civilian Persons in Time of War, 12August 1949

general support Support that is given to thesupported force as a whole and not to anyparticular subdivision thereof.

GH general hospital

GP general purpose

GPW Geneva Convention Relative to the Treat-ment of Prisoners of War, 12 August 1949

GTA graphic training aid

GWS Geneva Convention for the Ameliorationof the Condition of Wounded and Sick inArmed Forces in the Field, 12 August 1949

Glossary-7

C 1, FM 8-51

GWS (Sea) Geneva Convention for the Amelio-ration of the Condition of Wounded, Sick,and Shipwrecked Members of Armed Forcesat Sea, 12 August 1949

HHC headquarters and headquarters company

HHD headquarters and headquarters detachment

host nation A nation in whose territory theUnited States or allied forces are operating orsupporting the battle.

host-nation support Civil and military assistancerendered in peacetime and wartime to alliedforces and organizations located in the hostnation�s territory. The bases of such assis-tance are commitments arising from nationalagreements concluded among host nation(s),international organizations, and nation(s) havingforces operating in the host nation�s territory.

HSC headquarters and support company

IG inspector general

JAG judge advocate general

KIA killed in action

LBE load bearing equipment

«LT lieutenant

LTC lieutenant colonel

MAJ major

MASH mobile army surgical hospital

MC Medical Corps

MCW minimal care ward

MEDCOM medical command

MEDDAC medical department activity

medical equipment set(s) Chest(s) containingmedical instruments and supplies designed forspecific table(s) of organization and equip-ment units or missions.

medical intelligence That intelligence producedfrom the collecting, evaluation, and analysisof information concerning the medical aspectsof foreign areas which have immediate orpotential impact on policies, plans, andoperations.

medical treatment facility (MTF) Any facilityestablished for the purpose of providingmedical treatment. This includes aid stations,clearing stations, dispensaries, clinics, andhospitals.

METT-T mission, enemy, terrain, troops, andtime available

«MF2K Medical Force 2000

mg milligram

MIA missing in action

mobility The percentage of organic equipmentand personnel that can be moved in a singlelift using organic vehicles. It does not includepatients in the medical treatment facility.

MOPP mission-oriented protective posture

MOS military occupational specialty

MP military police

MRE meal(s), ready to eat

«MRI Medical Reengineering Initiative

MS Medical Service Corps

C 1, FM 8-51

Glossary-8

MSB main support battalion

MSMC main support medical company

MSR main supply route

MTF See medical treatment facility.

NBC nuclear, biological, and chemical

NCO noncommissioned officer

NCOIC noncommissioned officer in charge

NP neuropsychiatric

NYDN not yet diagnosed �nervous�

OPCON See operational control.

operation order (OPORD) A directive issued bya commander to subordinate commanders foreffecting the coordinated execution of anoperation, including tactical movementorders. (See also operation plan.)

operation plan (OPLAN) A plan for a militaryoperation. It covers a single operation orseries of connected operations to be carriedout simultaneously or in succession. Itimplements operations derived from thecampaign plan. When the time and/orconditions under which the plan is to beplaced in effect occur, the plan becomes anoperations order. (See also operation order.)

operational command North Atlantic TreatyOrganization: The authority granted to acommander to assign missions or tasks tosubordinate commanders, to deploy units, toreassign forces, and to retain or delegateoperational and/or tactical control as may bedeemed necessary. It does not of itselfinclude responsibility for administration orlogistics. May also be used to denote the

forces assigned to a commander. Departmentof Defense: The term is synonymous withoperational control exercised by the com-manders of unified and specified commandsover assigned forces in accordance with theNational Security Act of 1947, as amendedand revised (10 United States Code 124).(See also operational control.)

operational control (OPCON) The authoritydelegated to a commander to direct forcesassigned so that the commander mayaccomplish specific missions or tasks that areusually limited by function, time, or location;to deploy units concerned; and to retain orassign tactical control to those units. It doesnot of itself include administrative or logisticscontrol. In the North Atlantic TreatyOrganization, it does not include authority toassign separate employment of componentsof the units concerned. (See also assign;attach; operational command.)

operations security All measures taken tomaintain security and achieve tacticalsurprise. It includes countersurveillance,physical security, signal security, andinformation security. It also involves theidentification and elimination or control ofindicators which can be exploited by hostileintelligence organizations.

OPLAN See operation plan.

OPORD See operation order.

order A communication written, oral, or by signalthat conveys instructions from a superior to asubordinate. In a broad sense, the term orderand command are synonymous. However, anorder implies discretion as to the details ofexecution, whereas a command does not.

organic Assigned to and forming an essential partof a military organization; an element

Glossary-9

C 1, FM 8-51

normally shown in the unit�s table oforganization and equipment. (See also assign;attach; operational control.)

OT occupational therapy

patient A sick, injured, or wounded person whoreceives medical care or treatment frommedically trained (MOS-or AOC-specific)personnel.

PCP phencyclidine hydrochloride

PIES proximity, immediacy, expectancy, andsimplicity

PLL prescribed load list

PMCS preventive maintenance checks and services

POC point of contact

PW/POW prisoner(s) of war

PROFIS professional officer filler system

PVNTMED preventive medicine

QSTAG Quadripartite Standardization Agree-ment

«RCS requirement control symbol

rear area The area in the rear of the combat andforward areas. Combat echelons from thebrigade through the field Army normallydesignate a rear area. For any particularcommand, that area extending rearward fromthe rear boundary of their next subordinateformations, or units deployed in the mainbattle or defense area to their own rearboundary. It is here that reserve forces of theechelon are normally located. In addition,combat support and combat service supportunits and activities locate in this area. (See alsobrigade support area; division support area.)

reconstitution The total process of keeping theforce supplied with various supply classes,services, replacement personnel, and equip-ment required. This process maintains thedesired level of combat effectiveness andrestores units that are not combat effective tothe desired level through the replacement ofcritical equipment and personnel. Recon-stitution encompasses unit regeneration andsustaining support.

RTD return to duty

S1 Adjutant (US Army)

S2 Intelligence Officer (US Army)

S3 Operations and Training Officer (US Army)

S4 Supply Officer (US Army)

SOI signal operation instructions

SP Army Medical Specialist Corps

TEMPER tent, extendable, modular, personnel

theater of operations (TO) That portion of anarea of conflict necessary for the conduct ofmilitary operations, either offensive or defen-sive, to include administration and logisticalsupport.

TM technical manual

TMDE test, measurement, and diagnostic equip-ment

TO See theater of operations.

TOC tactical operations center

TOE table(s) of organization and equipment

TSOP tactical standing operating procedure

C 1, FM 8-51

Glossary-10

TTP tactics, techniques, and procedures

UCMJ Uniform Code of Military Justice

unit trains Combat service support personnel andequipment organic or attached to a force thatprovides supply, evacuation, and maintenanceservices. Unit trains, whether or notecheloned, are under unit control and noportion of them is released to the control of ahigher headquarters. Trains are normallyecheloned into combat and field trains. (Seealso combat trains; field trains.)

US United States

warning order A preliminary notice of an actionor order that is to follow. Usually issued as abrief, oral, or written message designed togive subordinates time to make necessaryplans and preparations.

WIA wounded in action

WWI World War I

WWII World War II

FM 8-51

R E F E R E N C E S

SOURCES USED DOCUMENTS NEEDED

These are the sources quoted or paraphrased inthis publication.

ABCA QSTAG

909. Principles of Prevention and Managementof Combat Stress Reaction, Edition 1. 25October 1991.

Army Publications

AR 40-501. Standards of Medical Fitness. 1 July1987. (Reprinted with basic including Cl. )

AR 310-25. Dictionary of United States ArmyTerms (Short Title: AD). 15 October 1983.(Reprinted with basic including Cl.)

AR 340-21. The Army Priuacy Program. 5 July1985.

AR 570-2. Manpower Requirements Criteria. 15May 1992.

DA Pam 600-69. Unit Climate Profile, Com-manders Handbook. 1 0ctober 1986.

FM 8-10-4. Medical Platoon Leaders’ Hand-book—Tactics, Techniques, and Proce-dures. 16 November 1990.

FM 8-10-24. Area Support Medical Battalion—Tactics, Techniques, and Procedures. 13October 1993.

FM 63-20. Forward Support Battalion. 26 Feb-ruary 1990.

FM 63-21. Main Support Battalion. 7 August1990.

FM 100-9. Reconstitution. 13 January 1992.FM 100-10. Combat Service Support. 18 Feb-

ruary 1988.FM 101-5-1. Operational Terms and Symbols.

21 October 1985.GTA 21-3-4. Battle Fatigue, Normal, Common

Signs, What to do for Self and Buddy.June 1986.

These documents must be available to the in-tended users of this publication.

*AR 40-66. Medical Records and Quality Assur-ance Administration. 31 January 1985.(Reprinted with basic including Cl. )

*AR 40-216. Neuropsychiatric and MentalHealth. 10 August 1984.

*AR 40-400. Patient Administration. 1 October1983.

*AR 635-200. Enlisted Personnel. July 1984.(Reprinted with basic including C1–14.)

*DA Pam 27-1. Treaties Governing Land War-fare. 7 December 1956.

*FM 8-10. Health Service Support in a Theaterof Operations. 1 March 1991.

*FM 8-10-3. Division Medical Operations Cen-ter—Tactics, Techniques, and Procedures.1 March 1991.

*FM 8-10-5. Brigade and Division Surgeons’Handbook—Tactics, Techniques, and Pro-cedures. 10 June 1991.

*FM 8-10-6. Medical Evacuation in a Theater ofOperations—Tactics, Techniques, and Pro-cedures. 31 October 1991.

*FM 8-10-8. Medical Intelligence in a Theater ofOperations. 7 July 1989.

*FM 8-42. Medical Operations in Low IntensityConflict. 4 December 1990.

*FM 8-50. Prevention and Medical Managementof Laser Injuries. 8 August 1990.

*FM 8-55. Planning for Health Seruice Support.15 February 1985.

*FM 8-230. Medical Specialist. 24 August 1984.*FM 21-10. Field Hygiene and Sanitation. 22

November 1988.*FM 22-51. Leaders’ Manual for Combat Stress

Control. (To be published.)*FM 27-10. The Law of Land Warfare. 18 July

1956. (Change 1, July 1976.)

*This source was also used to develop this publication.

References-1

FM 8-51

*FM 63-21. Main Support Battalion. 7 August1990.

*FM 100-5. Operations. 14 June 1993.DA Form 1155. Witness Statement on Individual.

1 June 1966.DA Form 1156. Casualty Feeder Report. 1 June

1966.DA Form 2404. Equipment Inspection and Main-

tenance Worksheet. 1 April 1989.DA Form 2405. Maintenance Request Register.

1 April 1962.DA Form 2407. Maintenance Request. August

1988.DA Form 2408-9. Equipment Control Record.

1 0ctober 1972.DA Form 2409. Equipment Maintenance Log

(Consolidated). 1 April 1992.DD Form 2A. US Armed Forces Identification

Card. 1 July 1974.DD Form 314. Preventive Maintenance Schedule

and Record. December 1953.DD Form 1265. Request for Conuoy Clearance. 1

January 1959.DD Form 1380. US Field Medical Card. (Books

consisting of 20 two-part sets. ) 1 June1962.

DD Form 1934. Geneua Convention IdentityCard for Medical and Religious PersonnelWho Serve In or Accompany the ArmedForces. July 1974.

DD Form 2163. Medical Equipment Verification/Certification. 1 November 1978.

READINGS RECOMMENDED

These readings contain relevant supplementalinformation.

AR 40-535. Worldwide Aerornedical Evacuation.AFR 164-5; OPNAVINST 4630.9C; MCOP4630.9A. 1 December 1975. (Reprintedwith basic including Cl. )

AR 40-538. Property Management During Pa-tient Evacuation. BUMEDINST 6700.2B;AFR 167-5. 1 June 1980.

AR 40-562. Immunizations and Chemoprophy -laxis. NAVMEDCOMINST 6230.3; AFR161-13; CGCOMDTINST 6230.4D. 7 oc-tober 1988.

FM 8-8. Medical Support in Joint Operations.NAVMED P-5047AFM 160-20. 1 June1972. (Reprinted with basic including Cl. )

FM 8-9. NATO Handbook on the Medical Aspectof NBC Defensive Operations. NAVMEDP5059; AFP 161-3. 31 August 1973. (Re-printed with basic including Cl.)

FM 8-285. Treatment of Chemical Agent Casual-ties and Con uentional Military ChemicalInjuries. AFM 160-12; NAVMED P-5041.28 February 1990.

FM 31-11. Doctrine for Amphibious Operations.NWP22(B)/AFM 2-53/LFM-01. 1 August1967. (Reprinted with basic includingCl-3.)

FM 41-5. Joint Manual for Civil Affairs. OPNAV09B2P1; AFM 110-7; NAVMC 2500. 18November 1966.

FM 100-27. US ArmyKL!3 Air Force Doctrine forJoint Airborne and Tactical Airlift Opera-tions. AFM 2-50. 31 January 1985. (Re-printed with basic including Cl.)

TB MED 507. Occupational and EnvironmentalHealth Prevention, Treatment, and Controlof Heat Injury. NAVMED P-5052 -5/AFP160-1. 25 July 1980.

Army PublicationsJoint and Multisenice Publications

AR 40-350. Medical Regulating To and Within theContinental United States. BUMEDINST6320.lD; A.FR 168-11; BMS CIR 75-15;CGCOMDTINST 6320.8A. 30 March 1990.

AR 5-9. Intraservice Support Installation AreaCoordination. 1 March 1984.

AR 40-2. Army Medical Treatment Facilities:General Administration. 3 March 1978.(Reprinted with basic including C1-2. )

References-2

FM 8-51

AR 40-3. Medical, Dental, and Veterinary Care.15 February 1985.

AR 40-4. Army Medical Department Facilities/Activities. 1 January 1980.

AR 40-5. Preuentiue Medicine. 15 October 1990.AR 40-35. Preuentiue Dentistry; 26 March 1989.AR 40-46. Control of Heaith Hazards from Lasers

AR

AR

AR

ARAR

AR

AR

AR

AR

AR

AR

AR

AR

and Other High Intensity Optical Sources.6 February 1974. (Reprinted with basicincluding Cl. )

40-48. Nonphysician Health Care Provider.3 December 1984. (Reprinted with basicincluding Cl. )

71-13. The Department of the Army Equip-ment Authorization and Usage Program.3 June 1988.

380-40. Policy for Safeguarding and Control-ling Communications Security (COMSEC)Material (U). 1 June 1982.

385-10. Army Safety Program. 23 May 1988.385-30. Safety Color Code Marking and

Signs. 15 September 1983.385-40. Accident Reporting and Records. 1

April 1987.385-55. Prevention of Motor Vehicle Acci-

dents. 12 March 1987.600-200. Enlisted Personnel Management

System. 5 July 1984. (Reprinted withbasic including C1-15. )

611-101. Commissioned Oficer ClassificationSystem. 30 April 1992.

611-201. Enlisted Career Management Fieldand Military Occupational Specialties. 30April 1992.

630-5. Leaue and Passes. 1 July 1984. (Re-printed with basic including Cl–1 1.)

700-138. Army Logistics Readiness and Sus-tainability. 16 June 1993.

750-1. Army Materiel Maintenance Policiesand Retail Maintenance Operations. 27September 1991.

DA Pam 738-750. Functional Users Manual forthe Army Maintenance System (TUMS).27 September 1991.

FM 3-5. NBC Decontamination. FMFM 11-100.23 Ju]y 1992.

FM 3-50. Smoke Operations. 4 December 1990.FM 3-100. NBC Defense, Chemical Warfare,

Smoke and Flame Operations. FMFM 11-2. 23 May 1991.

FM 8-21. Health Service Support in the Com-munications Zone. 1 November 1984.

FM 8-26. Dental Services. 9 September 1980.FM 10-14. Unit Supply Operations (Manual

Procedures). 27 December 1990.FM 10-14-1. Commander’s Handbook for Prop-

erty Accountability at Unit Level. 2 Nov-ember 1984.

FM 10-14-2. Guide for the Battalion S4. 30 De-cember 1981. (Reprinted with basicincluding Cl. )

FM 10-23. Basic Doctrine For Army FieldFeeding. 12 December 1991.

FM 10-63. Handling of Deceased Personnelin a Theater of Operations. A-FM 143-3;FMFM 4-8. 28 February 1986.

FM 10-63-1. Graves Registration Handbook. 17July 1986.

FM 10-69. Petroleum Supply Point Equipmentand Operations. 22 October 1986.

FM 19-1. Military Police Support for the AirLandBattle. 23 May 1988.

FM 19-30. Physical Security. 1 March 1979.FM 19-40. Enemy Prisoners of War, Civilian

Internees, and Detained Persons. 7 Feb-ruary 1976.

FM 20-31. Electronic Power Generation in theField. 9 October 1987.

FM 21-10-1. Unit Field Sanitation Team. 11October 1989.

FM 21-11. First Aid for Soldiers. 27 October1988. (Change 1, August 1989; Change 2,December 1991. )

FM 22-9. Soldiers Performance in ContinuousOperations. 12 December 1991.

FM 24-1. Signal Support in the AirLand Battle.15 October 1990.

FM 25-100. Training the Force. 15 November1988.

References-3

FM 8-51

FM 31-70. Basic Cold Weather Manual. 12April 1968. (Reprinted with basic in-cluding C 1. )

FM 34-3. Intelligence Analysis. 15 March1990.

FM 34-35. Armored Caualry Regiment (ACR)and Separate Brigade Intelligence andElectronic Warfare (IEW) Operations. 12December 1990.

FM 41-10. Ciuil Affairs Operations. 11 January1993.

FM 63-3. Combat Service Support Opera-tions – Corps (How to Support). 24 August1983.

FM 63-22. Headquarters and Headquarters Comp-any and Division Materiel ManagementCenter, Division Support Command, Ar-mored, Mechanized, and Motorized Divi-sions. 24 May 1988.

FM 90-3 (HTI?). Desert Operations (How toFight). 19 August 1977.

FM 90-6. Mountain Operations. 30 June 1980.FM 100-15. Corps Operations. September 1989.

FM 101-5. Staff Organization and Operations.25 May 1984.

FM 101-10-1/1. Staff Officers’ Field Manual—Organizational, Technical, and LogisticData (Volume 1). 7 October 1987.

FM 101-10-1/2. Staff O#icers’ Pield Manual—Organizational, Technical, and LogisticData, Planning Factors (Volume 2). 7 Oc-tober 1987.

TB Med 1. Storage, Preservation, Packing, Main-tenance, and Surveillance of Material:Medical Activities. 15 June 1981.

TM 38-750-1. The Army Maintenance Man-agement System (TAMMS) Field Com-mand Procedures. 29 December 1978.(Reprinted with basic including Cl–2. )

Nonmilitary Publications

American Psychiatric Association. Diagnos-tic and Statistical Manual of MentalDisorders, Third Edition, Revised.Washington, DC, 1987.

References-4

References-1

C 1, FM 8-51

*This source was also used to develop this publication.

REFERENCES

SOURCES USED

These are the sources quoted or paraphrased in thispublication.

ABCA QSTAG

909. Principles of Prevention and Managementof Combat Stress Reaction, Edition 1. 25October 1991.

Army Publications

AR 40-501. Standards of Medical Fitness. 1 July1987. (Reprinted with basic including C1.)

AR 310-25. Dictionary of United States ArmyTerms (Short Title: AD). 15 October 1983.(Reprinted with basic including C1.)

AR 570-2. Manpower Requirements Criteria. 15May 1992.

AR 340-21. The Army Privacy Program. 5 July1985.

DA Pam 600-69. Unit Climate Profile, CommandersHandbook. 1 October 1986.

FM 8-10-4. Medical Platoon Leaders� Handbook�Tactics, Techniques, and Procedures. 16November 1990.

FM 8-10-24. Area Support Medical Battalion�Tactics, Techniques, and Procedures. 13October 1993.

FM 63-20. Forward Support Battalion. 26 February1990.

FM 63-21. Main Support Battalion. 7 August 1990.FM 100-9. Reconstitution. 13 January 1992.FM 100-10. Combat Service Support. 18 February

1988.FM 101-5-1. Operational Terms and Symbols. 21

October 1985.GTA 21-3-4. Battle Fatigue, Normal, Common

Signs, What to do for Self and Buddy. June1986.

DOCUMENTS NEEDED

These documents must be available to the intendedusers of this publication.

*AR 40-66. Medical Records and Quality AssuranceAdministration. 31 January 1985. (Reprintedwith basic including C1.)

*AR 40-216. Neuropsychiatric and Mental Health.10 August 1984.

*AR 40-400. Patient Administration. 1 October 1983.*AR 635-200. Enlisted Personnel. July 1984.

(Reprinted with basic including C1�14.)*DA Pam 27-1. Treaties Governing Land Warfare.

7 December 1956.*FM 8-10. Health Service Support in a Theater of

Operations. 1 March 1991.«*FM 8-10-1. The Medical Company�Tactics, Tech-

niques, and Procedures. 29 December 1994.*FM 8-10-3. Division Medical Operations Center�

Tactics, Techniques, and Procedures. 1March 1991.

*FM 8-10-5. Brigade and Division Surgeons� Hand-book�Tactics, Techniques, and Procedures.10 June 1991.

*FM 8-10-6. Medical Evacuation in a Theater ofOperations�Tactics, Techniques, and Pro-cedures. 31 October 1991.

*FM 8-10-8. Medical Intelligence in a Theater ofOperations. 7 July 1989.

*FM 8-42. Medical Operations in Low IntensityConflict. 4 December 1990.

*FM 8-50. Prevention and Medical Management ofLaser Injuries. 8 August 1990.

*FM 8-55. Planning for Health Service Support. 15February 1985.

*FM 8-230. Medical Specialist. 24 August 1984.*FM 21-10. Field Hygiene and Sanitation. 22

November 1988.*FM 22-51. Leaders� Manual for Combat Stress

Control. (To be published.)*FM 27-10. The Law of Land Warfare. 18 July

1956. (Change 1, July 1976.)

C 1, FM 8-51

References-2

*FM 63-21. Main Support Battalion. 7 August1990.

*FM 100-5. Operations. 14 June 1993.DA Form 1155. Witness Statement on Individual.

1 June 1966.DA Form 1156. Casualty Feeder Report. 1 June

1966.DA Form 2404. Equipment Inspection and

Maintenance Worksheet. 1 April 1989.DA Form 2405. Maintenance Request Register.

1 April 1962.DA Form 2407. Maintenance Request. August

1988.DA Form 2408-9. Equipment Control Record.

1 October 1972.DA Form 2409. Equipment Maintenance Log

(Consolidated). 1 April 1992.DD Form 2A. US Armed Forces Identification

Card. 1 July 1974.DD Form 314. Preventive Maintenance Schedule

and Record. December 1953.DD Form 1265. Request for Convoy Clearance. 1

January 1959.DD Form 1380. US Field Medical Card. (Books

consisting of 20 two-part sets.) 1 June1962.

DD Form 1934. Geneva Convention IdentityCard for Medical and Religious PersonnelWho Serve In or Accompany the ArmedForces. July 1974.

DD Form 2163. Medical Equipment Verification/Certification. 1 November 1978.

READINGS RECOMMENDED

These readings contain relevant supplementalinformation.

Joint and Multiservice Publications

AR 40-350. Medical Regulating To and Within theContinental United States. BUMEDINST6320.1D; AFR 168-11; BMS CIR 75-15;CGCOMDTINST 6320.8A. 30 March 1990.

AR 40-535. Worldwide Aeromedical Evacuation.AFR 164-5; OPNAVINST 4630.9C; MCOP4630.9A. 1 December 1975. (Reprintedwith basic including C1.)

AR 40-538. Property Management During Pa-tient Evacuation. BUMEDINST 6700.2B;AFR 167-5. 1 June 1980.

AR 40-562. Immunizations and Chemoprophy-laxis. NAVMEDCOMINST 6230.3; AFR161-13; CGCOMDTINST 6230.4D. 7 Oc-tober 1988.

FM 8-8. Medical Support in Joint Operations.NAVMED P-5047/AFM 160-20. 1 June1972. (Reprinted with basic including C1.)

FM 8-9. NATO Handbook on the Medical Aspectof NBC Defensive Operations. NAVMEDP5059; AFP 161-3. 31 August 1973. (Re-printed with basic including C1.)

FM 8-285. Treatment of Chemical Agent Casual-ties and Conventional Military ChemicalInjuries. AFM 160-12; NAVMED P-5041.28 February 1990.

FM 31-11. Doctrine for Amphibious Operations.NWP22(B)/AFM 2-53/LFM-01. 1 August1967. (Reprinted with basic includingC1�3.)

FM 41-5. Joint Manual for Civil Affairs. OPNAV09B2P1; AFM 110-7; NAVMC 2500. 18November 1966.

FM 100-27. US Army/US Air Force Doctrine forJoint Airborne and Tactical Airlift Opera-tions. AFM 2-50. 31 January 1985. (Re-printed with basic including C1.)

TB MED 507. Occupational and EnvironmentalHealth Prevention, Treatment, and Controlof Heat Injury. NAVMED P-5052-5/AFP160-1. 25 July 1980.

Army Publications

AR 5-9. Intraservice Support Installation AreaCoordination. 1 March 1984.

AR 40-2. Army Medical Treatment Facilities:General Administration. 3 March 1978.(Reprinted with basic including C1�2.)

FM 8-51

Index-1

FM 8-51

Index-2

FM 8-51

Index-3

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Index-4

FM 8-51

Index-5

FM 8-51

Index-6

FM 8-51

Index-7

FM 8-51

Index-8

FM 8-51

Index-9

FM 8-51

Index-10

FM 8-5129 SEPTEMBER 1994

By Order of the Secretatary of the Army:

Official:

GORDON R. SULLIVANGeneral, United States Army

Chief of Staff

Administrative Assistant to theSecretary of the Army

07166

DISTRIBUTION:

Active Army, USAR, and ARNG: To be distributed in accordance with DA Form 12-1IE, requirementsfor FM 8-51, Combat Stress Control in a Theater of Operations, Tactics, Techniques, and Procedures(Qty rqr block no. 4901).