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

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

Chapter 9: Combat Stress Control in Operations Other than War

Headquarters, Department of the Army, Washington, DC

9-1. Introduction
The Army classifies its activities during peacetime and conflict as operations other than war. Conflict is characterized by hostilities short of war to secure strategic objectives.

a. The growing incidence of conflict pits Army forces against irregular or unconventional forces, enemy special operations forces (SOF) and terrorists. Conflict poses a threat to US interests at all times, not just in periods of active hostilities. United States citizens, especially military personnel and their families, may be at risk anywhere in the world.

b. The terrorist or guerrilla forces count on fear and terror as their principal weapon and objective. By attacking the defending military forces and civilian population only at times and places of their choosing, they deny the defender any safe areas and flaunt the inability of the authorities to protect themselves or their people. By hiding among the populace and using women and children as combatants, the guerrilla or terrorist provokes the defending forces to perceive the people as unworthy of protection. The defender may adopt harsh repressive measures and commit atrocities which turn the people against the defenders.

(1) Although the stressors of terrorism and guerrilla tactics are less overwhelming than those of war, they are deliberately designed to cause breakdown of military professionalism and discipline. As these events are reported in the media, the enemy expects that the home front in the US will perceive the conflict as unwinnable and immoral. The goal for the enemy is for the US home front to abandon support for the effort and even turn against our own soldiers.

(2) In operations other than war when combat operations are required (engagements), battle fatigue casualty rates rarely exceed one battle fatigue casualty per ten WIA. Other misconduct stress behaviors, including drug and alcohol abuse and criminal acts, become the more common and serious reflectors of combat stress in light combat operations. Table 9-1, page 9-3, lists some likely stress-producing aspects of operations other than war which involve conflict.

(3) Civil and military leaders would be in error to rely only on military technology and indiscriminate firepower to oppose a guerrilla force. These leaders must also recognize and defuse the political and psychological stress threat. If they fail to do this, they may win the battles in the field but still lose the war (or the post-treaty peace).

c. Forces for military operations other than war must be selected and task-organized to fit the situation. Combat, when it occurs, is strategically defensive and intended to permit political, social, and economic development activities. The nature of the conflict requires that coercive measures be the minimum necessary to achieve the purpose. This will be visible to the soldier largely in terms of extremely restrictive rules of engagement. For his own sake, as well as for the success of the mission, the soldier must understand the environment in which he is to operate and fight.

(1) Army actions in operations other than war must be fully coordinated with national strategy and fused at the operational level into a coherent effort. The effort must complement economical, political, and military activities. This linkage with such activities must be made clear to the soldiers. Failure to do so can lead to confusion and frustration among soldiers as to the purpose, attainability, and objectives of their mission.

(2) Public affairs plays a critical role in the operations other than war environment, across all of the operational categories. It supports the commander and soldier by --

• Assessing information needs.

• Formulating messages.

• Facilitating the flow of information.

• Providing communications channels.

• Serving as the primary interface between the military and the civilian media.

• A key public affairs mission is to reduce the soldiers' sense of isolation by --

• Reinforcing the role each soldier plays in the operation.

• Ensuring information flows in and out of the theater.

• Telling the Army story to the public in order to maintain support for the effort and the soldiers.

(3) Operations other than war (peacetime or conflict) require that the plan and the task organization of units be tailored to the specific operation. The following paragraphs review the operational categories and the special stressors that soldiers are likely to encounter.

9-2. Support for Insurgency Operations
a. Support for insurgency is a goal-directed activity. These operations are normally of long duration and predominantly conducted by indigenous or surrogate forces. These forces are organized, trained, equipped, supported, and directed in varying degrees by an outside source. Unconventional warfare, a tactic employed in insurgency or counterinsurgency, includes guerrilla warfare and other direct offensive, low-visibility, covert, or clandestine operations. It also includes the indirect activities of subversion, sabotage, intelligence collection, evasion, and escape. The primary forces used in unconventional warfare are SOF. Combat stress control personnel who support such operations must have the appropriate level of security clearance to debrief and treat SOF personnel at the conclusion of their mission.

b. Insurgency is an organized, armed, political struggle whose goal may be the seizure of power through revolutionary takeover and the replacement of the existing government. In some cases, however, insurgency is undertaken to break away from government control and establish an autonomous state within traditional ethnic or religious territorial bounds. It may even be conducted to extract limited political concessions that are unattainable with less violent means.

(1) The existing government will attempt to isolate the insurgents from the general population. Therefore, insurgents normally must live under austere or primitive conditions, have limited or no access to medical care, and often operate using hit-and-run tactics. The severity of those conditions will depend upon how much support the insurgents receive from the local population and the effectiveness of the government's repressive measures.

(2) If the US SOF were to provide support to a US-backed insurgent group, they would also operate and live in this austere environment. Issues which would contribute to combat stress, battle fatigue, and potential misconduct stress behaviors are listed in Table 9-2 along with leader and buddy actions to counteract these stressors.

(3) Insurgents frequently adopt terrorism as a tactic. This is one of the things that makes counterinsurgency so difficult. It also makes support for insurgency (should we be called upon to do it) such a moral dilemma.

(4) Insurgencies and use of terrorism independent of insurgencies probably pose stress which is as severe as that which occurs in the most violent of "conventional" wars. All the societal norms which Americans accept seem to be abandoned and perhaps irrelevant. The participants' moral compass may go haywire so that they have a hard time distinguishing right from wrong. Innocent persons are singled out for the most atrocious attacks because of their shock value.

(5) Inspired, compassionate leadership and firm discipline are required to prevent misconduct stress behaviors.

9-3. Support for Counterinsurgency Operations
Internal Defense and Development (IDAD) strategy is the full range of measures taken by a nation to promote its growth and protect itself from subversion, lawlessness, and insurgency. It focuses on building viable institutions (political, economic, military, and social) that respond to the needs of the society. Developmental programs, carefully planned, implemented, and publicized, can serve the interests of population groups and deny exploitable issues to the insurgents. Foreign Internal Defense (FID) is the participation by civilian and military agencies of a government in any of the action programs taken by another government to free and protect its society. Foreign Internal Defense is the US role in the IDAD strategy.

a. In countering an insurgency, the Army may employ specially trained forces or training teams. This sort of activity may include the transfer of defense equipment, the training of foreign soldiers, advisory assistance, or even the commitment of combat forces. All military efforts in a counterinsurgency campaign will be made in concert with the HN and the initiatives of other US government agencies involved to ensure a synchronized national effort.

b. The forces selected for FID will depend on the threat to be countered. Special operations forces, light and heavy forces, aviation units, logistical support, and a variety of training teams may be used for counterinsurgency efforts.

c. The high degree of selection and training, provided it is done well, tends to minimize battle fatigue casualties and misconduct stress behaviors. However, if units are hastily selected and deployed, they are likely to have problems facing the special stressors in operations other than war (listed in Table 9-1).

d. Refer to Table 9-3 for mental health considerations and recommendations in support of counterinsurgency operations.

9-4. Combatting Terrorism
a. Terrorism and the threat of terrorism are widespread in the modern world. Terrorism can occur throughout the operational continuum. It is defined as the unlawful use or threatened use of force or violence against people or property to coerce or intimidate governments or societies, often to achieve political, religious, or ideological objectives.

(1) Terrorists may be independent groups or may be supported covertly or openly by hostile states. Terrorist organizations sometimes cooperate with each other in pursuit of common strategic objectives.

(2) US Army doctrine calls for preventive action (antiterrorism) along with reactive measures (counterterrorism) to meet the terrorist threat to US forces, representatives, and agencies and to the security of American citizens and property.

(a) Antiterrorism consists of those defensive measures used to reduce the vulnerability of personnel, family members, facilities, and equipment to terrorist acts.

(b) Counterterrorism is comprised of those offensive measures taken to prevent, deter, and respond to terrorism. Terrorism must be dealt with in the Army's daily operations as well as being of concern in war and operations other than war. Terrorist tactics may be directed at service families, recreational facilities, and general targets such as commercial airliners.

(c) Awareness of the threat and recognition that the indicators of terrorist activity differ from those of the enemy on the conventional battlefield are essential to combatting terrorism.

(d) Leaders at all levels must develop a broad view of this threat which will guide them in securing their operations and in protecting their soldiers from terrorists as well as from conventional enemy military forces.

(e) At the same time, they must not impose excessive anxiety, restrictions, and repression which play into the enemies' game plan.

(3) United States counterterrorism forces must be protected against and treated for combined effects offrustration, moral conflict, and boredom which are the terrorists' main goals for success. When implementing preventive or reactive programs, the following should be considered:

• Battle fatigue is usually mild and can be managed in the units.

• Special programs may be needed to prevent and treat alcohol and drug misuse.

• Additional programs may be required to prevent misconduct against prisoners or noncombatants and other lapses of military discipline.

• Soldiers who return from counterterrorism missions and other special operations need a stand-down period. This should come before they are reunited with their families or other noncombatants. The stand-down period is needed to "defuse" the tension that has built up during the operational phase. These programs are also needed to protect against PTSD which may disable the soldier or veteran for several months or years after returning home.

b. Terrorist acts produce debilitating stress reactions due to the shock of the event, the sudden violation of familiar and safe settings, and the feeling of loss of control. The stress may impact not only on the direct victims of the terrorist act but also on the passive witnesses of the destruction, the immediate rescuers and care givers, and the more distant care givers, friends, coworkers, and family. The following feelings or behaviors may become evident:

• Hostile feelings (repressed or expressed).

• Feelings of dependence.

• Feelings of powerlessness or incompetence.

• Regressive behaviors (childish temper outbursts, stubbornness).

• Negative responses to relocation and isolation.

• Positive identification with the terrorists ("the Stockholm syndrome").

• Sense of being a victim.

• Negative feelings about one's own country or its allies.

c. Victims of disaster/hostage/terrorist situations suffer a high incidence of acute, chronic, and delayed PTSD in addition to possible medical and surgical injuries. Treatment of these disorders in the acute phase, and even better, preventive measures before symptoms occur, can prevent the development of many chronic or delayed disabilities.

(1) Task-organized multidisciplinary stress control teams provide mental health treatment services. These teams initiate preventive treatment measures to individuals or groups involved in disasters, terrorist activities, and hostage situations. Teams are task-organized depending upon the number of people involved in the specific incident and the nature of the incident.

(2) The team assists victims, family members, witnesses, immediate rescuers, and backup medical staff involved in terrorist or hostage situations. A variety of individual and group techniques are used to help return persons to normal functions and to reduce the impact of PTSD. Some examples of these techniques are as follows:

• Professional reassurance of the normality of acute stress reactions and the positive expectation of rapid recovery and coping.

• Critical event debriefing of groups. Everyone is encouraged to talk out what happened and what everyone did (saw, heard, smelled, felt) in detail. In the process, the group corrects misunderstandings and validates and ventilates feelings. Individual debriefing as needed.

• Extremely limited use of fast-acting sedating medication in special cases.

• Individual, group, or family follow-up as needed.

d. Refer to Table 9-4 for some operations other than war mental health recommendations in support of combatting terrorism.

9-5. Operations Other Than War (Peacetime Contingency Operations)
These operations are politically sensitive military activities. They are normally characterized by the short-term, rapid projection or employment of forces in operations other than war. They are often undertaken in crisis avoidance or crisis management situations requiring the use of military instruments to enforce or support diplomatic initiatives.

a. Several Types of Operations. There are numerous types of operations which are covered by this operational category. In each type of operation, different stress factors will be present. Some operations, such as strikes and raids, inherently involve combat, but are brief. Others, such as peacemaking and noncombatant evacuation operations, run a high risk of violence but under much more ambiguous conditions. Military operations other than war such as peacekeeping, nation building, and disaster relief should not lead to combat, but do involve their own types of stressors. Soldiers are expected to be ambassadors and representatives of the goodwill of the US, yet they may be separated from home or family, sometimes abruptly. They may have to live under uncomfortable or monotonous, boring conditions, perhaps for prolonged periods. In addition, they may be exposed to an entirely different culture whose practices may seem alien, backward, or even repulsive to those who do not understand the historical or practical reasons for them. However, misconduct stress behaviors on the part of our troops can turn local goodwill into enduring resentment and hatred. Table 9-5 provides some of the mental health considerations which may be present in any given peacetime contingency situation and recommended actions which may be taken. Each type of operation is presented below.

b. Attacks and Raids. The US conducts attacks and raids for specific purposes other than gaining or holding terrain. Attacks and raids can support rescue and recovery operations. They can destroy or seize equipment or facilities which significantly threaten national security interests. They can also support counter-drug operations by destroying narcotics production or temporary storage facilities used during shipment, or support HN's actions in this regard. Depending on the intensity and duration of combat and on the success (or lack of success), strikes and raids produce traditional combat stress behaviors. The level of secrecy in which the operation is conducted can produce added stress for the soldier and his family. Depending on the size and planned duration of the operation, mental health/combat stress control personnel may accompany the strike force or remain at home station. Mental health/combat stress control personnel should be involved as early as feasible in planning and recovery.

c. Shows of Force and Demonstrations. These operations lend credibility to our nation's promises and commitments. They increase our regional influence and demonstrate our resolve to use military force as an instrument of national power. Further, the NCA may order these operations to bolster and reassure friends and allies. Health service support activities to include combat stress control follow the traditional role of providing support to a combat force. Demonstrations may involve high anticipatory anxiety but usually do not cause psychic trauma unless open combat, accidental deaths, or terrorist acts result from them.

d. Rescue and Recovery Operations. Rescue and recovery operations are sophisticated actions requiring precise execution, especially when conducted in a hostile environment. These operations may be clandestine or overt. They may include the rescue of US troops or friendly foreign nations, or the location, identification, and recovery of sensitive equipment or items critical to US national security. The level of hostilities to be encountered will vary with each specific mission. Mental health support may be required by the individuals being rescued or the force employed. The level of security for the operation may result in added stressors to those accomplishing the mission.

e. Disaster Relief Operations. Disaster relief operations provide emergency assistance to victims of natural and man-made disasters abroad. These operations are responses to requests for immediate help and rehabilitation from foreign governments or international agencies. Mental health support may be required for both victims of the disaster and the military units and health professionals caring for them. The victims' plight may be truly distressing and leave memories of many horrible sights, sounds, and smells for all involved. Recent disasters within the US have also expanded the role of the military (Active and Reserve Components) in domestic disaster relief. In some instances, identification with the victims may even be stronger. For some units, their own families may be involved in the disaster while they must remain on duty for the common good.

f. Noncombatant Evacuation Operations. Noncombatant evacuation operations are conducted to relocate civilian noncombatants from locations in a foreign country. These operations are normally conducted to evacuate US citizens whose lives are in danger; however, they may also include the evacuation of HN or third country citizens. These operations are of short duration. They consist of rapidly inserting a force, occupying an objective, and making a planned withdrawal. The amount of force used is normally limited to that required for self-defense and the defense of the operations. Mental health support may be required for both the forces employed and the civilians being evacuated. The need for mental health intervention will depend upon the level of hostilities and the psychological trauma encountered. It also depends on the anticipated duration of the operation and the recent experiences of those being evacuated. After-action debriefing at the small unit level should be routine. All evacuees should receive large group stress debriefing. Critical event debriefings can then be scheduled for such groups who need them.

g. Operations to Restore Order ("Peacemaking''). These operations are intended to establish and restore peace and order through the use of force. The US conducts these operations when it is in its national interest. Intense efforts are made to stop a violent conflict and to force a return to political and diplomatic methods of resolution. The US typically undertakes "peacemaking" operations at the request of appropriate national authorities in a foreign country. It may also conduct these operations to protect US citizens as part of an international, multilateral, or unilateral operation. The threat of armed resistance or attack by one or more disgruntled parties in the conflict is high. This may take the form of overt battle, major terrorist attack, or covert harassment and sniping. The rules of engagement may require not returning fire until fired upon, with the source of hostile fire clearly identified. Combat stress control support for peacemaking forces requires the traditional support to combat forces. Peacemaking forces must also be prepared to counter added stressors. These stressors may include language and customs barriers, ambiguous threats, and the lack of freedom of movement.

h. Peacekeeping Operations. Peacekeeping operations are military operations conducted with the consent of the belligerent parties to a conflict. These operations are conducted to maintain a negotiated truce and to facilitate a diplomatic resolution. The US may participate in peacekeeping operations under the auspices of an international organization, in cooperation with other countries, or unilaterally. Peacekeeping operations support diplomatic efforts to achieve, restore, or maintain peace in areas of potential or actual conflict. Units of peacekeeping forces may use force only in clear cases of self-defense. Due to the nature of peacekeeping operations, misconduct stress behaviors can result from a number of factors. Another characteristic of peacekeeping is isolation of small units for prolonged periods with only radio or telephone contact with their superiors. Also, any violence directed against the peacekeepers will likely come from people whom they intend to be helping. Thus, a sense of betrayal aggravates the stress inherent in the event. Table 9-6 provides mental health considerations and recommendations in support of peacekeeping operations.

i. Humanitarian and Civic Assistance. US Army combat support/CSS units may be deployed or rotated to friendly HNs to assist that country in developing its resources. These activities serve the basic economic and social needs of the people of the country concerned. They --

• Support the civilian leadership.

• Benefit a wide spectrum of the community.

• Should be self-sustaining (once completed) or supportable by the HN civilian or military agencies. Examples

• include --

  • Providing medical, dental, and veterinary care in rural areas.

  • Training local health care personnel in hygiene and preventive medicine.

  • Assisting in establishing mental health and social service agencies.

  • Performing engineer projects, such as building roads, bridges, and flood control dams.

Army units engaged in humanitarian and civic assistance range from active Army units deployed for relatively long periods to Reserve Component units on annual training. These conditions can cause a wide variety of stressors related to acclimatization to the environment and culture, coupled with separation from home.

9-6. Stress Problems of Military Operations Other Than War
The stress problems of military operations other than war are recognized by Army long-range planners. The Army must develop an appreciation of low-key, frustrating, and frequently unglorious work. This will not be easy for our soldiers from a culture noted for its impatience and thirst for decisive outcomes. In some areas, we may have to "train down" to less sophisticated equipment because operations other than war frequently are not appropriate for displaying the latest technology. Finally, there is the matter of culture. The American sent to function in an alien culture will have to possess some knowledge of that culture if he is to successfully interact with and influence the members of that culture. For additional information on operations other than war and peacetime contingency operations, refer to FMs 100-5 and 100-20. For specific information on medical operations in this environment, refer to FM 8-42.