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

Appendix A

Headquarters, Department of the Army, Washington, DC

This appendix provides recommendations for how leaders can control situations or events that cause battle fatigue. Table A-1 summarizes the risk factors that are discussed.

A-1. Home Front
a. Risk Factor: Problems and uncertainties on the home front.\par

(1) Worrying about what is happening back home distracts soldiers from focusing their psychological defenses on the combat stressors. It creates internal conflict over performing their combat duty and perhaps not surviving to resolve the uncertainties at home. An Israeli Defense Force study conducted after the 1973 Yom Kippur War found concerns about the home front to be the strongest predictive factor which distinguished between soldiers who became "battle shock" casualties and those who were decorated for heroic acts.

(2) The home front problem may be a negative one -- marital or financial problems, illness, uncertain job security (if a reservist); or it may be something positive -- newly married, new baby. All soldiers face greater potential problems and uncertainties with personal matters if the military conflict is not popular at home.

b. Leader Actions: Stabilize the home front.\par

(1) Help families develop unit identity and a support system.

• Involve the soldiers' families in unit social activities. Teach them about the unit's mission and history and include them in the sense of unit cohesion.

• Know soldiers' personal backgrounds as well as their military skills. Keep notes to remember details about each soldier's spouse, children, parents, and outside interests which you can learn.

• Help soldiers and their families to use Army and civilian support services such as Army Community Service, Army Emergency Relief, post morale/welfare/recreation activities, and the Red Cross.

• Encourage soldiers and their families to draw moral support and assistance from the unit and its members.

• Use the unit or post chaplains and mental health team as valuable resources. Get to know them personally, and encourage soldiers and families to talk with them when they can help. Make command referrals to mental health when necessary.

• Promote and support a unit family or spouse network (family support group) which communicates information and provides emotional support and guidance for practical assistance to every unit family. Include those who live far from the unit's military post on the mail-out roster for disseminating information about the unit. \par

(2) Reduce problems of rapid mobilization and deployment for Active Component and Reserve Component soldiers. This turmoil must be reduced by prior planning which has been communicated to and practiced with the family. Help soldiers prepare themselves and their families for the disruption and stress of a rapid deployment.

• Establish a system which keeps family members informed about the progress of the deployment and the health and safety of their spouses, consistent with realistic security restrictions.

• Encourage family members to participate in family action plan or community action plan conferences.

• Encourage commanders to conduct periodic feedback sessions for families.

• Assure rapid humane casualty reporting to families and provide assistance to them.

• Involve families in organizing the unit's welcome home party.

(3) Prepare families in the theater of operations for the NEO plan. Soldiers will have great emotional stress moving out to their combat positions and keeping their minds focused on their missions if they are not confident that someone they trust is looking after their families in the best way the situation allows. Failure to provide that reassurance runs a high risk of battle fatigue casualties and of misconduct stress behaviors such as going AWOL to stay with the families.

• Have a credible NEO plan; talk about it and practice it.

• Have a credible contingency plan for what will be done if the NEO plan cannot be implemented because of political or operational reasons. Talk about that frankly, and practice the contingency plan, too. Someone who is known and trusted must be left in charge of those families.

• Make clear to the soldiers that the best way they can protect their families is by doing their combat duty.

A-2. New Soldier
a. Risk Factor: Soldier is new in the unit.

(1) The new soldier has not yet established trust and cohesion with buddies and leaders. The Israeli study, discussed above, found this to be the second strongest predictor distinguishing battle shock casualties from decorated heroes.\par

(2) New replacements who have no prior combat experience are at special risk because not only are they facing extreme stress for the first time, but also the veteran soldiers have little basis on which to trust them. Veteran soldiers who are coming to a new unit after recovering from a wound or as survivors from other units are also at risk. These veterans may adapt quicker than the new replacements, provided they do not have internal conflicts and too much unresolved battle fatigue.\par

(3) Soldiers who have been given increased/new job responsibilities, such as just being promoted to NCO, are at risk. These soldiers may also be under special stress for a while as they adjust to no longer being "one of the old gang" and develop new horizontal bonding with other NCOs.\par

(4) Building unit cohesion is extremely important. The most important motive which keeps soldiers doing their duty in combat is personal bonding. Personal bonding is the personal trust and loyalty among members of a small unit. This bonding makes them prefer to stick together in exceedingly stressful situations, even when great hardship and danger are present.

• The leader needs to encourage as much unit cohesion as possible. (See FM 22-100.) The leader ensures that the personal bonding is strengthened by a sense of the unit's military identity (esprit) and its mission.

• This combination of unit esprit and personal bonding makes "unit cohesion."

  • Unit esprit is like concrete; it keep its shape, but shatters easily.

  • Personal bonding alone is like steel wire mesh; it is hard to break but easy to bend.

  • Combining the two produces a result that is far stronger than the sum of its parts. Unit cohesion is like reinforced concrete. It neither bends nor breaks.

• Working together to overcome danger and survive is, in itself, a good way to produce fast cohesion. But there are two disadvantages in waiting until the danger is close before starting to develop unit cohesion.

  • First, there is the big risk that the danger and stress will break up the insufficiently cohesive team and roll over it. Everyone will simply get killed or develop total battle fatigue.

  • Second, it is possible to develop personally cohesive groups who care only about their own comfort and survival and not about the mission.

b. Leader Actions: Promote unit cohesion.

(1) Ensure that new arrivals are welcomed into the group and become known and trusted members quickly.

• In-brief the soldier explaining what the standards are and tell him how the unit has performed in terms of meeting its own standards.

• Appoint a suitable sponsor for each newcomer and monitor to see that the sponsor shows the newcomer around and assists him in settling in on the job and in the community.

• Introduce new personnel (formally or informally) to all unit members.

• Link the new soldier with an appropriate buddy or buddies in the combat zone. This is essential for proper orientation.

• Give newcomers time, if possible, to develop combat attitudes, skills, and cohesion over several days before putting them into extremely stressful or critical situations.

• Conduct formidable, meaningful combat training whenever possible, involving both the new and the veteran soldiers together. \par

(2) Impart unit pride and identity.\par

• Educate the soldiers regarding the history of the small unit, its parent units, the branch of service, and the Army.

• Tell stories which honor and illustrate historical examples of soldiers and units (as much like yours as possible) who showed initiative, endurance and resilience, who bounced back from defeat, who overcame heavy odds, or whose self-sacrifice led to eventual triumph of the higher cause ("Remember the Alamo!"). Do not just tell about easy military or small unit successes.

• Establish training criteria which will challenge each soldier or each member of a team, squad, platoon, and company. These criteria should be recognized as significant common challenges that all must pass.

• Use distinctive unit symbols, tokens, and awards (such as patches, plaques, and coins) which must be earned. Informal citations and distinctions can also be extremely meaningful. \par

(3) Keep members of the same small teams always working together with their leader.\par

• Assign details and projects to a team, and let its leader organize how they will be done.

• Send a group, small teams, or at least buddy pairs if there is an opportunity for R&R. Do not send a collection of individuals who will not work together in the future.

• Use equipment drills, physical fitness exercises, and team sports to promote mutual reliance and closeness within each team and positive competition and respect among all teams. These activities let off steam, prevent boredom, and help integrate new replacements during times of low mission activity.

• Praise and reward teams, as well as the individual members, for their performance.

• Use team-building techniques -- have team members set team goals. Conduct team rap sessions to talk about what is going well and not so well in the group. Encourage open, honest communication.

(4) Encourage unit-centered social interaction outside duty hours. Monitor these activities to--

• Prevent drug or alcohol abuse (which tense soldiers may want to use to "unwind").

• Prevent fraternization (within the chain of supervision; between officers, NCOs, and enlisted; between persons who are married to others, and so forth).

• Discourage cliques or interest groups which exclude or pick on other unit members.

(5) Bring the whole unit together, when the situation permits.

• Conduct formations, meals, award ceremonies, and other formal or informal occasions which let the teams (squads, platoons, and/or companies) get to know the members of the other teams.

• Conduct activities which let individuals see the whole unit working together.

c. Leader Actions: Conduct small team after-action debriefings after every difficult action (in training and in combat). An after-action debriefing is an extension of after-action reviews which are routine in training. Reconstruct what really happened so that the team benefits from the lessons learned. At the same time, this releases bottled-up emotions and inner conflict that can lead to decreased unit cohesion, battle fatigue, and perhaps even to PTSD. This is the purpose of the after-action debriefing. Feelings of anger and mistrust may go away on their own once the soldier sees how things looked to the others. At least the feelings are out in the open and can be dealt with honestly. Soldiers' natural emotions of loss and grief come out, too, when buddies are wounded or killed in combat. Guilt or shame may come out when soldiers make mistakes. Such soldiers can be comforted and helped to put things into perspective by the rest of the team. The mistakes can be acknowledged and forgiven or atoned for. When conducting the after-action debriefing, the leader must --

(1) Select a location that is relatively safe from enemy attack.

(a) Ensure the location has adequate comfort and enough light to see everyone.

(b) Bring the team (squad, crew, and/or section) together when the situation permits and while the events are still fresh in their minds.

(c) Include only those personnel who took part in the action.

Note
Exceptions for permitting others may include unit members or new replacements who just missed the action. Also, personnel that the team trusts, such as the medic or the chaplain, may be included.

(2) Set the ground rules.

(a) State that the purpose of the after-action debriefing is not to find fault or fix blame. The purpose is to share the experience as a team, to strengthen the team, and to talk and learn together how to do better.

(b) Allow all ranks to freely express their observations and opinions openly and honestly without fear of ridicule or reprisal from their peers or leaders. No verbal abuse or fighting is allowed.

(c) Ensure all personnel agree that personal information, feelings, and reactions which others share within the session will be privileged information and not be talked about outside the group with anyone.

(d) State that operational lessons learned or system problems which the debriefing identifies will be shared with other units or up the chain of command or the NCO chain of support. Such lessons and issues will be worded in terms that do not identify the specific team, unit, and individuals involved.

Note
Make clear that these ground rules do not exempt the leaders and soldiers in the team from upholding and defending the UCMJ and the Law of Land Warfare.\par

(e) Ensure personnel know their rights if the event being debriefed involved potentially illegal acts or misconduct stress behavior. Each individual, and the team as a whole, has an obligation to do the right thing; however, their individual rights must be protected. The team may wish to involve a chaplain or legal counsel in the debriefing or in a subsequent group session.

(3) Reconstruct the action from everyone's memories.

(a) Start just before the beginning of the action with the first person that was involved.

(b) Ask about facts and details to get a clear picture.

(c) Bring in others as they joined the action.

(d) Provide the opportunity for everyone to retell what he saw and did so that the big picture can be seen and agreed upon by everyone.

(e) Make a special effort to involve those who are silent and seem not to want to talk, but do not require anyone to speak.

(4) Share thoughts and reactions to the action.

(a) Do not ask specifically about emotions and feelings or force anyone to talk about them if he does not want to.

(b) Wait until the facts are clear, then ask about the thoughts that came to their minds during the action.

(c) Ask what were their reactions to those thoughts.

(d) Allow feelings to come out naturally, either in words or in the tone of voice, facial expression, body posture, or even tears. The feelings should then be acknowledged and validated by the leader and the rest of the team. This will encourage others to be more open about their feelings.

(e) Keep this a positive learning experience in which natural human emotions and mistakes, however painful or "bad," are accepted as natural but controllable.

(f) Prevent scapegoating or isolation of individual soldiers.

(5) Encourage talk about any physical or mental signs of battle fatigue anyone may be having if the action was a high stress event.

(a) Remind personnel that battle fatigue signs are a normal reaction.

(b) Ensure personnel that the battle fatigue signs normally improve with time and talk.

(6) Bring the focus back to the mission after the feelings have been recognized and ventilated.

(a) Expand on the mission.

(b) Encourage talk on what was learned and how to do it better the next time.

(c) Review what went well and the positive things that were accomplished.

(7) Use after-action debriefings to orient new unit members. These debriefings familiarize them with the unit's most recent history, introduce them to the veterans' roles and personalities, and acquaint them with the unit's TSOP. It also helps when merging survivors of two units into one, with or without other new replacements.

A-3. First Exposure
a. Risk Factor: First exposure to a major stressor.

(1) The first exposure to a significant stressor is usually a time of high stress and risk of battle fatigue. Likewise, it is inevitable when a unit or individual first encounters true combat with its extreme noise,confusion, wounding of soldiers, and violent death. Tough, realistic training helps, but no training can fully equal the real consequences of kill-or-be-killed. The shock will also be intense for medical personnel, even in rear area hospitals, unless they have had extensive emergency room experience.

(2) Even experienced troops may suffer increased battle fatigue when confronted with a surprise enemy weapon, tactic, or attack. Examples include the following:

• The first exposure to tanks and gas in WWI.

• German blitzkrieg tactics with Stuka aircraft, the "88" antitank gun, and later the "Screaming Meemie" mortar.

• Improved conventional munitions and napalm bombs (Israel against Egypt, US against North Vietnam) and wire-guided antitank missiles (Egypt and Syria against Israel).

• Strange, hostile terrain and climate. This type stressor can demoralize even experienced units. (At first, a crack Australian division suffered severe stress casualties when suddenly transferred from the desert of North Africa to the jungle of New Guinea.)

b. Leader Actions: Conduct rugged, realistic training.

(1) Build soldiers' confidence in their own ability, their leadership, and their equipment, initially through rugged, realistic training, and later through success on the battlefield.

• Tough means hard work and continuous operations even during inclement weather conditions.

• Realistic means as similar to the combat mission and combat environment as possible, including the noise, smoke, dust, confusion, delays, setbacks, casualties, and simulated danger and sights.

(2) Seek out challenging and difficult environments for training to increase the unit's skills and confidence. The purpose is not learning to suffer. The objectives of this training are twofold:

• First, learn to accomplish the mission in spite of suffering.

  • Build toughness, tolerance to discomfort, and the confidence that we can take it and do the job.

  • Perform essential tasks for mission accomplishment while adapting to combat and defending against enemy attack.

• Second, learn how to suffer as little as possible.

  • Know how to take care of yourself and each other so that everyone comes through "OK," even though the conditions are stressful.

  • Educate the soldiers to maintain themselves, each other, and the equipment as a matter of professional pride and personal caring, rather than just as discipline. Explain why it is important, not just picky details.

(3) Emphasize that the ultimate result should be success.

(4) Use tough training to achieve specific objectives:

• Learn each soldier's strengths and weaknesses.

• Maximize soldier's strengths while learning how to minimize his weaknesses.

• Identify which are the truly key combat mission tasks. These are given training emphasis. However, remember that some unglamorous things like preventive maintenance and resupply can be truly critical.

• Identify the best qualified soldiers to perform those key tasks. Individuals do differ in training, adaptability, and ability to learn under stress.

• Cross-train! There must be several people capable of doing every key task, including leader tasks and yours.

A-4. Unit Casualties
a. Risk Factor: Casualties in the unit.

• Soldiers in the unit being killed and wounded is the strongest indicator of "combat intensity" and usually is accompanied by increased battle fatigue casualties. This is especially true if many casualties occur in a short time.

• Heavy casualties naturally shake soldiers' confidence in their own chance of survival. The impact is strongest if losses are in the soldiers' own small unit. Loss of a trusted leader or close buddy is both an emotional shock and a threat to unit integrity and survival. New replacements are an unknown quantity who may not know the TSOP and cannot yet be fully relied upon. Losses naturally arouse the battle fatigue symptoms of reduced confidence, feeling exposed and abandoned, and perhaps guilt, anger, and mistrust.

• These feelings will be magnified if the soldier does not feel that everything feasible was done to care for and evacuate the wounded and that respect for the dead was not shown. Confidence in the health service support system can help compensate for the fear of being wounded.

b. Leader Actions: Prepare the unit to endure battle losses.

(1) Talk frankly and prepare for the possibility of casualties in the unit and of team members being killed.

• Talk in the unit about possible loss of leaders and unit members. It will happen in war (even in CSS units) and must not come as a surprise.

• Train junior leaders to take over when senior leaders need sleep or if they become casualties.

• Keep the junior leaders as continuously informed as possible so that they can assume command on short notice without missing stride.

• Cross-train soldiers so that every key task can be performed proficiently by several soldiers.

(2) Routinely practice casualty care and evacuation.

• Train everyone on basic lifesaving self-aid/buddy aid. Select the best soldiers for additional combat lifesaver training, one for every team or crew. Practice this routinely.

• Practice realistic use of any assigned medical personnel and evacuation of casualties as part of any combat exercise. If you can occasionally get moulage kits to make soldiers appear to have serious battle wounds, this will help to harden your soldiers to better face some of the sights of battle.

• Practice self-aid/buddy aid techniques for battle fatigue.

(3) Conduct the small team after-action debriefings after any losses (in training and in combat).

(4) Conduct memorial services for the unit's dead. This will help the soldiers in grieving, provided the service is done with sensitivity.

• While a unit chaplain may play an important role in this service, the commander and junior leaders should be the main participants.

• The dead soldier's friends and others who knew the soldier personally should have an active part in the planning the services, as well as special roles in the ceremony. All ideas should receive equal consideration.

(5) Plan ahead for a rapid, positive integration of new personnel.

A-5. Passive Posture, Defenseless to Attack, or Hit by Friendly Fire
a. Risk Factor: Under attack and unable to strike back.

• Indirect (artillery) fire usually causes more battle fatigue casualties in relation to killed and wounded than does direct fire. This is partly because of the massed, impersonal destruction that a barrage can cause.

• Even more, it is because the troops feel themselves helpless victims of pure chance. Armor and air attacks also tend to produce disproportionate battle fatigue casualties in troops who are not trained to shoot back, such as rear area support units.

• In WWII, many battle fatigue casualties were attributed to the troops' perception that German tanks, "88" artillery, and other weapons were far better than our own, so that we did not have a fair chance to strike back.

• In operations other than war (conflicts), similar frustration is produced by hidden snipers who fire from areas where return fire is limited by the rules of engagement. It may be caused by mines and booby traps and by combatants who cannot be distinguished from the civilians one is supposed to protect. However, this is more likely to trigger misconduct stress behaviors than battle fatigue.

b. Leader Actions: Train troops in active defense against these threats.

(1) Prepare units for the experience of being bombarded.

• Expose all troops in training to the sights and sounds of heavy artillery or air attack impacting at close range. This can be done in suitably safe bunkers, ideally with live artillery fire, but if that is unfeasible, with pyrotechnics and sound effects.

• Explain to the troops that dug-in but inexperienced troops usually believe that everyone else has been killed in a barrage and are surprised when everyone (or almost everyone) climbs up out of his holes when it is over.

• Train how to dig in to protect against bombardment. Dig in at every location (balancing the amount of digging against other missions, enemy, terrain, troops, and time available factors). Take pride in camouflage, dispersion, and light discipline.

(2) Train soldiers in active defensive tactics.

• Drill troops in how to defeat infantry and armor forces.

• Drill troops in air defense tactics. Train all who are not in the direct path of an attacking aircraft to engage it with their rifles. This is as much a protective measure against battle fatigue as it is an air defense technique since it changes them from being helpless victims to being hunters who are helping their buddies.

  Note
  Being hit by friendly fire (whether direct or indirect) or losing troops in a senseless accident produces more battle fatigue because one cannot strike back and it seems so needless.

(3) Drill to prevent friendly fire casualties.

• Drill relentlessly in identification of combat vehicles, equipment, and aircraft to minimize mistakes in identification.

• Remind everyone that our weapons and those of our allies and potential adversaries have been sold around the world and could end up on either or both sides in any conflict. Know the weapons the enemy is using. Drill to identify enemy weapons and weapons systems by name.

• Practice rigorous coordination and communication within and between units.

  • Ensure all personnel are proficient in and knowledgeable of the procedures for challenging, identifying, and communicating with US and allied ground and air forces. Practice these procedures frequently during all operational and environmental conditions to identify and correct any deficiencies.

  • Inform everyone, down to the lowest level, of the friendly forces likely to be encountered in the scheme of maneuver, but be alert and ready for the possibility of change without notice, including the enemy appearing where friends are expected and vice versa.

  • Continually conduct risk assessment and control procedures.

(4) Frequently review the TSOP for rules of engagement, danger, and close fire support, and modify or change as required. Maintain the best balance between suppressing or destroying the enemy's capability to inflict damage on us while preventing mistaken fire on friendly forces.

A-6. Immobility
a. Risk Factor: Immobility during static, heavy fighting.

• The highest rates of battle fatigue have usually been in static situations where the fighting is heavy, resulting in little opportunity to move around. This occurs when troops are pinned down in bunkers, trenches, or ruins (WWI and Korean War trench lines, Anzio in WWII). It occurs for the attacker and the defender who must fight at close quarters, day after day, and for armored troops when they are deployed on restrictive terrain.

• Conversely, during highly mobile warfare, whether maneuvering in battle, pursuing, or even in hasty retreat, obvious battle fatigue symptoms and casualties often are not recognized until a safe place or stable lull is reached. (However, many soldiers may have been killed, wounded, or missing as a direct consequence of battle fatigue symptoms but were not classified as battle fatigue casualties.)

b. Leader Actions: Recognize the static, heavy fighting and institute protective measures for trench, bunker, or urban warfare.

• Rotate units frequently back to reserve positions where they can move around freely whenever the tactical situation permits.

• Keep the troops informed and try to give them the best possible support for food, water, clothing, supplies, and mail up to the farthest forward positions.

A-7. Lack of Information/Support
a. Risk Factor: Lack of information and failure of expected support. When troops do not know what is planned, they feel isolated, unappreciated, and forgotten. Whenever support or relief does not show up, they may feel deserted. This is especially true if the failure is unexplained. They lose the perspective of the greater mission and are less able to maintain a positive perspective on the combat stressors. They tend to fear the worst, and rumors take hold and lead to battle fatigue and even panic.

b. Leader Actions: Keep information flowing.

(1) Keep yourself informed.

• Actively seek out information from the chain of command, the chain of support, and other reliable sources.

• Do not ignore less reliable sources of information, but try to get confirmation before committing totally to act on it.

(2) Keep all the troops informed with the best, honest information.

• Keep the troops well informed of their goals, the situation, and how they are doing. Information flow must be a routine, ongoing process which is transmitted down to the lowest level. Explain to troops that information will be disseminated through the chain of command.

• Use in-country public affairs assets. Public affairs can play a key role in helping commanders meet the communications needs of their soldiers. Public affairs officers advise commanders and their leaders on the information needs of units, assisting in the development of messages, facilitating the flow of information, and providing communications channels.

• Stop rumors and counsel rumor-mongers while giving out the best, most reliable information you have, with appropriate caveats about its limitations. Remember, even telling the troops that you do not have any new information is meaningful information to them. It lets them know that you are keeping them informed.

• Tell the troops what kind of supporting arms are expected, but explain that other units and missions also have a claim to them -- and support may not be immediate.

• Do not conceal unpleasant possibilities, but put dangers in the perspective of how the unit will prepare to overcome them. Always give them some guidance they can begin to act on and not just sit and worry.

• When operational security does not permit informing the troops on upcoming operations, keep them informed in other areas. Once the security requirements are lifted, brief the troops and provide as much information as possible.

A-8. Nuclear, Biological, and Chemical Weapons
a. Risk Factor: High threat of NBC weapons use and actual use. The invisible, pervasive nature of many of these weapons creates a high degree of uncertainty and ambiguity with fertile opportunity for false alarms, rumors, and maladaptive stress reactions. The terrible nature of some of these weapons will create fear for the future, the homeland, and perhaps even for the survival of civilization.

b. Leader Actions: Prepare troops for NBC threat contingencies.

(1) Keep information flowing, dispel myths, and control rumors.

• Discuss the situation and its possible long-term implications honestly.

• Maintain the view that the best chance for the future will be maintained if the unit stays effective.

(2) In training, emphasize that our intention is deterrence.

• Tell the lesson of history that NBC weapons are much less likely to be used against us if we show by our defensive training that they will not give an enemy enough advantage to justify the risk of his using them against us. If we train and the enemy does use them, we also have our best chance of surviving and winning.

(3) Put NBC (and especially chemical) defense in realistic perspective.

• Point out that low-dose exposure will be much more common than high-dose (potentially lethal) exposure.

• Compare the risks of the most likely threat with the increased risk of facing the conventional threat in varying levels of MOPP. Think of the decision to put yourself or your unit into MOPP as being like the decision of how much cover to take when under the threat of conventional weapons when you have a mission to accomplish.

• Change to MOPP levels that permit accomplishment of the mission and survival of the soldier.

(4) Practice flexible MOPP procedures when there is only a threat of chemical agent use, or low doses in the surrounding areas, and there is a critical mission to be done that is impaired or endangered by MOPP.

• Mission-oriented protective posture flexibility means that some team members perform the mission-essential heavy work, fine finger movements, and visual and auditory tasks at a lower level of MOPP (or mask only) while others stay at a higher MOPP level.

• Those in high MOPP stay ready to take over the task and provide assistance to the members of the first group as they go to MQPP Level 4 if the unit is hit with chemicals.

• In any potential biological or chemical risk situation, some members of the unit are at some protective level at all times, with MOPP rotation set by the TSOP.

(5) Emphasize buddy aid by those in MOPP rather than self-administration of antidotes such as atropine, which may have harmful effects if taken in the absence of nerve agent.

• Soldiers may take the first autoinjection of atropine (Mark I Kit) if they believe they have been exposed.

• Get to a buddy to confirm the symptoms within 10-15 minutes and administer a second Mark I only if it is truly needed.

(6) Reduce ambiguity by having a unit TSOP with clear, objective criteria for all levels of MOPP.

• Some members of the team automatically mask or go to MOPP Level 1 or 2 whenever any unidentified aircraft are seen, or potentially contaminated patients arrive, or there is incoming artillery or smoke. They monitor the detection equipment and prepare to give aid if agents are present.

• Those who are performing critical jobs which cannot be performed well in mask or overgarment continue to perform those tasks. They stay ready to go to a protective posture immediately if a NBC threat is confirmed.

• Specify in the TSOP how to decrease MOPP levels and unmask sequentially as a team, not all at once. The unmasking drill needs to be practiced. Give active reassurance to the first group to unmask, assuring them that their buddies are observing and can help them if any harmful agent is present.

(7) Train in the protective mask often and require prolonged wear. It takes repeated familiarization and time to acclimate and get over the common claustrophobic feeling. The respiratory threat from almost all NBC agents is much greater than the skin contact threat. Inhaled nerve or cyanide kills in minutes. Inhaled blister and choking agents act slowly, but once they are in the lungs, one cannot get them out. Absorption of most agents through the skin is slower. This allows time to wash them off and use antidotes if available.

• Start with enjoyable activities to overcome initial anxiety. Wear the mask often in garrison, even at desk jobs. The more often soldiers wear their mask the quicker they become familiar with it.

• Have periodic prolonged wear (8+ hours) to help soldiers realize they can tolerate the discomfort of the mask. Wear the mask while performing tasks which relate to combat duties.

• Wear the gloves often (with and without mask) until most of the essential jobs can be done in them.

(8) Train sometimes in MOPP Level 4 (or simulated MOPP Level 4, which is to overdress while wearing the protective mask, overboots, and gloves). However, this training is less important than mastering the mask alone.

(9) Issue each soldier his own personal mask whenever feasible. This ensures that each soldier's mask is the correct size and places responsibility for care of the mask on each soldier. A soldier will feel more trust, confidence, and even grudging "cohesion" for his mask if it is his and he is issued the same mask every time.

(10) Use any mask confidence exercise only as a culmination of training and proof of success. This requires teams to enter an area where a riot control agent has been released and --

• Perform their team jobs together.

• Drink water through the drinking tube.

• Unmask briefly while holding their breath and keeping their eyes closed.

• Remask, reseal, and clear the mask before breathing. The soldier can then leave without feeling unpleasant symptoms from the tear gas if everything works well. The purpose of the exercise is to build confidence in the mask, not to destroy it.

(11) Emphasize professionalism in training.

Conduct cross-training to allow effective crew rotation and physical conditioning which extends the limits of the soldier.

• Emphasize the common soldiering skills.

• Emphasize that we train to do our missions this way because it is the TSOP. We do it because we are smart, survival-skilled soldiers.

• Practice all critical tasks with at least the mask on until they can be done automatically. This is essential.

• Simple routine or overlearned tasks are the least susceptible to degradation.

(12) Leaders must be positive role models. They must be highly visible and positive in doing the MOPP training themselves.

(13) Make NBC field training exercises realistic.

• Integrate NBC conditions into realistic training exercises. Cohesion and esprit de corps are achieved by working together to overcome (or prevail in spite of) hardship and discomfort which NBC training provides.

• Work together as a team to develop coping techniques which deal with individual limitations encountered while performing routine tasks during realistic training. Develop and practice ways to identify individuals in MOPP, to assess their alertness, comprehension, and well-being, and to give and receive emotional support.

• Make frequent use of simulated agents such as methyl salicylate (oil of wintergreen). These provide realistic practice with detection equipment and protective gear.

• Teach threat limitations as well as strengths. For example, teach that the threat is not everywhere but decreases with distance from point of dispersal and time and can be reduced by skilled use of terrain, cover, and wind direction.

• Stress the need for contamination avoidance and use of collective protection and decontamination means. Also stress individual, crew, and unit proficiency in the tactics, techniques, and procedures of NBC defense.

• Make exercise scenarios plausible. Exercise detection, monitoring, reporting, and risk estimation. Use reports of nuclear weapons explosions only if they fit well in the exercise scenario. Since we cannot adequately simulate a real nuclear burst, use "precautionary alerts" to exercise TSOP.

• Make the dispersal and "hardening" of a unit's position the unit's standard way of setting up (so that it is less vulnerable to nuclear flash and blast). Reinforce this by frequent practice of nuclear blast and radiation protective drills, both for what to do with a few minutes advance warning and for when the first warning is just the flash.

(14) Train hard and be prepared to manage heat stress in well-acclimatized, fit soldiers. We must push our well-prepared troops to a level of acceptable risk.

• Be alert and fully prepared to manage heat stress (heat cramps, heat exhaustion, and even the exceedingly early signs of heat stroke [which are revealed by mental symptoms of elation, confusion, disorientation, and perhaps hallucinations and belligerence before they progress to coma, seizures, and danger of permanent brain damage or death]). Take this risk only after specific preparation of every soldier involved and of the unit. Adequate preparation includes -- Physical (aerobic and muscle) fitness. Acclimatization to the area of operations and conditioning to various MOPP levels, especially MOPP Levels 3 and 4. Acclimatization by doing more work in hot conditions.

• Water availability and command emphasis on drinking "by the numbers" (so much per hour).

  Note
  Leaders must be concerned about soldiers' health, but they should be careful not to lose credibility through overreaction to perceived hazards.

• Skin and foot care.

• Medical awareness with backup personnel and preparation of evacuation means.

• Management of psychological stress symptoms, such as hyperventilation, by using self-calming relaxation and buddy aid techniques.

  Warning
  Unfit, unacclimatized troops should not be overexerted in training as this could cause severe injury or even death. A special physical training program will be required to integrate such soldiers into a regular Army physical training program.

(15) Emphasize the importance of timely prophylactic/treatment materials once the causative chemical or biological agent is known.

A-9. Deprived of Sleep
a. Risk Factor: Sleep loss. Battle fatigue can occur without sleep loss, but insufficient sleep can be a major\par contributing factor. The sleep-deprived soldier or leader has difficulty thinking and reasoning and becomes easily confused and overly suggestible with poor judgment. Pessimistic thinking takes hold and everything seems too difficult. Sleep loss alone can cause the tired brain to see things which are not there (visual hallucinations) or to perceive things which are there as something totally different. When anxiety and vigilance (staying awake on watch) are added, the soldier may be temporarily unable to distinguish between reality and what he fears. Normal physical symptoms of stress can become magnified into disabling illnesses.

b. Leader Actions: Practice sleep discipline and sleep planning. Sleep discipline means sleeping when and where you are directed. Sleep discipline is intended to provide the best sleep possible in the time and place available. Because battle is both stressful and unpredictable, a flexible plan is needed to supply everyone with sufficient sleep.

(1) Set shifts whenever possible.

• Shifts which allow each individual 6 to 8 hours of continuous sleep when feasible are preferred. Provide soldiers with a minimum of 4 hours of uninterrupted sleep in a 24 hour period (6-8 hours optimum). This greatly extends soldiers and crew endurance limits.

• The standard wartime shift is 12 hours on and 12 hours off (two shifts per day). This has the advantage of simplicity, requires fewer skilled personnel, and has only two shift changes when information must be exchanged.

(2) Supervisors should consider alternative shift plans, if flexibility of sleep hours is required in a combat mission situation. For many jobs, 12 hours on duty may be too mentally or physically exhausting, leading to poor performance in the last several hours. Or the work load may be so variable that it is sometimes necessary to keep both shifts on duty, in which case one shift may have to go 36 hours without sleep.

• The sleep does not have to be continuous. While 6 to 8 hours of continuous sleep is preferred, studies show that several blocks of sleep which add up to 6 hours in 24 are adequate for most people. The fewer the blocks, the better.

• Consider two shifts per day, each working 6 hours on, 6 hours off, (or 6 1/2 on, 51/2 off, with overlap for shift changes). This works everyone half the time, but gives everyone two chances each day to get 3 to 5 hours of sleep. The world's sailing navies used 4 hours on, 4 hours off for centuries because of the heavy work and frequent need to call all hands on deck.

• Use the 6 hours on, 6 hours off alternative only in work situations where the duty station, dining facility, sleeping quarters, and other essentials are close together, such as in small base areas. Otherwise, too much time is wasted going back and forth to quarters and the dining facility.

• Ensure all essential information is transmitted and understood when the shifts change.

• Avoid shifts which set the period of sleep at different times each day -- such as 8 hours on, 8 hours off. This tends to disrupt the body's 24 hour/day biological rhythm and leads to poor performance as well as personal discomfort. Whenever possible, people should get at least some sleep at the same time each day.

  Note
  In CONOPS, if shifts are impractical, try to give all individuals at least 4 hours of uninterrupted sleep each 24 hours (5 hours if sleep is interrupted).

(3) Identify and take special precautions to protect the performance of those critical tasks which are vulnerable (sensitive and likely to break down) due to sleep loss, especially planning, initiating, reasoning, cognition, and vigilance. Remember, 4 hours each 24 hours is far from ideal.

• Do not go with only 4 hours sleep each 24 hours for more than 1 or 2 weeks before paying back sleep debt.

• If at all possible, give the individuals whose key tasks are vulnerable to sleep loss 6 hours sleep a day.

(4) Assign naps.

• It is helpful to get 1 hour sleep here, 2 hours there. Even a little sleep is better than none. It is not necessary that it all be in one block.

• Even brief (15 to 30 minute) naps help against sleep debt. However, 5-minute naps do not help.

• Plan time to wake up from naps. After a nap, mental task performance is often much worse for several minutes after waking up than it was just before the person went to sleep. The brain needs time to "warm up."

(5) Practice counterfatigue measures to use when soldiers must continue to work or fight without enough sleep.

• Use ways to increase alertness.

• Add changing sensations. Of course, this must not interfere with the task. For example, one can listen to the radio while driving on the highway at night but not on guard duty. It is best for the soldier not to be too comfortable. He can snack on something with a strong taste. Protein is better than carbohydrates for staying alert. Caution is needed in using stimulant drugs. Caffeine (coffee, tea, and cola) is relatively safe for most people for short-term use, but may make it difficult to sleep when opportunities arise. Amphetamines and other strong stimulant drugs are more dangerous; they can cause panic attacks, hyperactivity, and temporary paranoid psychotic reactions which last several days. Also, people "crash" when they stop using such strong stimulants and many even get seriously depressed.

• Add physical movement if the task lacks it. The soldier should take stretch breaks and jog to increase circulation. He should fidget in place if he cannot leave the duty station.

• Add social stimulation. Use the buddy system, assigning two people to work together. Of course, this means one fewer person is getting time to sleep. With workers who must be at different isolated locations, alternate having them call each other by radio or telephone to ensure that they remain alert.

• Add sense of urgency. Brief troops about the urgency of the task. Be sure to explain why it is important to stay awake. If it is hard to keep urgency in mind, use "game playing" to maintain interest by adding competition or suspense.

• Add feedback of performance. If the task does not automatically provide feedback, actively try to create it. The leader can provide feedback by spot-checking for compliance, building feedback into the task, and contacting the users of the service to make sure they are satisfied.

• Rotate jobs. If the job requires continual attention or is physically demanding, it will be vulnerable to sleep loss. If you cannot provide breaks, try having people switch jobs, preferably to something quite different. This can give surprising improvement in performance, provided the soldier knows how to do the new job well. In order to rotate jobs, you must have cross-trained personnel in advance. Make sure all essential information is exchanged, understood, and recorded when the switch is being made. Otherwise, worse difficulties may result.

• Use ways to support memory.

• Clarify and modify the task. Try to simplify orders and complex sequences. This has to be done before people get too tired to use good judgment. Double-check such sequences (get independent verification). Document in writing what was done.

• Use performance aids, if new learning is needed. Take notes. Draw simple diagrams or maps to involve visual-spatial memory as well as verbal memory. Write down all orders and read back input to ensure that it has been understood and copied correctly. Refer to these aids later when short-term memory has forgotten exactly what was said.

• Drill the task to "overlearn it" until it is automatic. The common saying is "He knows it so well he can do it in his sleep." Even complex tasks will be resistant to sleep loss if they have been practiced until they need only be started to run themselves through to completion without having to think about them.

• Build in cues and reminders of the self-initiated parts within the task itself or the situation. Have checklists and TSOP, put up signs, write notes -- then practice! This is especially relevant for tasks, such as preventive maintenance and ordering more supplies. These are easily omitted by tired workers, but the whole mission may collapse suddenly if they are not done.

• Determine performance decrement factors through realistic mission training in MOPP Levels 3 and 4. These factors can then be used to state realistic mission requirements for units and crews.

• Divide the labor (task paralleling). Put more people to doing the entire job. This works if having more people doing the same overall task means less work for each person and especially if it gives more time for each element of the task. Of course, it also means that fewer people are getting to sleep, and it is harder to coordinate the information, so do this only for essential, critical tasks. Let the other tasks wait (see priorities, below).

• Divide the responsibilities of the time-shared task where one person normally has to do two or three things all mixed together. Assign several people, but modify the task so that each person has responsibility for only one task element and can concentrate fully on it. The hidden danger of this remedy shows up if several people must transmit information among themselves, since communication and memory are impaired by sleep loss.

• Simplify priorities. Sleep-deprived people have trouble deciding what is most important. They tend to hang up on choices (taking longer and longer, or not choosing at all), or they unthinkingly do what is easiest, or most learned, or most obvious. Specify what is most important versus what should be dropped out. You should decide this while fresh, build it into your TSOP, and practice it.

(6) Get good sleep before CONOPS or an afternoon nap before night operations. You cannot "stockpile" sleep, but starting out without any sleep debt delays the onset of degraded performance.

• In CONOPS or SUSOPS, never waste a chance to let someone in the unit sleep. Spread such opportunities around to give everyone enough.

Note
Be careful. Do not allow sleep in unsafe conditions, such as under vehicles or in vehicles with the motors running. Beware of the tendency for tired people to slack off and use poor judgment.

A-10. Physically Run-Down
a. Risk Factor: Run-down physical condition. This contributes to battle fatigue by sapping soldiers' ability to function and, therefore, their confidence to accomplish the mission and survive. Neither physical fatigue nor sleep loss necessarily cause battle fatigue, but they can be strong contributing factors. To the extent that these factors are involved, they are easier to prevent or correct than are most of the factors listed earlier. The more physical exhaustion is present in battle fatigue casualties, the more confident we can be that soldiers will recover completely. These soldiers return to duty once we have replenished the physical resources. However, our treatment must also restore their confidence.

(1) Dehydration deserves special mention because it can be extremely subtle.

• A stressed soldier under battlefield, MOPP, or heavy work conditions can become exceedingly dehydrated without feeling thirsty. This is especially true in hot climates, in MOPP, or the arctic. Dehydration renders the blood less able to carry oxygen to the brain and muscles. This results in instant battle fatigue.

• Colonel (later Brigadier General) S.L.A. Marshall, the US Army historian who pioneered the technique of interviewing combat teams while the battle was still going on, discovered this in himself during his first exploratory mission on Kwajalein in WWII. Colonel Marshall was a man who was literally fearless, so this came as a surprise to him. He summarized the lesson by writing, "No one ever told me that dehydration causes cowardice in its most abject form."

(2) Poor diet is common, if not inevitable, in combat and tends to lower one's energy level and sense of being strong and alert. While some people eat more when anxious or depressed, most eat less. Stomach pain and nausea are common signs of battle fatigue which further inhibit eating. The monotony and unpalatability of some meal(s), ready to eat (MRE) or tray-packs (T Rations), will not help. Such rations are even less likely to be eaten if they must be eaten cold. Many soldiers may start eating only a few, select items which do not provide all-around nutrition.

(3) Poor hygiene is common, if not inevitable, in combat and tends to lower one's energy level and sense of being alert and "human." We have all had the experience of coming in from days out in the field, dragging, and how much better we felt after that first hot shower. Imagine how much worse the "dragging" is if that poor hygiene goes on for weeks. Poor hygiene can also lead to disease.

(4) Low-grade environmental or stress-related illnesses further sap the soldiers' strength and confidence. Chronic diarrhea, persistent cramps in the stomach, fever from malaria or virus, or skin infections or blisters that do not heal can make soldiers feel exhausted and demoralized, setting them up for battle fatigue. Units whose leaders do not monitor and enforce basic preventive medicine and hygiene measures are likely to suffer low morale and high battle fatigue rates. Conversely, being in a unit where a sense of caring, order, and TSOP is maintained is a strong stress reducer. It not only maintains health but also promotes unit pride, cohesion, and confidence.

b. Leader Actions: Protect the physical well-being of the troops. In combat, never waste the strength of the soldiers for trivial matters because there will be many occasions when it will be necessary for soldiers to accept hardship to gain the advantage.

(1) Ensure the best water, food, equipment, shelter, and sanitation (and sleep) possible under the circumstances of the mission.

• Enforce water discipline.

• Enforce food discipline; ensure soldiers eat an adequate balanced diet from their MRE, T Rations, or A Rations.

• Enforce basic personal hygiene and preventive medicine practices.

• Assure latrines are kept clean.

• Provide time for troops to bath or shower at least once weekly and more often when feasible.

(2) Explain why the hardship is necessary when unable to provide well for the soldiers' physical needs.

• Put it back in the perspective of how "we will cope."

• Remind them of those times in earlier training when they overcame the hardship to accomplish the mission.

A-11. Inadequate Fitness
a. Risk Factor: Lack of physical fitness. Being physically fit is not a guarantee against becoming a battle fatigue casualty, but not being physically fit is an invitation for it. Sudden overuse of the cardiovascular system, muscles, joints, and bones that have not been prepared for the strain can lead to immediate failure and serious injury. Even if these are avoided, the unfit soldiers will be subject to days of stiffness, aching, and weakness. During this time, they are at extremely high risk for battle fatigue, especially if further demands are made on them.

b. Leader Actions: Assure physical fitness.

• Physical fitness programs are useful in promoting unit cohesion, but they are also important in themselves as protection against battle fatigue. Being super-fit is not a guarantee against disabling battle fatigue, but it does increase self-confidence (and the confidence of buddies) and delays the onset of muscular fatigue.

• Assure that everyone in the unit has --

  • Aerobic fitness (endurance).

  • The necessary muscle strength in the parts of the body which they will use in their combat role.

  • Calluses in the right places (to avoid developing blisters).

  • The necessary flexibility and agility for the tasks to be done, including the combat self-defense tasks like digging. This is especially necessary for some combat support/CSS personnel whose garrison or field jobs tend to be sedentary. \par

A-12. Older Veteran or Short-Timer
a. Risk Factor: Cumulative combat exposure or "being short."

• These are special situations where the individual is at high risk for battle fatigue.

• The "old sergeant syndrome" of WWII occurred in the veteran soldier who had been in combat for a long time. He had risen to a responsible position but had seen all his old buddies killed or wounded and replaced by new, inexperienced soldiers. The only way home was death, mutilation, or, if exceedingly lucky, the "million dollar wound." Although he often insisted that he wanted to stay in combat, he felt guilt at his weakness. He had become overly cautious, indecisive, anxious, and depressed.

• An "old sergeant" variation, seen also in Vietnam, was the NCO or officer who extended for a second or third tour but who was so embittered and hardened to combat that he was in danger of committing some of the misconduct stress behaviors.

• "Short" soldiers are those who are coming close to the date when they will rotate home from the combat tour. Neither they nor their buddies want them to get hit on their last day (or week, or month, or mission) in combat. This was a common experience in Vietnam (with the 365-day tour) and in Korea (with the "point system" used late in the war). In WWII, it was seen in aircrews who rotated home after some number of missions, and in the Marines when it was established that they would be rotated home after three amphibious operations. A similar reaction may occur in the last days before an expected cease-fire or armistice.

b. Leader Actions: Recognize and manage the "old veteran" or "short-timer" syndrome.

• Maintain a rotation schedule which avoids relieving soldiers from dangerous duty prematurely at the expense of others, without keeping them in so long that they become ineffective and dangerous.

  • Develop rotation standards based on the overall situation.

  • Reassign the "old veteran" to a responsible rear echelon job rather than risk a serious failure in combat or a case of battle fatigue that does not respond to treatment and leaves the soldier permanently scarred.

  • Support and protect those individuals who are showing more signs of battle fatigue than the average. This is done without creating a social expectation of relief from dangerous duty that saps the fighting strength.

  • Use judgment when discussing this topic so that it does not become a "self-fulfilling prophecy."

• Do not set an automatic policy of relieving "short' soldiers from dangerous missions during their final weeks. This will move the "short-timer" syndrome even earlier in the last months.

• Give the individual soldiers (or units) who are preparing to rotate home a period of several days of minimal danger just before departure.

  • Schedule this time for postdeployment debriefings. These sessions are similar to the routine after-action debriefings but on a larger scale.

  • Concentrate on remembering and reviewing in detail the major events (good or bad) of the tour, sharing the common experiences and feelings.

  • Actively work through unresolved, painful, or controversial issues.

  • Discuss (receive briefings on) how the home front (family, Army, nation) may have changed or may react to returning veterans and their needs.

  • Normalize the common postcombat (traumatic) stress signs/symptoms most will have.

  • Review coping techniques.

• Conduct a suitable memorial ceremony prior to departure from the combat zone to provide a sense of completion and closure for those soldiers returning home.

• Coordinate with the rear detachment and family support group to schedule information briefings pertaining to redeployment of the unit to its home station.

• Plan a welcome home/memorial ceremony which include the family and garrison community.