LEADERS' MANUAL FOR COMBAT STRESS CONTROL
ORGANIZATION AND FUNCTIONS OF ARMY MEDICAL
DEPARTMENT COMBAT STRESS CONTROL UNITS
Combat stress control is now recognized as an Army Medical Department functional area for
doctrinal and planning purposes. As such, it is distinguished from the other nine Army Medical
Department functional areas of health service support which are --
a. Patient evacuation and medical regulating.
c. Health service logistics/blood management.
d. Dental services.
e. Veterinary services.
f. Preventive medicine services
g. Area medical support.
h. Command, control, communications, computers, and intelligence (C4I).
i. Medical laboratory services.
B-2. Army Medical Department Combat Stress Control Program
a. Combat stress control refers to a coordinated program for the prevention and treatment
of battle fatigue and other harmful stress related behaviors. Combat stress control is
implemented by mental health personnel organic to units and by specialized medical
combat stress control units which are a corps-level (or echelon above corps) asset. The
combat stress control organization must function flexibly across the full range of combat
intensities and operational scenarios including war and operations other than war.
b. There are six major combat stress control programs or functions which have different
relative importance in different scenarios. The usual order of priority is as follows:
(1) Consultation. Liaison, preventive advice, education programs, planning, and
stress control interventions to supported unit commanders and staff.
(2) Reorganization (reconstitution) support. Assistance at field locations to battle
fatigue units which are withdrawn for rest, reorganization, and integration of new
(3) Proximate neuropsychiatric triage. Sorting battle fatigue cases based on
where they can be treated to maximize return to duty, separating out true
neuropsychiatric or medical/ surgical patients.
(4) Stabilization. Immediate, short-term management and evaluation of severely
disturbed battle fatigue casualties, neuropsychiatric, and alcohol and drug misuse
cases to determine return to duty potential or to permit safe evacuation.
(5) Restoration. One to three days of rest, replenishment, and activities to restore
confidence of battle fatigue casualties at "forward" medical units.
(6) Reconditioning. An intensive 4- to 21-day program of replenishment, physical
activity, therapy, and military retraining for battle fatigue casualties and
neuropsychiatric cases (including alcohol and drug misuse) who require this to
return to duty.
B-3. Basic Tenets of Army Medical Department Combat Stress Control
a. Army Medical Department combat stress control is unit-identified and missionoriented.
(1) The combat stress control concept differs from conventional clinic or
community mental health in its explicit identification with and utilization of the
strengths of Army organization and ethics.
(2) Mental health personnel assigned combat stress control duties are clearly
identified as members of a specific TOE unit. They may be organic members of
line medical units (such as the mental health section of the division's medical
support company or the corps' area support medical battalion), or they may be
members of a medical combat stress control unit which has a formal support
relationship with the line units (such as a medical detachment or medical
company, combat stress control).
(3) Combat stress control personnel work closely with the chain of command and
the chain of support in the context of the supported units' changing missions.
They work in the supported units' locations, or as close as is feasible under the
(4) Mental health/combat stress control personnel also work with the individual
soldiers and (in peacetime) with the soldier's family members. However, these
soldiers and families are considered valued members of the supported unit; they
are not labeled as patients or clients. Combat stress control personnel begin with a
presumption of normality (that the soldier [or family member] is a normal, well
intentioned human being). They presume that these soldiers or family members
are trying in good faith to master the sometimes excessive stressors of military
life and that they want to succeed. This presumption can only be displaced by a
thorough evaluation which proves the contrary, or by failure to improve after
sufficient expert treatment.
b. Army Medical Department combat stress control is proactive and prevention-oriented.
(1) Combat stress control personnel/units dedicate much of their time and
resources to activities which assist the commanders of units in controlling
stressors. They identify stress problems before they lead to dysfunction or stress
casualties. This early identification permits the retention and recovery of mildly
and moderately overstressed soldiers, in their units, on duty status.
(2) Even when providing reactive treatment to heavily overstressed soldiers who
are in crisis, combat stress control personnel continually look for the primary
causal factors (stressors). They work with the chain of command and the chain of
support to gain control of the stressors or control stress which may adversely
affect soldiers and their families. The objective is not only to help the afflicted
soldiers and return them to effective duty, but also to prevent future affliction in
(3) Even when overcommitted to treating mass casualties, combat stress control
units remain alert and prepared to reallocate resources. When necessary, combat
stress control resources deploy to support units in forward areas. There, they
provide early preventive intervention for stressed soldiers and assist command to
gain control of the correctable stressors. The intent of early preventive
intervention is to --
- Minimize the flow of battle fatigue casualties.
- Provide treatment for and return to duty of soldiers.
- Minimize the risk of future suffering and disability (prevent PTSD)
B-4. Organizational and Operational Concept for Army Medical Department Combat
a. Organic Mental Health Sections. Mental health personnel are organic to medical
elements of divisions, separate brigades, and the area support medical battalion.
(1) Division mental health sections have a psychiatrist, a social work officer, a
clinical psychologist, and seven behavioral science specialists. At least one
behavioral science NCO and one mental health officer should be allocated
routinely to work in each maneuver brigade.
(2) The area support medical battalion has a psychiatrist, a social work officer,
and eight behavioral science specialists. A behavioral science NCO may be
allocated to work with each area support medical company.
(3) Separate heavy brigade medical companies will have three behavioral science
specialists (currently no officer). Some SOF units have a clinical psychologist.
Armored cavalry regiments currently have no organic mental health personnel.
b. Mission of the Organic Mental Health Section. The mission of the organic mental
personnel is to provide command consultation, training, technical supervision, staff
planning, and clinical evaluation (neuropsychiatric triage). They must be mobile -- able to
travel to military units. They can provide brief forward treatment to small numbers of
cases during combat operations. Their assets are not sufficient to provide longer
treatment for large numbers of battle fatigue or neuropsychiatric casualties without
sacrificing their other critical preventive and staff functions.
c. Combat Stress Control on Today's Battlefield. On today's battlefield, each maneuver
brigade covers a larger and more fluid area and has greater fire power and responsibility
than did a WWII division. The Army operations concept makes the brigades even more
the basic warfighting echelon. Winning the first battles will be critical and may require
reconstitution of attrited units and rapid return of temporarily disabled soldiers to their
units. The organic division mental health personnel must be reinforced if cases are to be
restored in the brigade and division support areas. Separate brigades and armored cavalry
regiments will also require this reinforcement.
(1) The combat stress control organization must achieve a balance between
prepositioning elements far forward and having other elements further to the rear.
The far forward teams provide consultation, triage, and immediate treatment. The
rearward teams support rear battle; these teams take the overflow and problem
cases from forward areas. The rearward teams are ready on short notice to
redeploy forward to the areas of greatest need, such as to the mass casualty or
(2) The organic mental health sections are essential to provide the infrastructure
of mental health personnel who share familiarity and trust with unit leaders. These
factors are necessary for effective consultation and prevention.
(3) Under the combat stress control concept, the organic mental health section
provides the points of contact for reinforcing elements from corps-level combat
stress control units. These higher-echelon elements will deploy into the brigade,
division or corps area to assume the treatment role and assist in other functions.
The point of contact is essential for coordinating, updating, orienting and
facilitating the attachment of reinforcing combat stress control elements. A
combat stress control team which tries to join a unit during deployment, combat,
or reconstitution will be less effective unless it has mental health points of
contact. The mental health points of contact who have developed trust and
familiarity with the supported units are of great assistance in facilitating the
combat stress control support process.
d. Reinforcing Combat Stress Control Teams. The reinforcing combat stress control
teams are small, mobile teams made up of various combinations of the five mental health
disciplines. These teams may include a psychiatrist, social work officer, clinical
psychologist, psychiatric nurse, occupational therapist, and their enlisted specialists.
These teams will have their own tactical vehicles and bring a limited amount of supplies.
These combat stress control teams will come from either the medical companies or
medical detachments, combat stress control.
(1) The organizational concept for combat stress control packages the five subdisciplines
(officers and enlisted specialists) of the mental health team into 4- or
11-person standard "modular teams." All combat stress control members have
basic skills to direct the management of generalized stress casualties while each
brings expertise to an area of specific responsibility, to be partially cross-trained
to others. Teams are combined into larger task-organized combat stress control
elements. The 4- or 11-person teams can be subdivided. Personnel may be crossattached
between teams by their parent combat stress control unit to fit the
specific mission. The modified teams and task-organized combat stress control
elements will be tailored to make best use of available resources and the abilities
and experience of the individual team members.
(2) The combat stress control modular "teams" are as follows:
- Combat stress control preventive team: Psychiatrist, social work officer,
and two behavioral science specialists. The team is allocated one truck
- Combat stress control restoration team: Psychiatric nurse, clinical
psychologist, occupational therapy officer, two each of their enlisted
specialists, noncommisioned officer in charge (NCOIC), and a patient
administration specialist. This team is allocated two or three trucks with
(3) The combat stress control preventive and combat stress control restoration
teams are incorporated into two units: medical detachment and medical company,
combat stress control.
e. Medical Detachment, Combat Stress Control.
(1) One combat stress control detachment normally supports one division or two
or three separate brigades or regiments.
(2) Each combat stress control detachment has three combat stress control
preventive teams and one combat stress control restoration team.
(3) The detachment normally sends combat stress control preventive teams
forward to the brigade support area while the combat stress control restoration
team staffs a "fatigue center" for restoration in the division support area or
forward corps. While in these areas, the detachment is under operational control
of the supported unit. Parts of teams may go forward to ambulance exchange
points or maneuver battalions not in contact.
f. Medical Company, Combat Stress Control.
(1) Each combat stress control company supports two or more divisions in the
corps area. Each combat stress control company has six combat stress control
preventive teams and four combat stress control restoration teams. These are
normally task-organized into two or more elements, ideally one task-organized
combat stress control element for each division supported. When total work load
allows, each task-organized element staffs a combat fitness reconditioning center,
collocated with a corps hospital; this may be augmented with elements of a
medical company, holding.
(2) Each task-organized element sends teams to provide consultation to corps
units and to reinforce area support medical companies when needed. It maintains
contact with the supported division mental health section and combat stress
control detachment in the divisions. The combat stress control company sends
teams forward to reinforce combat stress control elements as required.
(3) The combat stress control company headquarters collocates with either a
medical brigade, medical group, or area support medical battalion headquarters.
Combat stress control company support personnel are detailed to the taskorganized
combat stress control elements. The combat stress control company
exercises command and control for its task-organized combat stress control
elements and for the combat stress control detachments which they support.
(4) The combat stress control company reports to and coordinates with the mental
health staff sections of the medical group and medical brigade. These small
headquarters staff sections advise and assist the combat stress control company
regarding the employment, support, and reallocation of combat stress control
assets to support the corps' area of operations.
g. Combat Stress Control in Army Operations.
(1) The combat stress control organization is designed to be utilized for war and
operations other than war. In war, their primary mission is prevention and rapid
return to duty of battle fatigue casualties. Teams must be available in sufficient
numbers, pre-positioned forward to react immediately, with rearward teams ready
to reinforce forward where battle fatigue casualties occur.
(2) In operations other than war, fewer combat stress control units are needed.
These combat stress control units are dispersed in support of division mental
health and corps units. The focus of their support is the prevention of misconduct
stress behaviors and perhaps treatment of substance misuse in theater.
(3) Prevention of PTSD by predeployment briefings, after-action debriefings, and
prehomecoming debriefings is a concern at all intensities.
(4) In peacetime, combat stress control detachments (both Active Component and
Reserve Component) must habitually train with the divisions they supported
during wartime (and/or with other similar divisions). The combat stress control
company must develop similar habitual relationships with units in their corps and
with the corps' combat stress control detachments. Combat stress control teams
should routinely augment organic mental health sections. They should work with
maneuver brigades/regiments which lack organic mental health to provide
preventive consultation and practice their combat role.
B-5. Combat Stress Control in the Continuum of Army Life
Combat stress control is not simply a medical responsibility. Fundamentally, it is a leadership
responsibility at all echelons. Since stress can have a monumental impact (positive or negative)
on the military, stress control activities should be a part of many Army activities. The stress
control effort must be concentrated in all three continuums of Army life which are --
A weakness or a gap at any point defined by those three continuums can cause weakness,
overload, or breakdown at points along the other continuums. All players along the dimensions
of responsibility, especially the mental health/ combat stress control personnel, need to achieve
and maintain the broad, three-dimensional system perspective.
LEADERS' MANUAL FOR COMBAT STRESS CONTROL
Table of Contents
Chapter 1 - Overview of Combat Stress Control
Chapter 2 - Stress and Combat Performance
Chapter 3 - Postive Combat Stress Behaviors
Chapter 4 - Combat Misconduct Stress Behaviors
Chapter 5 - Battle Fatigue
Chapter 6 - Post-Traumatic Stress Disorder
Chapter 7 - Stress Issues in Army Operations
Chapter 8 - Stress and Stressors Associated with Offensive/Defensive Operations
Chapter 9 - Combat Stress Control in Operations other than War
Chapter 10 - War and the Integrated (Nuclear, Biological and Chemical) Battlefield
Chapter 11 - Prevention of Battle Fatigue Casualties and Misconduct Stress Behaviors
Appendix A - Leader Actions to Offset Battle Fatigue Risk Factors
Appendix B - Organization and Functions of Army Medical Department Combat Stress Control Units
Appendix C - United States Army Bands
Appendix D -The Unit Ministry Team's Role in Combat Stress Control and Battle Fatigue Ministry
Appendix E - Example Lesson Plan
Glossary - Abreviations and Acronyms
References - Sources Used