The U. S. Army Future Concept for the Human Dimension

6-2. Combat and Operational Stress

One of our cultural myths has been that only weaklings break down psychologically [and that] strong men with the will to do so can keep going indefinitely.
G.W. Beebe and J.W. Appel

Variation in Psychological Tolerance to Ground

Combat in World War II, Final Report, 1951
Traditionally, the loss of life, the number of seriously wounded, and property destruction measure the costs of war. Yet, within the last century, the realization emerged that the physical costs of war are not the only ones. Continuous, protracted combat is largely a twentieth century phenomenon. Prior to World War I, battles typically lasted only a matter of days before participants disengaged to recover and reset. World War I that introduced twenty-four hour combat lasting months and years, and it was in this conflict that armies first suffered large numbers of psychological casualties.
Soldiers engaged in combat and other military operations often witness horrific events. They kill others, risk death and wounds, and experience the loss of close friends. Modern military operations expose Soldiers to many sources of stress. Casualties caused from COSR can be from a single traumatic event or prolonged exposure to combat, and the numbers of psychological casualties can be as high or higher than the number of wounded or killed in action. For combatants in modern war, there is greater likelihood of becoming a psychological casualty than a casualty of enemy fire. There is also the danger of long-term stress or “post combat stress” reactions. Together these effects often extend beyond the lives of those who were there and shape the lives of family, friends, and communities for years afterwards.

Reinforced by many years of study and experience, what is known today about the causes, symptoms, resulting behaviors, prevention and treatment of combat and operational stress remains remarkably similar to the body of knowledge developed in earlier conflicts dating back two centuries or more. What has changed is classification and understanding. AR 40-216 and FM 4-02.51 contain current Army policy and doctrine on the cause, prevention, and treatment of combat and operational stress casualties. It defines combat stress as “all the physiological and emotional stresses encountered as a direct result of the dangers and mission demands of combat.” Combat and operational stress control consists of programs developed and actions taken by Army leaders to prevent, identify, and manage adverse COSR in units. The purpose of stress control is to promote Soldier and unit readiness by developing adaptive stress reactions; preventing maladaptive stress reactions; assisting Soldiers with controlling COSR; and, assisting Soldiers with behavioral disorders.
The future OE operates with no front lines, no sanctuary, and 360-degree AOs. In this environment, all Soldiers are at risk albeit at different levels. The frequency and intensity of conflict will also differ among and even within units. As many behavior specialists and mental healthcare providers argue, this environment may produce a greater likelihood of psychological casualties due to stress because of the random nature of combat, the restrictive nature of the rules of engagement, and the ambiguity associated with their combat role within the OE.¹⁵⁴ The types of missions in these environments also require knowledge and skills that differ from traditional warfighting skills including cultural understanding and historical context, negotiation and mediation skills, the ability to diffuse potential incidents of violence and toleration for frustration, local hostility, and provocation. Such missions require a degree of restraint that can be in conflict with the aggressive spirit deliberately cultivated in Soldiers beginning in IET, the instinct for self-preservation and the traditional warrior role resulting in rising anger among Soldiers and the temptation to retaliate.¹⁵⁵ Illustrative of this complex and unorthodox environment is the concept of the three-block war that spans the spectrum of military operations where Soldiers could conceivably engage in peacekeeping, combat, and humanitarian operations simultaneously within a three block urban environment.¹⁵⁶
Operating in this environment becomes especially frustrating against adversaries difficult to distinguish from the populace. An adversary that causes widespread suffering and commits brutal atrocities, including killing innocents in violation of the laws of armed conflict, only increases Soldier anxiety. Other noncombat related stressors, such as uncertainty of redeployment and duration of deployment, lack of privacy and personal space, and family separation accompanied by domestic problems, adds to this environment. Soldiers also endure stresses from environmental extremes, nutritional irregularity, sleep deprivation, primitive living conditions, and dehydration. Even when the threat of violence is low, boredom, repetitive and unchallenging tasks, and ill-defined purpose provide their own share of operational stress. As figure 6-1 reflects, the psychological effects of combat and other operations are complex and varied, not the result of a single type of stressor and affecting every individual differently. This chart also reinforces the fact that stress effects can be cumulative rather than simply the result of single traumatic events. Any combination of physical and mental stressors can contribute to stress casualties.


Figure 6-1. Combat and Operational Stressors
In spite of the range of differences associated with the spectrum of future military operation, all Soldiers require emotional, cognitive, and behavioral control over common symptoms of stress. It is common for Soldiers to experience the emotions of fear and hopelessness, mood swings, and anger. Soldiers may experience difficulties that are cognitive in nature, such as difficulties concentrating, short-term memory loss, nightmares, and flashbacks. Soldiers may also act on this stress through behavior symptoms ranging from simple carelessness, to impulsiveness, to insensitivity and animosity in their dealings with others, to acts of misconduct (fig 6-2). Growing evidence points to how many of the symptoms for stress overlap with symptoms caused by mild traumatic brain injuries secondary to the concussive effects of nearby explosions. This reinforces the need for preventive strategies, education, awareness, and interventions appropriate to the cause or source of stress.


Figure 6-2. Stress Behaviors in Combat and Other Operations
Despite the numerous sources of stress they encounter, most Soldiers do not become psychological casualties. Stress is an integral part of military service and leaders must assist Soldiers to develop mechanisms to cope with stress in training and on operations. COSR occur when intense or prolonged stressors deplete the Soldier’s coping resources creating a sense of helplessness, fear, and isolation. One of the greatest stressors is the fear of death or injury, but the fear of letting fellow Soldiers down may be even greater. For leaders the mere chance of sending subordinates to their deaths is an e
You can reach into the well of courage only so many times before the well runs dry.

Ardant du Picq, Battle Studies, 1870

normous stressor that may be more powerful than the fear of personal injury or death.
Fear is a rational response to abnormal experiences and generates physiological reactions as well as a psychological and emotional one. The immediate response to fear classified as “fight or flight” is instinctive and essential to survival. Normal stress reactions can have a positive impact and help Soldiers function better by increasing alertness, cognitive processing, strength, and endurance. In combat however, fear of death and serious injury is omnipresent and exhausting, constantly drawing on the Soldier’s ability to maintain the courage and the will to fight. The effects are cumulative and as Lord Moran asserts in his classic work, The Anatomy of Courage, on his experiences in World War I.
Moran observed that psychological casualties occurred both from brief but intense combat and from prolonged exposure; findings confirmed by other armies and in subsequent conflicts. Adding even stronger emphasis, the Army’s report on combat exhaustion in World War II concluded:
There is no such thing as “getting used to combat.” . . . Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure . . . psychiatric casualties are as inevitable as gunshot and shrapnel wounds. Most men were ineffective after 180 or even 140 days. The general consensus was that a man reached his peak of effectiveness in the first 90 days of combat, that after that his efficiency began to fall off, and that he became steadily less valuable after that until he was completely useless . . . .¹⁵⁷
Not all deployed Soldiers face the same risk of injury or death. Soldiers who spend a significant amount of time in proximity to the enemy and populations are at the greatest risk. Being in mortal danger everyday, 10-12 hours a day for weeks and months on end is physically and mentally draining. Arguing that the intensity of combat in the current and future environment is unlike the intensity of earlier wars “demonstrates a lack of appreciation of what constitutes combat in general, and ignorance as to the level of combat Soldiers and Marines are experiencing.”¹⁵⁸ Today’s junior leaders have spent two to three of their first years in the Army deployed in a complex evolving environment for which there are no clear school solutions. Frequently, they must learn the lessons of complex warfare while fielding unfamiliar equipment and bearing responsibility for what their subordinates do at all times.
Consistent with rotation practices in World War II and Korea, the Mental Health Advisory Team IV Operation Iraqi Freedom 05-07, Final Report strongly recommends establishing in-theater unit rotation policies. It supports a longer period of recovery rather than the in-country rest and recreation (that few combat troops were allowed to take) or the two-week individual rotation policy currently in effect in OEF and OIF.¹⁵⁹ Steeling the Mind, a separate RAND Corporation study, examines the psychological implications of stress in future urban warfare and agrees with the recommendation adding, introduce, and integrate replacements into the unit during in-theater rotations.¹⁶⁰ Allowing replacements to train with the veterans improves cohesion and unit effectiveness. Both of these recommendations are currently in place and will warrant integration in future operations.
Endorsing the findings of an earlier Walter Reed Army Institute of Research Land Combat Study, the Mental Health Advisory Team IV report also recommends shorter deployments because deployment length relates to mental health. Earlier conflicts indicated that shorter deployment periods provided greater hope among Soldiers that they might survive unharmed. The Walter Reed study also found that the current dwell time between unit deployments is insufficient for Soldiers to reset mentally. As a result, even though second time deployed Soldiers are generally older, more senior, better educated, married, and more experienced—factors thought to be mentally protective or restorative—they are twice as likely to screen for mental health problems as those deployed for the first time. It is simple human nature to breathe a sigh of relief at the end of a combat tour. It is similarly natural for returnees to wonder if, having survived the first time, their number might come up the second or third time. The percentages of all Soldiers screening for potential mental health problems is increasing as OEF and OIF continue. This finding has major implications for the Army operating in future environment characterized by near persistent conflict and an OPTEMPO that assumes multiple operational deployments in a career of service for both active and reserve component Soldiers. This finding also confirms the earlier World War II study that Soldiers do not “get used to combat” and that previous experience does not “inoculate” Soldiers against COSR.