Field Manual No. 22-51: Leaders' Manual for Combat Stress Control: Booklet 1

Chapter 4: Combat Misconduct Stress Behaviors

Headquarters, Department of the Army, Washington, DC

4-1. Introduction
Misconduct stress behaviors are most likely to occur in units with poor morale or in units where problems exist. This chapter discusses misconduct stress behaviors. It identifies factors which could increase such behaviors and factors which help protect against such behaviors.

4-2. Indications of Potential Misconduct Stress Behaviors
Since WWI, leaders and mental health personnel have been taught to monitor for indicators of poor morale and problems in a unit. These indicators may include increased --

• Disease and nonbattle injury rates.

• Disciplinary infractions.

• Absent without leave (AWOL) rates.

• Drug and alcohol abuse.

Often, these misconduct stress behaviors may be the result of stressors and increased stress in a unit. These indicators could be a warning that the potential exists for heavy battle fatigue casualties if this unit is sent to combat.

4-3. Behaviors of Primary Concern to Command and the Law of Land Warfare
Reacting to some misconduct stress behaviors is primarily the responsibility of the commanders and the legal system. While all misconduct stress behaviors are disciplinary problems, the extreme examples are violations of the Law of Land Warfare. Violations of the Law of Land Warfare must be reported and the offender(s) brought to justice. While medical, psychological, or psychiatric consultation may, in specific cases, be requested to document mental or organic illness that might support a defense of insanity, combat stress alone is no defense for criminal misconduct. Severe combat stress could be considered as an extenuating factor in determining the soldier's sentence. Examples of such misconduct stress behaviors follow.

4-4. The Misconduct Stress Behavior of Opting Not to Take Prisoners
a. It has always been true (although not always admitted) that there comes a time in the heat of battle when soldiers in combat may decide to deliberately kill the enemy rather than take them as prisoners. The normal rage of combat stress will not accept that the enemy soldier who has just fought to his last bullet, killed your buddy, and almost killed you should survive to be a prisoner of war (PW), safe from the continuing danger that you must still face. This rage of battle can reach epic proportions in otherwise excellent soldiers. S.L.A. Marshall described two exemplary bayonet assaults in which victorious US units took no prisoners and went on to slaughter the barnyard or pack animals -- and were ashamed to admit it afterwards.

b. Soldiers may feel guilty about not having accepted the surrender of the enemy, just as they often feel guilty about killing their first armed enemy at close range. Later, they may feel guilty about not feeling guilty any more -- about how easy it has become.

c. Good leaders must work to keep the rage of battle from leading to massacre. Appeals to higher ethical ideals and respect for the enemy as brave soldiers similar to ourselves are useful but may be unheeded in the noise of battle. It may be more productive to remind the soldiers (and oneself) that there are good reasons for accepting surrender of the enemy and treating the prisoners humanely:

• Not all the enemy fight to the last bullet. Many probably were there under duress, kept their heads down, and only fired their weapons haphazardly while their superiors were watching.

• Alive, enemy prisoner(s) of war (EPW) may give valuable information to our military intelligence personnel.

• Other enemy soldiers, hearing that surrender is possible, will be less likely to fight so desperately when confronted, thereby decreasing our casualties.

• The enemy will be more likely to accept the surrender of our soldiers who may find themselves in a hopeless position.

• Killing enemy soldiers who are attempting to surrender is murder and a violation of the Law of Land Warfare.

• It must be reported by any who observe it and may result in trial by court-martial.

• Soldiers who commit such acts in combat are likely to feel great guilt about it after returning home and are often haunted by the memory for the rest of their lives.

4-5. The Misconduct Stress Behavior of Killing Enemy Prisoners
a. The ambiguous case of not recognizing attempts to surrender during a hot assault can be distinguished from killing soldiers who surrender after no (or only token) resistance. There is no excuse for killing prisoners after they surrender unless they are resisting or attempting to escape. Although the same urge for revenge may still be understandable, if prisoners are killed without cause, it is undoubtedly murder. Killing of prisoners must be actively prevented by command as a serious violation of the Law of Land Warfare. Violators are subject to trial and punishment.

b. It is also understandable but an unacceptable stress reaction for stressed commanders to overlook such incidents when done by otherwise good soldiers whom they need as fighters. Overlooking these incidents and failing to take action to prevent them is itself a violation of the Law of Land Warfare and may subject such commanders to trial by court-martial.

Note
All personnel, including health care providers and combat stress control/ mental health personnel, must be alert for signs of misconduct stress behaviors. They must advise the commander. Chaplains also should be alert and inform command about trends or stories/rumors of misconduct stress behavior. They, however, must maintain an individual soldier's confidentiality if told in the course of their religious duties.

4-6. The Misconduct Stress Behavior of Mutilating Enemy Dead
a. This practice has been prohibited by civilized nations as a violation of the Law of Land Warfare but may still be approved in some regions of the world. Collecting scalps, ears, gold teeth, and so forth as trophies can still become common practice (as in the island battles of the Pacific in WWII)as signs of racial hatred and dehumanization against a stubborn and merciless enemy.

b. Leaving deliberately mutilated bodies (especially with facial and genital mutilation) for the enemy to find is less common, but also occurs as bitterness increases. Despoiling or pillaging the dead is, of course, a war crime and is punishable by court-martial.

Note
Mutilating the dead must be prohibited, since it dehumanizes both those who do it and those who condone it. It tends to provoke reprisals, alienate world and home front opinion, and contribute to guilt and post-traumatic stress symptoms when the soldier returns home.

4-7. The Misconduct Stress Behaviors of Torturing Prisoners, Using Excessive Force or Brutality, and Killing Animals
a. In some cultures or religions (such as many of the seventeenth/eighteenth century North American Indian tribes), torture has been accepted by all parties as the proper thing to do. The captive warrior who died bravely under torture was highly respected. Under the Law of Land Warfare, torture is a war crime and is forbidden but is still sometimes practiced. It may be erroneously justified as necessary to gain information to assure victory and save friendly lives or to intimidate the opposition, especially in counterinsurgency scenarios.

Note
If torture to gain information or to intimidate is allowed, even tacitly, it can become an all-too-easy outlet for combat stress-related tension and frustration, with steadily worsening consequences.

b. The more insidious and common form of this misconduct stress behavior is to react with excessive force or brutality to episodes of provocation. The boundary between excessive and prudent is a gray area. It is related to the magnitude of the enemy provocation and the likelihood of its continuing if not answered. Examples of overreaction include reacting to a single sniper or mortar fire from a civilian housing area with massive artillery and air attack, or going in to beat all the villagers and destroy all the houses.

c. It is difficult and frustrating for soldiers to adhere to strict rules of engagement, such as never firing into civilian areas until fired on and only returning fire with precision when the specific enemy has been located. It is especially difficult if the enemy is deliberately using such areas as sanctuaries and the civilians are tacitly or even explicitly siding with the enemy. Such self-control is, however, often essential to accomplish the national objectives in military operations other than war. To maintain fire discipline, leaders must instill and continually reinforce a sense of strong unit identity and cohesion that actively encourages and rewards correct behavior.

d. Stress-induced behaviors that impair fire discipline can also cause friendly fire casualties. In some cases, overeagerness to attack the enemy (perhaps resulting from the positive combat stress behaviors of desire for glory, medals, or promotion) may lead to tragic error. Too much arousal or anxiety may cause soldiers who are "on a hair trigger" to misidentify vehicles, to make errors in reading maps or grid coordinates, or to shoot first and ask questions later. There is a well-documented tendency for hypervigilant persons to misinterpret and even to misperceive stimuli in ways which seem to confirm their preconceived fears.

(1) Consider the pressure on the tank crew which is constantly remembering that in an engagement between two equal opponents the tank that fires second has only one chance out of five of surviving. Add to that many hours of continuous operations and rapid movement with little sleep. Now add that beyond the unit's right boundary is an unknown friendly unit. This unit may be from a different division, corps, service, or allied nation. The tank unit's leader and higher headquarters must recognize that these tank crews are at high risk of violating the TSOP and firing across the boundary into the neighboring area.

(2) In such situations, the unit leaders (even tired, anxious leaders) must perform a recurring process of risk analysis and risk management. Friendly fire casualties cannot rationally be completely prevented in modern, fast-moving battles. Commanders and leaders must implement policies and prudent precautions which will minimize friendly fire casualties while also minimizing the risk of the enemy killing our soldiers.

(3) The targeting policy which maximizes the odds of hitting the enemy first may be entirely justified at the beginning of the battle. Then, the enemy's strength is uncertain and his crews and tanks must be assumed approximately equal in quality to our own. Later in the battle, a more cautious policy may be justified. It may be clearer that most (if not all) of the enemy are undertrained, out-gunned, and badly overstressed. Our own crews, though still aggressive, are becoming fatigued as a result of the battle or because of sleep loss. Their alertness, coordination, and senses may be dull.

(4) The leaders must recognize these stress factors. They must implement precautions to ensure that there are no friendly fire casualties. They must consider modifying or changing the targeting policy if stress factors are high. They must then assure that the change, its reasons, and any related coordinating instructions are passed down the chain of command to every crew. Recent experience is that leaders will be held publicly accountable if they fail to do this and friendly deaths result. This is true even though the leaders' misconduct may be a reaction only to their own combat stress.

e. Other examples of excessive force or brutality involve the killing of animals.

(1) Soldiers may deliberately shoot domestic animal(s) of local farmers as acts of hatred or revenge. Soldiers may later claim that the animal(s)' death was an accident. Leaders should investigate and ensure appropriate actions are implemented to prevent future incidents of this nature. All soldiers must understand that the senseless killing of animals is a punishable crime under the UCMJ.

(2) Warning signs of excessive stress may be indicated when individual soldiers begin to mistreat, torture, and kill animals. These types of behaviors are warning signs to commanders and leaders that self-control among some of their soldiers is wearing thin. Unit cohesion may also suffer, since other members of the unit may feel revulsion and anger at such behaviors. Leadership must recognize such signs of stress and take actions to provide less destructive ways of relieving the tension and frustration.

4-8. The Misconduct Stress Behaviors of Looting, Pillage, and Rape
a. All these behaviors (looting, pillage, and rape) may be misconduct stress behaviors, although they may also be committed by soldiers with antisocial norms or personality traits and no combat exposure. They may reflect aberrant group norms in soldiers who have experienced little combat stress. Less than 180 years ago, it was the accepted custom that besieged cities which did not surrender before their wall was breached and which therefore had to be taken by assault, were always turned over to the troops to loot and rape. This is no longer acceptable and is a violation of the Law of Land Warfare. However, the stressed combat veteran may still feel entitled to collect souvenirs and perhaps to loot, pillage, and even rape the hostile (or even friendly) noncombatants. He may feel he has earned the right by his suffering, risks, and losses.

b. Rape is sometimes used as a symbolic act of dominance, not only over female victims, but also over males in her social system who are powerless to prevent it. Rape forcibly degrades and humiliates the victim and everyone in his or her group, which naturally provokes resentment and reprisal.

Note
Only a strong chain of command and a unit identity which says, "We don't do that and those who do aren't one of us and will be punished" can keep looting and rape from happening.

c. The distinction between looting and raping local nationals versus voluntary donation and social interactions is not always clear when only the soldiers have weapons. Sexual exploitation of local women by soldiers may foster local resentment and detract from the mission, even when paid for with food, cigarettes, money, or luxury items. Leaders, combat stress control/mental health personnel, and chaplains need to be alert to these facts to prevent abuse. It is the commander's responsibility to set and demand high standards as the ethical role model for the unit.

4-9. The Misconduct Stress Behavior of Fraternization
a. Incidents of fraternization, sexual favoritism or harassment, prostitution, and even rape may occur within US Army units. The stress of combat, the reminders of the nearness of death, prolonged separation from home, boredom, and other stressors bring out the natural human tendencies to form relationships -- or to exercise aggressive impulses and personal dominance.

(1) Sexual misconduct stress behaviors within units can be destructive to unit cohesion and morale. That is especially true when leader-subordinate or officer-enlisted relationships are (or are misperceived to be) directly involved. Even misconduct stress behaviors involving mutually consenting peers can seriously disrupt unit functioning. This can also hamper individual and family readjustment after the return home.

(2) All unit members, as well as unit leaders and staff members of higher commands, have the personal responsibility to maintain a professional and social climate which prevents the misconduct of fraternization from getting started. Everyone should actively discourage (rather than tacitly condone or assist) mixed-gender couples from pairing off except when required by the mission. At the same time, there should be ample opportunity for larger group, mixed gender social activities and morale support.

b. Leadership must set the example and must enforce the UCMJ regulations against fraternization, harassment, adultery, and criminal assault. The enforcement policy must be made unquestionably clear to all unit members in advance. Punishment for violating the fraternization policy must be evenly and strictly executed.

4-10. The Misconduct Stress Behavior of Killing Noncombatants
a. Some incidents of mass execution of civilians (for example, those committed by Nazi Germany) are acts of deliberate policy and are outside the scope of this discussion. Others, like the My Lai massacre in Vietnam, although premeditated, are clearly reactions to cumulative combat stress. These misconduct stress behaviors are likely, especially in guerrilla warfare, when some seemingly noncombatants, such as women and children, are in fact ununiformed combatants. Misconduct stress behavior is also likely when the sympathies of the civilian noncombatants have become suspect as they allow the soldiers' buddies to be killed and mutilated by mines and booby traps which they themselves avoid.

b. Other examples of killing civilians may be impulsive, individual stress reactions or rage attacks: One soldier who has just seen his buddy killed impulsively shoots two children on a water buffalo. The hot, angry, frustrated soldier shoots the peasant who is shouting at him in a foreign language about trampling her vegetable garden. The fact is that overstressed human beings with loaded weapons are inherently dangerous.

Note
Commission of murder and other atrocities against noncombatants must be reported as a war crime and punished if responsibility is established. This must be done even though we may pity the overstressed soldier as well as the victims.

4-11. The Misconduct Stress Behavior of Fighting with Allies or United States Forces
a. Fighting is, of course, what soldiers are trained to do, but they are supposed to direct that skill and energy against the enemy. However, highly cohesive groups, where they believe they are the best, naturally make derogatory remarks about each other. Honor may then require that the insult be resolved by fighting. As long as the fighting is fair and forbids dangerous weapons and crippling techniques, it may actually help sustain cohesion and fighting spirit while promoting grudgingly mutual respect. Such fights between members of different units with rival traditions, different services, or allied forces have sometimes been tacitly or even explicitly condoned by their leaders. A better solution is to initiate a competitive sports program among the rivals which allows them to test each other's strength and courage with less risk of serious injury.

b. Fighting against allies and other US forces becomes a more dangerous stress behavior when it is the result of --

• Alcohol abuse.

• Stress of impending or past battle.

• Battle-generated mistrust.

• Cultural differences.

• Racial prejudice.

• Ethnic prejudice.

It clearly becomes misconduct when the rules of fairness are stretched so that seriously harmful tactics, techniques, and weapons are used. The result is then injury or death. Persistent bad feelings may result that interfere with cooperation between units, services, and allies.

c. This misconduct stress behavior is most common in the period of tension before deployment to battle, or of persistent tension during prolonged lulls or withdrawal of units from combat. Most soldiers who are in battle against the real enemy (or on brief R&R) are not looking for these "intramural" fights. However, some rear area support troops may be, to try to enhance their macho image. That can irritate the combat troops until serious fights result.

Note
Leaders and combat stress control/ mental health personnel must be alert and sensitive to signs that stress is driving high spirits and unit pride across the very fine line from occasional friendly intramural fighting to misconduct stress behaviors.

d. It is obviously serious when fights break out between groups who have been traditional allies in such brawls, or within a previously cohesive unit. It is also traditionally more serious (and usually subject to serious UCMJ disciplinary action) when a soldier strikes a superior officer or an NCO. This, too, can clearly be due to combat or other stress, which might be taken into consideration in deciding punishment.

4-12. The Misconduct Stress Behavior of Being Absent Without Leave or Deserting
Going AWOL or deserting may be misconduct stress behaviors, but are punishable under the UCMJ unless there exists some legal justification or excuse. Possible defenses to a charge of AWOL or desertion include insanity or amnesia with the (rare) trance type of battle fatigue. In the Western democracies, less use of capital punishment for civilian crimes has also reduced the frequency of firing-squad executions of deserters "to discourage the others." Nevertheless, the death penalty is still allowed under the UCMJ for deserting in time of war.

4-13. The Misconduct Stress Behavior of Refusing to Obey an Order
a. A soldier deliberately refusing to obey an order in combat, as a misconduct stress behavior, may be tactically inappropriate (based on an unduly narrow, self-interested, or pessimistic perception of the situation). Alternatively, it may be tactically appropriate (based on a realistic perception that the order is unwise and will get one killed for no purpose). However, all orders which do not involve explicit violation of the Law of Land Warfare are presumed to be lawful and must be obeyed. The dictates of a person's conscience, religion, or personal philosophy (let alone fear or misgivings) cannot legally justify or excuse the disobedience of a lawful order. Combat refusal by units has historically been dealt with by measures as extreme as summary execution of ringleaders or decimation (the arbitrary execution of every tenth soldier). The UCMJ currently provides a maximum punishment of death for this offense when it is committed before the enemy.

b. Army operations expects leaders to keep troops informed of the "Big Picture" and the commanders' intent. Good leaders may give their subordinates more opportunity to express their concerns about an order which they consider unwise and to suggest alternatives to accomplish the objective. Once ordered, however, combat refusal of lawful orders will still be punishable. The alternatives to unwise yet lawful orders will continue to be --

• An. appeal to higher headquarters through the chain of command, chain of support, or special staff (perhaps with a dramatic demonstration of good faith, such as requesting to be relieved of responsibility or command while continuing in the mission as a common soldier).

• Vigorous compliance to the lawful order (it is worth remembering that the famous Charge of the Light Brigade in the Crimean War was successful, although costly and pointless except for the glory it won).

• Cautious and skillful compliance while hoping for a reappraisal and reprieve.

• Unacceptable solutions, such as one of the other negative combat stress behaviors, including involuntary disability through battle fatigue.

c. Less extreme forms of this type of misconduct stress behaviors would be refusing, ignoring, shirking, or otherwise avoiding orders which do not involve the combat mission. The orders may be obeyed but with obvious signs of disrespect to the superior officer or NCO. Persistent breaches of military courtesies, uniform regulations, and other general orders or TSOPs may also be misconduct stress behaviors and are sometimes seen in otherwise effective combat veterans.

d. The distinction between misconduct stress behavior and battle fatigue can be blurred in reality. If an act of insubordination is clearly a misconduct stress behavior and the tactical situation allows, the leader may elect to handle it by telling everyone, "Oh, he's just got battle fatigue" and treating it with reassurance, brief rest, physical replenishment, and activities to restore confidence. In a situation that requires stronger disciplinary action, such as insolence or assault on a superior, the soldier may be charged with insubordination or combat refusal even though it is a misconduct stress behavior.

4-14. The Misconduct Stress Behavior of Threatening to Kill or Killing Unit Leaders or Other Soldiers
a. Threatening to kill or killing unpopular leaders or soldiers (called "fragging" and so named from the technique of rolling a fragmentation grenade into the victim's bunker) is also a criminal act and subjects the offender to disciplinary action. To the extent that this behavior is related to combat stress (rather than to some other grudge), it may involve an individual or group perception that the victim is --

• Excessively eager to commit the unit to danger.

• Grossly incompetent.

• Unfair in sharing of the risks.

b. Other cases may be unpremeditated flashes of rage provoked by intense stress and the loss of usual inhibitions against violence through combat experience. For example, a special operations forces medic had just brought his dead teammate from an ambush to a supporting hospital. When a mortuary affairs specialist casually flicked cigarette ashes onto his dead buddy's face, the medic drew his knife with every intention of cutting the clerk's head off. Fortunately for both soldiers, bystanders intervened before the clerk was seriously hurt. Fortunately for the medic, his own chain of command understood his misconduct stress behavior. They convinced the hospital commander that it was not in anyone's best interest to press charges.

4-15. Misconduct Stress Behaviors of Special Concern to the Medical System (Along with Command)
Some soldiers exhibiting misconduct stress behaviors attempt to use the medical evacuation and treatment system to escape their stressful duty. Other soldiers displaying misconduct stress behaviors require medical or surgical treatment for the consequences of their misbehavior. Medical personnel and administrators must recognize these cases and report them to the chain of command. The chain of command may take disciplinary action and act to prevent future cases. These misconduct stress behaviors of special concern are discussed in the following paragraphs.

4-16. Malingerers
a. Malingerers are those few soldiers who, in an effort to avoid duty, deliberately and willfully fake illness, physical disablement, mental lapse, or derangement, including battle fatigue. They must be counseled and returned to their units, even if they are suffering from combat stress. Malingering is an offense under the UCMJ (Article 115). The issue is not the presence of stress but whether the symptoms are under voluntary control. The most reliable test is whether the symptoms go away when the soldier does not think he is being watched and return when he thinks he is. Usually the malingerer cannot fake perfectly the physical and mental indications of true physical or psychiatric disorders.

b. The problem is how to distinguish malingering from the physical dysfunction, memory loss, and excessive pain and disability forms of battle fatigue (see Chapter 5). Unlike malingering, these are involuntary, but they also may fluctuate over time and with level of attention. They seldom mimic true physical or psychiatric disorders faithfully. It has been observed that the malingerer is likely to resent, avoid, or try to fake diagnostic tests such as hypnosis and truth serum (sodium amytal) interviews. True battle fatigue cases usually cooperate willingly. However, as true battle fatigue cases recover from the psychologically caused loss of physical function, they may go through a phase of feeling that it is now under voluntary control and, feeling guilty, may mistakenly believe (and confess) that they were malingering all along.

c. The boundary between malingering as a misconduct stress behavior and battle fatigue can be another gray area when both may be present in the same soldier. If all that is needed to correct the apparent deliberate faking and turn the highly stressed malingerer back into a good soldier is a day or two of relatively light duty, physical replenishment, and encouragement, the leader or treater may elect to call it battle fatigue, treat the battle fatigue, and not press charges unless the soldier continues to malinger.

d. Another form of malingering is making suicide threats and gestures (nonlethal attempts) for the purpose of escaping unwanted duty. Here, the problem is to distinguish malingering from true depression or impaired impulse control due to stress or battle fatigue where the risk of death on a further suicide attempt is very real. Treating the threat or gesture as a cry for help and assisting the soldier in coping with the stressors without seeding trim home may separate the malingerer from the true sufferer.

4-17. Self-Inflicted Wounds
a. Self-inflicted injuries must be investigated. If deliberate, they are a form of malingering under UCMJ (Article 115). Such injuries may require disciplinary action as well as surgical treatment. Typical examples are shooting or stabbing oneself in the foot or nondominant hand. More ingenious is throwing a hand grenade through a door and holding one's arm out in hopes of being hit by a fragment. In WWI, some soldiers deliberately exposed a patch of skin in mustard-contaminated areas. Good and even excellent soldiers have said that the temptation to give oneself a "million-dollar wound" becomes hard to set aside as the combat stress level increases. Some soldiers yield to the temptation. Occasionally, buddies even collaborate to give each other wounds and alibis. Fatigue, inattention, and carelessness make unintentional self-inflicted wounds more likely.

b. Preventable DNBI may be the consequences of the inattention and indifference to hygiene and self-care. Inattention and indifference are common signs of battle fatigue. The results of stress-induced negligence may include dehydration, diarrhea, dysentery, malaria, blisters, and cold injury. Also, stress-induced carelessness can cause mashed fingers, sprained ankles, and more serious bodily injuries. Such disabling conditions may be a deliberate form of malingering; however, this is often difficult to prove. Sex with promiscuous partners and prostitutes may result in sexually transmitted diseases (STD). With the spread of acquired immunodeficiency syndrome (AIDS), STD can once again result in a soldier's slow death from a nonbattle cause. All DNBI must be treated and, if necessary, evacuated, but command must be advised to redouble self-aid, buddy aid, and preventive medicine measures. If these actions are not done, a few negligent cases can quickly grow into an epidemic or an evacuation syndrome. Examples include gonorrhea (WWII Italian theater), frostbite (Korea), and malaria (Vietnam).

c. Other equally important considerations are wounds or death due to failure to take cover or other obvious precautions. While this is not deliberate misconduct, there are many anecdotes of combat-experienced soldiers who reach a stage where they appear to be functioning well but are so task-oriented or so fatalistic that they become easy, unnecessary victims. Many such cases involved leaders who failed to take cover in the presence of known snipers. Some survived to require surgical care. Many did not. It seems that the psychological defense mechanisms of the resistance stage of stress have betrayed, rather than protected, them. In other cases, inattention due to fatigue played an important role. In a few cases where other background data are available, unconscious or deliberate suicidal intent may be suspected.

4-18. Drug and Alcohol Abuse
a. Substance abuse is classified as a neuropsychiatric disorder, but may also be misconduct stress behavior. It may represent self-medication for the anxiety and traumatic memories of combat or for the boredom and frustrations of rear area duties. Substance abuse may give group users an extended family and an inappropriate sense of belonging to a special group who is "superior" to (but persecuted by) outsiders or authority. This may be an unfortunate by-product of cohesion-producing group dynamics.

b. The following are some of the problems related to substance abuse:

• Intoxication or withdrawal (from alcohol, barbiturates, tranquilizers, narcotics, stimulants, and hallucinogenic drugs) may require hospitalization for medical/neuropsychiatric stabilization.

• Overuse of amphetamine-type stimulants (as deliberate abuse or by well intentioned soldiers and leaders trying to stay alert) may cause panic attacks, manic hyperactivity, rage attacks, and paranoid psychosis. Discontinuing amphetamines causes a "crash" with possible serious depression and suicidal thinking.

• Abuse of anabolic steroids for body-building has been associated with mood swings and violent attack episodes ("roid rage").

• Hallucinogenic drugs cause bizarre sensory distortion, poor judgment, and occasionally, panic and dangerous behavior. Fumes (inhaled accidentally or as deliberate abuse) from gasoline, solvents, and spray can propellants can cause disoriented, crazy, and violent behavior.

• Atropine, the antidote for nerve agents, can cause severe heat stress, as well as vision and cognitive problems, even at low doses. Higher doses may produce disoriented, crazy behavior if administered when no nerve agent is present. This is especially true in sleep-deprived or otherwise physiologically overstressed soldiers.

c. Substance dependency and addiction require rehabilitation or administrative disposition. Some substance abusers have good potential for return to duty, especially if the use is stress-related. It is important not to reward substance abuse with medical evacuation to CONUS unless there are other medical or surgical complications which require it. Detoxication should be accomplished in the theater (combat zone or COMMZ) and the soldier returned to duty for administrative action.

4-19. Factors Which Increase Misconduct Stress Behavior
The following factors may increase misconduct stress behavior:

a. Permissive attitude and availability and use of drugs in the region by civilians, especially around posts or garrison areas.

b. Inadequate enforcement of the unit's Alcohol and Drug Abuse Prevention and Control Program before deployment; failing to identify and treat (or discharge) misusers. This is a critical issue for Reserve Component as well as Active Component units.

c. Availability and distribution networks (both legal and illegal) for alcohol and different types of drugs in the theater. Some drugs are much more available at lower prices in some foreign countries or regions.

d. Unsupervised and unwise use of amphetamines and other strong stimulants to remain awake in CONOPS. This can produce dangerous (usually temporary) neuropsychiatric illness. Also, it may lead to dependency and addiction in originally well-intentioned, good soldiers, including leaders.

e. Boredom and monotonous duties, especially if combined with chronic frustration and tension.

f. False alarms of nerve agent presence resulting in self-administration of atropine. Atropine can cause problems with vision, cognitive skills, and performance if taken when a nerve agent is not present.

g. Victorious pursuit of a retreating enemy. This reduces battle fatigue casualties but may not inhibit commission of criminal acts (killing of EPW, rape, looting) or alcohol/drug misuse unless command retains tight moral control.

h. Hasty withdrawal. Here, few battle fatigue casualties enter medical channels, although battle fatigue soldiers may be lost as KIA, missing in action (MIA), or captured instead of becoming medical patients. Other stressed soldiers may willfully desert or surrender. Looting can occur, "justified" by the rationalization that the property would just be seized by the enemy. Rape, murder, and other criminal actions taken as reprisal can be triggered by stress if the retreating troops feel hindered by EPW or if the civilians being left behind were not friendly. Leaders must take care not to lose control of the withdrawal or be too zealous in encouraging a "scorched earth" policy.

i. Beleaguered unit which cannot evacuate any (or only the most severely wounded) casualties. Here, too, few soldiers are identified as battle fatigue casualties although some may become ineffective due to the severe stress. Other soldiers may go AWOL.

j. Rapid return of soldiers to close contact with noncombatant military, civilians, or families after an intense battle experience without a unit stand-down period in which to defuse.

k. Commission of atrocities by the enemy, especially if against US personnel, but also if against local civilians.

l. Racial and ethnic tension which can occur within the US civilian population and among Army personnel. Tension and misconduct may also stem from major cultural and physical/ racial differences between US soldiers and the local population.

m. Local civilian population may be perceived as hostile, untrustworthy, or "subhuman." This is more likely to happen if there is a lack of education and understanding of cultural differences. Exploitation of cultural differences through propaganda to create disharmony and mistrust may be an objective of the enemy.

n. Failure of expected support, such as reinforcement or relief; inadequate resupply; inadequate medical support and evacuation. Soldiers who feel abandoned and on their own may resort to illegal measures to get what they think they need. Combat soldiers naturally tend to feel "entitled" to claim what they have "earned," and this may lead to looting and worse.

o. High personnel turbulence, lack of unit cohesion, especially of vertical bonding between leaders and troops. "Substance-of-choice" can become a "ticket" for inclusion into a group.

p. Loss of confidence in leaders, in supporting or allied units, and in equipment as compared to the enemy's. These also can lead soldiers to a sense of abandonment, desperation, and the "right" to take shortcuts to get what they need and deserve.

q. Popular opposition at home to the war; lack of understanding or belief in the justness of the effort. Some soldiers may find this an excuse to desert or refuse lawful orders. Others who continue to do their duty may show their resentment by lashing out at the local population or by using drugs and alcohol.

r. Lack of a believable plan for protecting families in the theater, either by evacuating them or keeping them secure under reliable authority. Some soldiers may go AWOL to stay with them or attempt to take them to safety.

4-20. Factors Which Protect Against Misconduct Stress Behavior
a. The following factors protect against misconduct stress behaviors:

• High unit cohesion -- represents the commitment of soldiers of all ranks to each other and the strength of their willingness to fight and sacrifice personal safety. It is a product of bonding of soldiers with each other and the bonding between leaders and subordinates. Cohesion requires strong bonds of mutual respect, trust, confidence, and understanding within units. Cohesive units function smoothly and perform well under stress. In organizations with high cohesion, the unit identity forbids abuse of substances and emphasizes adherence to the Law of Land Warfare.

• Tough, realistic training -- provides the training, including faithful adherence to rules of engagement, which support the Law of Land Warfare and addresses cultural issues. Tough and realistic training is designed to develop and challenge each soldier and unit. Tough training occurs when leaders and soldiers mutually experience realistic exhausting conditions that prepare both, as a team, for the stress of combat.

• Unit leaders, medical personnel, and chaplains are trained -- to recognize battle fatigue and early warning signs of misconduct stress behaviors.

• Units are withdrawn from combat periodically -- to rest, refit (reconstitute if necessary), and absorb new replacements who arrive and are integrated as cohesive teams, not individuals.

• Leaders demonstrate competence, courage, candor, and commitment. Leaders show caring for the soldiers and make provisions for their physical, mental, and spiritual well-being as the tactical situation permits.

• Leaders keep troops informed -- of the objectives of the operations and war (including psychological operations and diplomatic, political, and moral objectives). They focus the soldiers' appraisal of the situation to maintain positive coping against the temptations to misconduct stress behaviors. The commander should utilize his public affairs officer and the public affairs assistance available to him in an effort to keep soldiers informed.

• Leaders conduct after-action debriefings -- which defuse resentments and tension prior to soldiers coming in close contact with noncombatants (military, allied, civilian, or family). This is most important for soldiers who return from special operations, direct action, special reconnaissance, or counterterrorism missions.

b. The situations listed above can be extremely beneficial for leaders and troops in maintaining and enforcing a unit self-image that regards misconduct behaviors as unacceptable. If that view is lacking, these same situations may even contribute to substance abuse and violations of the laws of war.