First Aid for Soldiers FM 21-11

FM 21-11 First Aid for Soldiers: Chapter 8

First Aid for Psychological Reactions

Headquarters, Department of the Army, Washington, D.C., October 27, 1988

INTRODUCTION
During actual combat, military operations continue around the clock at a constant pace, and often under severe weather conditions. Terrible things happen in combat. During such periods the soldier's mental and physical endurance will be pushed to the limit. Psychological first aid will help sustain the soldier's mental/physical performance during normal activities, and especially during military operations under extremely adverse conditions and in hostile environments.

8-1. Explanation of Term "Psychological First Aid"

Psychological first aid is as natural and reasonable as physical first aid and is just as familiar. When you were hurt as a child, the understanding attitude of your parents did as much as the psychological effect of a bandage or a disinfectant to ease the pain. Later, your disappointment or grief was eased by supportive words from a friend. Certainly, taking a walk and talking things out with a friend are familiar ways of dealing with an emotional crisis. The same natural feelings that make us want to help a person who is injured make us want to give a helping hand to a buddy who is upset. Psychological first aid really means nothing more complicated than assisting people with emotional distress whether it results from physical injury, disease, or excessive stress. Emotional distress is not always as visible as a wound, a broken leg, or a reaction to pain from physical damage. However, overexcitement, severe fear excessive worry, deep depression, misdirected irritability and anger are signs that stress has reached the point of interfering with effective coping. The more noticeable the symptoms become, the more urgent the need for you to be of help and the more important it is for you to know HOW to help.

8-2. Importance of Psychological First Aid

First aid can be applied to stress reactions of the mind as well as to physical injuries of the body. You must know how to give psychological first aid to be able to, help yourself, your buddies, and your unit in order to keep performing the mission. Psychological first aid measures are simple and easy to understand. Improvisation is in order, just as it is in splinting a fracture. Your decision of what to do depends upon your ability to observe the soldier and understand his needs. Time is on your side, and so are the resources of the soldier you are helping. Making the best use of resources requires ingenuity on your part. A stress reaction resulting in poor judgment can cause injury or even death to yourself or others on the battlefield. It can be even more dangerous if other persons are affected by the judgment of an emotionally upset individual. If it is detected early enough, the affected soldier stands a good chance of remaining in his unit as an effective member. If it is not detected early and if the soldier becomes more and more emotionally upset, he may not only be a threat to himself and to others, but he can also severely affect the morale of the unit and jeopardize its mission.

8-3. Situations Requiring Psychological First Aid

• Psychological first aid (buddy aid) is most needed at the first sign that a soldier cannot perform the mission because of emotional distress. Stress is inevitable in combat, in hostage and terrorist situations, and in civilian disasters, such as floods, hurricanes, tornadoes industrial and aircraft catastrophes. Most emotional reactions to such situations are temporary, and the person can still carry on with encouragement. Painful or disruptive symptoms may last for minutes hours, or a few days. However, if the stress symptoms are seriously disabling, they may be psychologically contagious and endanger not only the emotionally upset individual but also the entire unit. In such situations, you may be working beside someone who cannot handle the impact of disaster. Even when there is no immediate danger of physical injury, psychological harm may occur. For instance, if a person is unable to function because of stress, it may cause that person to lose confidence in himself. If self-confidence cannot be restored, the person then may become psychologically crippled for life.

• Sometimes people continue to function well during the disastrous event, but suffer from emotional scars which impair their job performance or quality of life at a later time. Painful memories and dreams may recur for months and years and still be considered a normal reaction. If the memories are so painful that the person must avoid all situations which arouse these memories or if he becomes socially withdrawn, or shows symptoms of anxiety, depression, or substance abuse, he needs treatment. Experiences of police, firemen, emergency medical technicians, and others who deal with disasters has proved that the routine application of psychological first aid greatly reduces the likelihood of future serious post-traumatic stress disorders. Thus, applying psychological first aid as self-aid and buddy aid to all the participants, including those who have functioned well, is beneficial.

8-4. Interrelation of Psychological and Physical First Aid

Psychological first aid should go hand in hand with physical first aid. The discovery of a physical injury or cause for an inability to function does not rule out the possibility of a psychological injury (or vice versa). A physical injury and the circumstances surrounding it may actually cause an emotional injury that is potentially more serious than the physical injury; both injuries need treatment. The person suffering from pain, shock, fear of serious damage to his body, or fear of death does not respond well to joking, indifference, or fearful-tearful attention. Fear and anxiety may take as high a toll of the soldier's strength as does the loss of blood.

8-5. Goals of Psychological First Aid

The goals of psychological first aid are to--

• Be supportive; assist the soldier in dealing with his stress reaction.

• Prevent, and if necessary control, behavior harmful to him and to others.

• Return the soldier to duty as soon as possible after dealing with the stress reaction.

8-6. Respect for Others' Feelings

a. Accept the soldier you are trying to help without censorship or ridicule. Accept his right to his own feelings. Even though your feelings, beliefs, and behavior are different, DO NOT blame or make light of him for the way he feels or acts. Your purpose is to help him in this tough situation, not to be his critic. A person DOES NOT WANT to be upset and worried; he would "snap out of it" if he could. When he seeks help, he needs and expects consideration of his fears, not abrupt dismissal or accusations. You may be impressed with the fact that you made it through in good condition. You have no guarantee that the situation will not be reversed the next time.

b. Realize that people are the products of a wide variety of factors. All persons DO NOT react the same way to the same situations. Each individual has complex needs and motivations, both conscious and unconscious, that are uniquely his own. Often, the "straw that breaks the camel's back" the one thing that finally causes the person to be overloaded by the stressful situation is not the stressor itself, but some other problem. Thus, an injury or an emotional catastrophe will have a personal meaning for each individual. Even though you may not share the reactions or feelings of another person and even though the reactions seem foolish or peculiar, you must realize that he feels as he does for a reason. You can help him most by accepting this fact and by doing what you can for him during this difficult time. He is doing the best he can under the circumstances. Your positive assistance and trust may be what he needs to do better.

8-7. Emotional and Physical Disability

a. Accept emotional disability as being just as real as physical disability. If a soldier's ankle is seriously sprained in a fall, no one (including the injured man himself) expects him to run right away. A soldier's emotions may be temporarily strained by the overwhelming stress of more "blood and guts" than he can take or by a large-scale artillery attack. DO NOT demand that he pull himself together immediately and carry on without a break. Some individuals can pull themselves together immediately, but others cannot. The person whose emotional stability has been disrupted has a disability just as real as the soldier who has sprained his ankle. There is an unfortunate tendency in many people to regard as real only what they can see, such as a wound, bleeding, or an X-ray of a diseased lung. Some people tend to assume that damage involving a person's mind and emotions is just imagined, that he is not really sick or injured, and that he could overcome his trouble by using his will power.

b. The terms "it's all in your head," "snap out of it," and "get control of yourself" are often used by people who believe they are being helpful. Actually, these terms are expressions of hostility because they show lack of understanding. They only emphasize weakness and inadequacy. Such terms are of no use in psychological first aid. A psychological patient or a physical patient with strong emotional reactions to his injury does not want to feel as he does. He would like to be effective, but he is temporarily overcome with either fear, anxiety, grief, guilt, or fatigue. He feels lost and unable to control his emotions. Reminding him of his failure to act as others do only makes him feel worse. What he needs is calm, positive encouragement, such as reminding him that others have confidence in his ability to pull together and are also counting on him. Often this reassurance combined with explicit instruction and encouragement to do a simple, but useful task (that he knows how to do), will restore his effectiveness quickly.

8-8. Emotional Reaction to Injury

Every physically injured person has some emotional reaction to the fact that he is injured.

a. A minor injury such as a cut finger causes an emotional reaction in most people. It is normal for an injured person to feel upset. The more severe the injury, the more insecure and fearful he becomes, especially if the injury is to a body part which is highly valued. For example, an injury to the eyes or the genitals, even though relatively minor, is likely to be extremely upsetting. An injury to some other part of the body may be especially disturbing to an individual for his own particular reason. For example, an injury of the hand may be a terrifying blow to a baseball pitcher or a pianist. A facial disfigurement may be especially threatening to an actor.

b. An injured person always feels less secure, more anxious, and more afraid not only because of what has happened to him but because of what he imagines may happen as a result of his injury. This fear and insecurity may cause him to be irritable, stubborn, or unreasonable. He also may seem uncooperative, unnecessarily difficult, or even emotionally irrational. As you help him, always keep in mind that such behavior has little or nothing to do with you personally. He needs your patience, reassurance, encouragement and support. Even though he seems disagreeable and ungrateful at first, ensure that he understands you want to help him.

8-9. Emotional Reserve Strength of Distressed Soldiers

Realize that distressed soldiers have far more strength than appears at first glance. An injured or sick person may not put his best foot forward. The strong points of his personality are likely to be hidden beneath his fear, anguish, and pain. It is easy to see only his failures even though he worked efficiently beside you only a short time ago. With your aid he will again become helpful. Whatever made him a good soldier, rifleman, or buddy is still there; he is needed.

8-10. Battle Fatigue (and Other Combat Stress Reactions [CSR])

Battle Fatigue is a temporary emotional disorder or inability to function, experienced by a previously normal soldier as a reaction to the overwhelming or cumulative stress of combat. By definition, battle fatigue gets better with reassurance, rest, physical replenishment and activities which restore confidence. Physical fatigue, or sleep loss, although commonly present, is not necessary. All combat and combat support troops are likely to feel battle fatigue under conditions of intense and/or prolonged stress. They may even become battle fatigue casualties, unable to perform their mission roles for hours or days. Other negative behaviors may be CSRs, but are not called battle fatigue because they need other treatment than simple rest, replenishment and restoration of confidence. These negative CSRs include drug and alcohol abuse, committing atrocities against enemy prisoners and noncombatants, looting, desertion, and self-inflicted wounds. These harmful CSRs can often be prevented by good psychological first aid; however, if these negative actions occur, these persons may require disciplinary action instead of reassurance and rest.

8-11. Reactions to Stress

Most people react to misfortune or disasters (military or civilian, threatened or actual) after the situation has passed. All people feel some fear. This fear may be greater than they have experienced at any other time or they may be more aware of their fear. In such a situation, they should not be surprised if they feel shaky, become sweaty, nauseated or confused. These reactions are normal and are not a cause for concern. However, some reactions, either short or long term, will cause problems if left unchecked. The following are consequences of too much stress:

a. Emotional Reactions.

(1) The most common stress reactions are simply inefficient performances, such as:

• Slow thinking (or reaction time).

• Difficulty sorting out the important from all the noise and seeing what needs to be done.

• Difficulty getting started.

• Indecisiveness, trouble focusing attention.

• A tendency to do familiar tasks and be preoccupied with familiar details. This can reach the point where the person is very passive, such as just sitting or wandering about not knowing what to do.

(2) Much less common reactions to a disaster or accident may be uncontrolled emotional outbursts, such as crying, screaming, or laughing. Some soldiers will react in the opposite way. They will be very withdrawn and silent and try to isolate themselves from everyone. These soldiers should be encouraged to remain with their assigned unit. Uncontrolled reactions may appear by themselves or in any combination (the person may be crying uncontrollably one minute and then laughing the next or he may lie down and babble like a child). In this state, the person is restless and cannot keep still. He may run about, apparently without purpose. Inside, he feels great rage or fear and his physical acts may show this. In his anger he may indiscriminately strike out at others.

b. Loss of Adaptability.

(1) In a desperate attempt to get away from the danger which has overwhelmed him, a person may panic and become confused. In the midst of a mortar attack, he may suddenly lose the ability to hear or see. His mental ability may be so impaired he cannot think clearly or even follow simple commands. He may stand up in the midst of enemy fire or rush into a burning building because his judgment is clouded and he cannot understand the likely consequences of his behavior. He may lose his ability to move (freezes) and may seem paralyzed. He may faint.

(2) In other cases, overwhelming stress may produce symptoms which are often associated with head injuries. For example, the person may appear dazed or be found wandering around aimlessly. He may appear confused and disoriented and may seem to have a complete or partial loss of memory. In such cases, especially when no eye witnesses can provide evidence that the person has NOT suffered a head injury, it is necessary for medical personnel to provide rapid evaluation for that possibility. DO NOT ALLOW THE SOLDIER TO EXPOSE HIMSELF TO FURTHER PERSONAL DANGER UNTIL THE CAUSE OF THE PROBLEM HAS BEEN DETERMINED.

c. Sleep Disturbance and Repetitions. A person who has been overwhelmed by disaster or some other stress often has difficulty sleeping. The soldier may experience nightmares related to the disaster such as dreaming that his wife, father, or other important person in his life was killed in the disaster. Remember that nightmares, in themselves, are not considered abnormal when they occur soon after a period of intensive combat or disaster. As time passes, the nightmares usually become less frequent and less intense. In extreme cases, a soldier, even when awake, may think repeatedly of the disaster, feel as though it is happening again, and act out parts of his stress over and over again. For some persons, this repetitious reexperiencing of the stressful event may be necessary for eventual recovery; therefore, it should not be discouraged or viewed as abnormal. For the person reexperiencing the event, such reaction may be disruptive and disturbing regardless of the reassurance given him that it is perfectly normal. In such a situation, a short cut that is often possible involves getting the person to talk extensively, even repetitiously, about the experience or his feelings. This should not be forced; rather, the person should be given repeated opportunities and supportive encouragement to talk in private, preferably to one person. This process is known as ventilation.

d. Other Factors. In studies of sudden civilian disasters, a rule of thumb is that 70 to 80 percent of people will fall into the first category (a above). Ten to 15 percent will show the more severe disturbances (b and c above). Another 10 to 15 percent will work effectively and coolly. The latter usually have had prior experience in disasters or have jobs that can be applied effectively in the disaster situation. Military training, like the training of police, fire, and emergency medical specialists in civilian jobs, is designed to shift that so that 99 to 100 percent of the unit works effectively. But sudden, unexpected horrors, combined with physical fatigue, exhaustion, and distracting worries about the home front can sometimes throw even well-trained individuals for a temporary loss.

e. Psychiatric Complications. Although the behaviors described (a through c above) usually diminish with time, some do not. A person who has not improved somewhat within a day, even though he has been given warm food, time for sleep, and opportunity to ventilate, or who becomes worse, deserves specialized medical/psychiatric care. Do not wait to see if what he is experiencing will get better with time.

8-12. Severe Stress or Battle Fatigue Reactions

You do not need specialized training to recognize severe stress or battle fatigue reactions that will cause problems to the soldier, the unit, or the mission. Reactions that are less severe, however, are more difficult to detect. To determine whether a person needs help you must observe him to see whether he is doing something meaningful performing his duties, taking care of himself, or behaving in an unusual fashion or acting out of character.

8-13. Application of Psychological First Aid

The emotionally disturbed soldier has built a barrier against fear. He does this for his own protection, although he is probably not aware that he is doing it. If he finds that he does not have to be afraid and that there are normal, understandable things about him, he will feel safer in dropping this barrier. Persistent efforts to make him realize that you want to understand him will be reassuring, especially if you remain calm. Nothing can cause an emotionally disturbed person to become even more fearful than feeling that others are afraid of him. Try to remain calm. Familiar things, such as a cup of coffee, the use of his name, attention to a minor wound, being given a simple job to do, or the sight of familiar people and activities will add to his ability to overcome his fear. He may not respond well if you get excited, angry, or abrupt.

a. Ventilation. After the soldier becomes calmer, he is likely to have dreams about the stressful event. He also may think about it when he is awake or even repeat his personal reaction to the event. One benefit of this natural pattern is that it helps him master the stress by going over it just as one masters the initial fear of jumping from a diving board by doing it over and over again. Eventually, it is difficult to remember how frightening the event was initially. In giving first aid to the emotionally disturbed soldier, you should let him follow this natural pattern. Encourage him to talk. Be a good listener. Let him tell, in his own words what actually happened (or what he thinks happened). If home front problems or worries have contributed to the stress, it will help him to talk about them. Your patient listening will prove to him that you are interested in him, and by describing his personal catastrophe, he can work at mastering his fear. If he becomes overwhelmed in the telling, suggest a cup of coffee or a break. Whatever you do, assure him that you will listen again as soon as he is ready. Do try to help put the soldier's perception of what happened back into realistic perspective; but, DO NOT argue about it. For example, if the soldier feels guilty that he survived while his teammates were all killed, reassure him that they would be glad he is still alive and that others in the unit need him now. If he feels he was responsible for their deaths because of some oversight or mistake (which may be true), a nonpunishing, nonaccusing attitude may help him realize that accidents and mistakes do happen in the confusion of war, but that life, the unit, and the mission must go on. (These same principles apply in civilian disaster settings as well.) With this psychological first aid measure, most soldiers start toward recovery quickly.

b. Activity.

(1) A person who is emotionally disturbed as the result of combat action or a catastrophe is basically a casualty of anxiety and fear. He is disabled because he has become temporarily overwhelmed by anxiety. A good way to control fear is through activity. Almost all soldiers, for example, experience a considerable sense of anxiety and fear while they are poised, awaiting the opening of a big offensive; but this is normally relieved, and they actually feel better once they begin to move into action. They take pride in effective performance and pleasure in knowing that they are good soldiers, perhaps being completely unaware that overcoming their initial fear was their first major accomplishment

(2) Useful activity is very beneficial to the emotionally disturbed soldier who is not physically incapacitated. After you help a soldier get over his initial fear, help him to regain some self-confidence. Make him realize his job is continuing by finding him something useful to do. Encourage him to be active. Get him to carry litters, (but not the severely injured), help load trucks, clean up debris, dig foxholes, or assist with refugees. If possible, get him back to his usual duty. Seek out his strong points and help him apply them. Avoid having him just sit around. You may have to provide direction by telling him what to do and where to do it. The instructions should be clear and simple; they should be repeated; they should be reasonable and obviously possible. A person who has panicked is likely to argue. Respect his feelings, but point out more immediate, obtainable, and demanding needs. Channel his excessive energy and, above all, DO NOT argue. If you cannot get him interested in doing more profitable work, it may be necessary to enlist aid in controlling his overactivity before it spreads to the group and results in more panic. Prevent the spread of such infectious feelings by restraining and segregating if necessary.

(3) Involvement in activity helps a soldier in three ways:

• He forgets himself.

• He has an outlet for his excessive tensions.

• He proves to himself he can do something useful. It is amazing how effective this is in helping a person overcome feelings of fear, ineffectiveness, and uselessness.

c. Rest. There are times, particularly in combat, when physical exhaustion is a principal cause for emotional reactions. For the weary, dirty soldier, adequate rest, good water to drink, warm food, and a change of clothes, with an opportunity to bathe or shave may provide spectacular results.

d. Group Activity. You have probably already noticed that a person works, faces danger, and handles serious problems better if he is a member of a closely-knit group. Each individual in such a group supports the other members of the group. For example, you see group spirit in the football team and in the school fraternity. Because the individuals share the same interests, goals, and problems, they do more and better work; furthermore, they are less worried because everyone is helping. It is this group spirit that wins games or takes a strategic hill in battle. It is so powerful that it is one of the most effective tools you have in your "psychological first aid bag." Getting the soldier back into the group and letting him see its orderly and effective activity will reestablish his sense of belonging and security and will go far toward making him a useful member of the unit.

8-14. Reactions and Limitations

a. Up to this point the discussion has been primarily about the feelings of the emotionally distressed soldier. What about your feelings toward him? Whatever the situation, you will have emotional reactions (conscious or unconscious) toward this soldier. Your reactions can either help or hinder your ability to help him. When you are tired or worried, you may very easily become impatient with the person who is unusually slow or who exaggerates. You may even feel resentful toward him. At times when many physically wounded lie about you, it will be especially natural for you to resent disabilities that you cannot see. Physical wounds can be seen and easily accepted. Emotional reactions are more difficult to accept as injuries. On the other hand, will you tend to be overly sympathetic? Excessive sympathy for an incapacitated person can be as harmful as negative feelings in your relationship with him. He needs strong help, but not your sorrow. To overwhelm him with pity will make him feel even more inadequate. You must expect your buddy to recover, to be able to return to duty, and to become a useful soldier. This expectation should be displayed in your behavior and attitude as well as in what you say. If he can see your calmness, confidence, and competence, he will be reassured and will feel a sense of greater security.

b. You may feel guilty at encouraging this soldier to recover and return to an extremely dangerous situation, especially if you are to stay in a safer, more comfortable place. Remember though, that if he returns to duty and does well, he will feel strong and whole. On the other hand, if he is sent home as a psycho, he may have self-doubt and often disabling symptoms the rest of his life.

c. Another thing to remind yourself is that in combat someone must fight in this soldier's place. This temporarily battle fatigued soldier, if he returns to his unit and comrades, will be less likely to overload again (or be wounded or killed) than will a new replacement.

d. Above all, you must guard against becoming impatient, intolerant, and resentful, on one hand, and overly solicitous on the other. Remember that such emotion will rarely help the soldier and can never increase your ability to make clear decisions.

e. As with the physically injured soldier, the medical personnel will take over the care of the emotionally distressed soldier who needs this specific care as soon as possible. The first aid which he has received from you will be of great value to his recovery.

f. Remember that every soldier (even you) has a potential emotional overload point which varies from individual to individual, from time to time, and from situation to situation. Because a soldier has reacted abnormally to stress in the past does not necessarily mean he will react the same way to the next stressful situation. Remember, any soldier, as tough as he may seem, is capable of showing signs of anxiety and stress. No one is absolutely immune.

8-15. Tables. See Tables 8-1, 8-2, and 8-3 for more information.